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The Health Care Law:The Health Care Law:Strengthening America’s Health Care SystemStrengthening America’s Health Care System

Marjorie McColl PettyMarjorie McColl PettyRegional DirectorRegional Director

U.S. Department of Health & Human ServicesU.S. Department of Health & Human ServicesRegion 6 – Region 6 –

Arkansas, Louisiana, New Mexico, Oklahoma & Arkansas, Louisiana, New Mexico, Oklahoma & TexasTexas

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An Unsustainable Status QuoAn Unsustainable Status Quo 46 million uninsured Americans 46 million uninsured Americans

Health insurance premiums for family coverage at a small Health insurance premiums for family coverage at a small business increased 85 percent since 2000business increased 85 percent since 2000

16% of our economic output tied up in the health care 16% of our economic output tied up in the health care system system

Without reform, by 2040, 1/3 of economic output tied up in Without reform, by 2040, 1/3 of economic output tied up in health care--15% of GDP devoted to Medicare and Medicaidhealth care--15% of GDP devoted to Medicare and Medicaid

Without reform, the number of uninsured would grow to 58 Without reform, the number of uninsured would grow to 58 million in 2020*million in 2020*

*Source: Urban Institute: “The Cost of Failure to Enact Health Reform: 2010-*Source: Urban Institute: “The Cost of Failure to Enact Health Reform: 2010-2020” March 15, 20102020” March 15, 2010

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The Health Care Law The Health Care Law in a Nutshellin a Nutshell

Market-basedMarket-based• Preserves the uniquely American system of Preserves the uniquely American system of

private and public insuranceprivate and public insurance State-runState-run

• States control Health Insurance Exchanges, States control Health Insurance Exchanges, regulate health insurance rates, receive grant regulate health insurance rates, receive grant opportunities for innovative care expansion opportunities for innovative care expansion and improvementand improvement

Consumer-centeredConsumer-centered• Protects consumers from insurance rate hikes Protects consumers from insurance rate hikes

and pre-existing condition exclusion, increases and pre-existing condition exclusion, increases access to affordable health care, and improves access to affordable health care, and improves health care qualityhealth care quality

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Building on Current System, Offering Building on Current System, Offering Affordable ChoicesAffordable Choices

Affordability: Affordability: Makes health insurance affordable for middle class Makes health insurance affordable for middle class

and small businessesand small businesses Delivers one of the largest tax cuts for health care Delivers one of the largest tax cuts for health care

in historyin history Reduces premiums and out-of-pocket costsReduces premiums and out-of-pocket costs

New Private Plan Choices:New Private Plan Choices: Establishes new competitive health insurance Establishes new competitive health insurance

marketplaces, Exchangesmarketplaces, Exchanges Gives millions of Americans the same private Gives millions of Americans the same private

insurance choices that members of Congress will insurance choices that members of Congress will havehave

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Holding Insurance Companies Holding Insurance Companies AccountableAccountable

Accountability: Accountability: Medical Loss RatioMedical Loss Ratio Rate ReviewRate Review Pre-Existing Conditions CoveredPre-Existing Conditions Covered

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Improving Care for IndividualsImproving Care for Individuals

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New Consumer ProtectionsNew Consumer Protections

• Bans discrimination against children with pre-Bans discrimination against children with pre-existing conditions (< age 19)existing conditions (< age 19)

• Prohibits insurance companies from Rescinding Prohibits insurance companies from Rescinding Coverage in absence of fraudCoverage in absence of fraud

• Insuring children to age 26Insuring children to age 26

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New Consumer ProtectionsNew Consumer Protections

• Eliminates lifetime limits on insurance Eliminates lifetime limits on insurance coveragecoverage

• Restricts annual dollar limits on insurance Restricts annual dollar limits on insurance coveragecoverage

• Appealing insurance company decisionsAppealing insurance company decisions

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ExchangesExchanges Exchanges are designed for consumers and small Exchanges are designed for consumers and small

businesses.businesses. ••They are State-based competitive marketplaces where They are State-based competitive marketplaces where

individuals and small businesses can:individuals and small businesses can: ––Find information and compare health plansFind information and compare health plans ––Determine eligibility for tax credits for private insurance or Determine eligibility for tax credits for private insurance or

health programs like the Children’s Health Insurance Program health programs like the Children’s Health Insurance Program (CHIP)(CHIP)

––Easily enroll in a health insurance plan that meets their needs.Easily enroll in a health insurance plan that meets their needs. ••The Affordable Care Act and the proposed rules build a The Affordable Care Act and the proposed rules build a

number of important consumer protections into Exchanges.number of important consumer protections into Exchanges.

The material in this presentation should not be viewed as having any independent legal effect, or relied The material in this presentation should not be viewed as having any independent legal effect, or relied upon as an interpretation or modification of the related proposed rule or statute. Not all issues or upon as an interpretation or modification of the related proposed rule or statute. Not all issues or exceptions are fully addressed. exceptions are fully addressed.

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Immediate Bridge Programs to Immediate Bridge Programs to Increase Access to InsuranceIncrease Access to Insurance

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Pre-Existing Condition Insurance PlansPre-Existing Condition Insurance Plans The Pre-Existing Condition Insurance Plan (PCIP):The Pre-Existing Condition Insurance Plan (PCIP):

• Administered by either your state or the U.S. Department of Administered by either your state or the U.S. Department of Health and Human ServicesHealth and Human Services

• Will provide a new health coverage option for you if you Will provide a new health coverage option for you if you have been uninsured for at least six months, you have a have been uninsured for at least six months, you have a pre-existing condition or have been denied health coverage pre-existing condition or have been denied health coverage because of your health condition, and are a U.S. citizen or because of your health condition, and are a U.S. citizen or are residing here legallyare residing here legally

Plans are active from Plans are active from 2010-20142010-2014• Will cover primary and Will cover primary and

specialty care, hospital specialty care, hospital stays, and prescription stays, and prescription drugsdrugs

• Won’t charge a higher Won’t charge a higher premium based on premium based on pre-existing conditionpre-existing condition

• Eligibility not based on Eligibility not based on incomeincome

Eligibility for PCIPEligibility for PCIP

A person applying for PCIP must:A person applying for PCIP must: Reside within the service area of the PCIP;Reside within the service area of the PCIP; Be a U.S. citizen or reside in the U.S. Be a U.S. citizen or reside in the U.S.

legally;legally; Have been without health coverage for a Have been without health coverage for a

minimum of 6 months before applying; minimum of 6 months before applying; and and

Have a pre-existing condition, as defined Have a pre-existing condition, as defined by the PCIP and approved by HHSby the PCIP and approved by HHS

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PCIP Offers Comprehensive PCIP Offers Comprehensive BenefitsBenefits……

Care in medical offices for treatment of illness or Care in medical offices for treatment of illness or injuryinjury

Emergency servicesEmergency services Inpatient and outpatient hospital servicesInpatient and outpatient hospital services Inpatient and outpatient mental health and Inpatient and outpatient mental health and

substance abuse servicessubstance abuse services Prescription drugsPrescription drugs Home health care and hospice servicesHome health care and hospice services Outpatient laboratory and diagnostic servicesOutpatient laboratory and diagnostic services In- and out-of-network benefitsIn- and out-of-network benefits

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For more information on the Pre-existing For more information on the Pre-existing Condition Insurance Plan, please visit Condition Insurance Plan, please visit

http://www.pcip.gov

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Strengthening MedicareStrengthening Medicare

Strengthening Medicare: Strengthening Medicare: Closes the ‘donut hole’ Closes the ‘donut hole’ Provides better chronic care coordinationProvides better chronic care coordination Free preventive careFree preventive care Extends the life of the Medicare Trust Fund by Extends the life of the Medicare Trust Fund by

more than a decademore than a decade

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2011 Enrollment

Medicare Medicaid Children’s Health Insurance Program

48.6M• 36.7M Original Medicare • 11.9M Medicare Advantage• 35.6M get Part D Rx benefitso 29.4M in Part Do 6.2M through Retiree Drug

Subsidyo 10.7M low-income have drug

coverage

67M5M+

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Medicare Open EnrollmentMedicare Open Enrollment

New enrollment period – Oct. 15-Dec. 7New enrollment period – Oct. 15-Dec. 7 Star Ratings on Medicare.govStar Ratings on Medicare.gov CMS financial rewards for qualityCMS financial rewards for quality Medicare Advantage premiums 4% lowerMedicare Advantage premiums 4% lower Medicare Advantage projected enrollment Medicare Advantage projected enrollment

10% higher10% higher Average prescription drug plan premiums Average prescription drug plan premiums

will remain unchanged in 2012.will remain unchanged in 2012.

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Strengthening MedicareStrengthening Medicare

Medicare Advantage Proposed RuleMedicare Advantage Proposed Rule Implement the Donut Hole Discount Implement the Donut Hole Discount

ProgramProgram Expand part D coverageExpand part D coverage Raise Quality Standards for PlansRaise Quality Standards for Plans Expand Benefits for Dual EligiblesExpand Benefits for Dual Eligibles

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Durable Medical Equipment Durable Medical Equipment Competitive Bidding ProgramCompetitive Bidding Program

Reduce Out-of-Pocket ExpensesReduce Out-of-Pocket Expenses Save Medicare Program MoneySave Medicare Program Money Quality Accredited SuppliersQuality Accredited Suppliers

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Supporting Preventive Health CareSupporting Preventive Health Care

Preventive BenefitsPreventive Benefits Wellness Assessment and Prevention Wellness Assessment and Prevention

PlanPlan No deductibles or co-payments for:No deductibles or co-payments for:

• ““Welcome to Medicare” physical exam, Welcome to Medicare” physical exam, • bone mass measurement, bone mass measurement, • mammograms, mammograms, • pap test and pelvic exam,pap test and pelvic exam,• colorectal cancer screening colorectal cancer screening • medical nutrition therapy for individuals with medical nutrition therapy for individuals with

diabetes and kidney disease.diabetes and kidney disease. https://mymedicare.govhttps://mymedicare.gov

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Preventive BenefitsPreventive Benefits

Coverage for Screening and Coverage for Screening and Counseling for Alcohol MisuseCounseling for Alcohol Misuse

Screening for DepressionScreening for Depression

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Preventive Care Under Health Preventive Care Under Health Care LawCare Law

Comprehensive coverage of clinical preventive Comprehensive coverage of clinical preventive services for Americans will stop disease before its services for Americans will stop disease before its onsetonset

Provisions of Health Care Law to support access to Provisions of Health Care Law to support access to clinical preventive services:clinical preventive services:• Eliminates cost-sharing in Medicare for clinical preventive Eliminates cost-sharing in Medicare for clinical preventive

services recommended by the US Preventive Services services recommended by the US Preventive Services Task Force beginning 2011Task Force beginning 2011

• Increases FMAP funding by 1% for states that eliminate Increases FMAP funding by 1% for states that eliminate cost-sharing for clinical preventive services for Medicaid cost-sharing for clinical preventive services for Medicaid recipients in 2013recipients in 2013

• Requires health plans to eliminate cost-sharing for Requires health plans to eliminate cost-sharing for clinical preventive services, effective September 2010clinical preventive services, effective September 2010

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Million HeartsMillion Hearts

Improving Quality of Improving Quality of Health CareHealth Care

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CMS Transition StrategyCMS Transition Strategy

From From

Claims Payer Supporting Fragmented CareClaims Payer Supporting Fragmented Care

ToTo

Value Adding Partner Supporting Seamless Value Adding Partner Supporting Seamless Coordinated CareCoordinated Care

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Improving Health Care QualityImproving Health Care Quality

Value-based PurchasingValue-based Purchasing Focus on Hospital Acquired Focus on Hospital Acquired

ConditionsConditions Reducing Unnecessary Hospital Reducing Unnecessary Hospital

ReadmissionsReadmissions

10-12-1110-12-11

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Defining SuccessDefining Success

• Better Health Better Health

• Better Care Better Care

• Lower costLower cost

…….Through continuous improvement.Through continuous improvement

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Partnership for Patients: Partnership for Patients: Better Care, Lower CostsBetter Care, Lower Costs

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• On any given day, 1 out of every 20 patients in American hospitals is affected by a hospital-acquired infection.

• Among chronically ill adults, 22 percent report a “serious error” in their care.

• One out of seven Medicare beneficiaries is harmed in the course of their care, costing the federal government over $4.4 billion each year.

• Medical harm is the fourth leading cause of death in the U.S. Each year, 100,000 Americans die from preventable medical errors in hospitals– more than auto accidents, AIDS, and breast cancer combined.

• Despite pockets of success -- we still see massive variation in the quality of care, and no major change in the rates of harm and preventable readmissions over the past decade.

We can do much better – and we must.

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Partnership for Patients: Better Care, Lower Partnership for Patients: Better Care, Lower CostsCosts

GOALS:GOALS:1.1. Keep patients from getting injured or sicker.Keep patients from getting injured or sicker. By the end of 2013,  By the end of 2013,

preventable hospital-acquired conditions would preventable hospital-acquired conditions would decrease by 40%decrease by 40%.  . 

This would mean approximately 1.8 million fewer injuries to This would mean approximately 1.8 million fewer injuries to patients with more than patients with more than 60,000 lives saved60,000 lives saved over the next three over the next three years.years.

2. 2. Help patients heal without complication.Help patients heal without complication. By the end of 2013,  By the end of 2013, preventable complications during a transition from one care setting to preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be another would be decreased so that all hospital readmissions would be reduced by 20%reduced by 20%. . 

This would mean more than This would mean more than 1.6 million patients would 1.6 million patients would

recoverrecover from illness without suffering a preventable from illness without suffering a preventable complication requiring re-hospitalization within 30 days of complication requiring re-hospitalization within 30 days of discharge.discharge.

Potential to save up to $35 billion dollars over Potential to save up to $35 billion dollars over three years.three years.

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How to Get Involved!How to Get Involved! Join the Partnership for Patients – Sign the Join the Partnership for Patients – Sign the

Pledge!Pledge!

Go to www.healthcare.gov/partnershipforpatientsGo to www.healthcare.gov/partnershipforpatients

Accountable Care Organizations Accountable Care Organizations

Final RegulationFinal Regulation Coordinated CareCoordinated Care Medicare Shared Savings ProgramMedicare Shared Savings Program Advance Payment ModelAdvance Payment Model

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Advanced Primary Care Advanced Primary Care Practice DemonstrationPractice Demonstration

Health centers rewarded for quality Health centers rewarded for quality of care of care

Medical homeMedical home Coordinated careCoordinated care Impact on acute care setting and Impact on acute care setting and

costscosts

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Other HHS NewsOther HHS News Adult Protective Services Resource Adult Protective Services Resource

CenterCenter Nutrition and Aging Resource CenterNutrition and Aging Resource Center Go4Life – NIA CampaignGo4Life – NIA Campaign

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Other Resources:Other Resources: Healthcare.gov – Healthcare.gov –

www.healthcare.gov

HHS Web site – HHS Web site – www.hhs.gov

Medicare.gov Medicare.gov http://www.medicare.gov or 1-800-Medicare or 1-800-Medicare

The Center for Consumer Information & Insurance OversightThe Center for Consumer Information & Insurance Oversighthttp://cciio.cms.gov

CMS Innovations CenterCMS Innovations Centerhttp://innovations.cms.gov

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