health care shalls in the affordable care act

8/6/2019 Health Care Shalls in the Affordable Care Act

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CareDeliveryRequirements,

ProvisionsandAgendasfromthe

AffordableCareAct

Presentation to the

Alliance of Community Health PlansMarch 21, 2011


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The new Health Care Reform Bill

(ACA) is often described as a billthat is focused exclusively on

insurance issues.

That is inaccurate.


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The bill explicitly and very directly mandatesmore than eighty specific care delivery, care

quality and care effectiveness programs,functions, goals and measurements. The bill alsosets up a number of programs designed to help

caregivers improve care.

The following slides outline ACA care provisions.


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MandatesNationalQualityPlan

The bill requires the HHS Secretary to develop a

NationalStrategytoImproveHealthCareQualitytoimprove health outcomes and efficiency, identify areasfor improvement, address gaps in comparative

effectiveness information and data gathering, and

improve research and dissemination of best practices.

The national health care quality plan and strategymust be updated annually.

ACA

PROVISION

RELATING

TO

CARE


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RequiresQualityMeasurementstoTrack

Annual

Quality

Strategy

The bill requires the Secretary in conjunction with

AHRQ and CMS to develop quality measures conforming

to the National Quality Strategy The Secretary must

develop, and periodically update providerlevel outcome

measures for hospitals and physicians, including:

ACAPROVISIONRELATINGTOCARE


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Acute

and

Chronic

Care

Disease

Measures

Bill requires the development of 10 specific high

value outcome measurements for acute care and

chronic diseases by March 2012, for the country.



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PrimaryandPreventiveCareMeasures

Bill requires the development of 10 outcome

measurements for both primary care and

preventive care by March 2013 for the country.



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ReducesHospital AcquiredInfections

PenalizesWorstHospitals

Reduces Medicare payments to hospitals for

hospitalacquired conditions, hospital acquiredinfections, and preventable readmissions; imposes

monetary penalty on hospitals with the worst rates

of hospitalacquired conditions.



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CreatesMedicaidHealthQualityMeasures

Establishes Medicaid Quality Measurement Program,

requiring state Medicaid plans to report on state

specific health quality measures, as determined by theHHS Secretary; requires HHS Secretary to test,

validate, and develop the quality measures.



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CreatesQualityMeasuresforLong Term

Care,RehabandHospice

Creates a quality measures reporting system for

longterm care hospitals, inpatient rehabilitationfacilities, cancer hospitals, and hospice programs.



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CoordinatesQualityWorkfor23Federal

Departments

Creates an Interagency Working Group on Health

Care Quality to coordinate quality activities across23 federal departments.



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PaysHospitalsforPerformanceLevelsfor

MultipleConditions

Promotes valuebased purchasing in Medicare by

paying hospitals based on performance on qualitymeasures for common and highcost conditions,

including acute myocardial infarction, heart failure,

pneumonia, surgeries, and healthcare associated

infections. (On or after October 1, 2012.)



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VariesPhysicianPaymentsBasedonthe

QualityofCare

Modifies the Medicare physician fee schedule to

incorporate payments that vary based on the quality

of care provided. The modifier will be applicable to

specific physicians and physician groups, as

determined by HHS, beginning January 1, 2015, and

will apply to all physicians and physician groupsstarting January 1, 2017.



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BestPracticeDisseminationandUse

Develops a collaborative of health care institutions

responsible for developing, documenting and

disseminating best practices; implementing best

practices within institutions to demonstrateimproved quality, efficiency; and providing

assistance to other health care institutions on how

to employ best practices and proven care methods.



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NewModelsforBetterEmergencyCare

Directs the HHS Assistant Secretary for

Preparedness and Response to award grants to pilot

projects that design, implement, and evaluate new

models for emergency care. Funds emergencymedicine research, pediatric emergency medicine

research to improve trauma center capacity.



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ConsumerPortalWebsite

Creates a website, HealthCare.gov, to educate

consumers about the Affordable Care Act

including insurance coverage options andinformation on health care quality and preventive

care.



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ExtendsPhysicianQualityIncentives

Extends the Physician Quality Reporting Initiative,

a program that makes incentive payments to

physicians who report quality measures data toMedicare.



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CreatesClinicalEffectivenessInstitute

Establishes the PatientCentered OutcomesResearch Institute that will conduct research

comparing clinical effectiveness, appropriateness,

and processes used for medical treatments and

procedures. The Institutes research will assist

patients, providers, purchasers, and policy makers

in making informed health decisions based on

continuously improving the delivery of health care,fully informed by data about the effectiveness of

various approaches to care.



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UsesMedicareDatabaseForQuality

Measurements

Directs the HHS Secretary to make standardized

extracts of Medicare claims data available toqualified entities for analysis of provider and

supplier performance on quality, efficiency, and

effectiveness.



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ImprovesHome BasedCarefor

PatientswithMultipleConditions

Establishes the CommunityBased Care

Transitions Program to improve homebasedchronic care management for Medicare

beneficiaries with multiple chronic conditions.



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CreatesHomeCareServicesforCertain

MedicaidPatients

Creates the Community First Choice Option, which

gives states the ability to offer home andcommunitybased attendant services to certain

Medicaid beneficiaries.



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CreatesCollaborativeCareNetwork

Establishes the CommunityBased Collaborative

Care Network Program to support providers

that work collaboratively to coordinate care forlowincome and underinsured populations.



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CreatesInterdisciplinaryCareTeams

Establishes interdisciplinary community health

teams, created by grants and contracts to eligible

organizations from the HHS Secretary, to facilitatecollaboration between primary care providers and

communitybased prevention, patient education,

and other resources.



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CoordinatesCareforDualEligibles

Creates the Federal Coordinated Health CareOffice, a new office within the Centers forMedicare and Medicaid Services to improvecoordination of care for dual eligibles individuals who qualify for both Medicare andMedicaid coverage.



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CreatesNationalCongenitalHeartCare

TrackingProgram

Creates a National Congenital Heart Disease

Surveillance System to track epidemiologicaldata on heart disease and identify areas forprevention and outreach.



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EstablishesCentersofExcellenceForDepression

Establishes Centers of Excellence for Depression a network of organizations developing and

implementing evidencebased treatment andprevention standards; fostering communicationwith stakeholders; leveraging communityresources; and promoting use of electronic health

records to coordinate and manage treatment ofdepressive disorders.



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CreatesNationalDiabetesReportCard

Creates a National Diabetes Report Card:

biennial, publiclyavailable report of aggregate

prevention, quality of care, risk factors, andoutcomes data for diabetic patients.



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EstablishesBundlingorEpisodeof

Care PaymentDemonstrationProjects

Establishes a national pilot program by 2013 to

improve patient care and reduce Medicare costsby bundling payments for episodes of care.



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FocusesonImprovingHospitalUtilizationforMedicare

Extends the Medicare Hospital Gainsharing

Demonstration, which evaluates arrangementsbetween hospitals and providers aimed at

improving utilization of inpatient hospital

resources.



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EstablishesAccountableCareOrganizations(ACOs)forMedicare

Beneficiaries

Allows for the creation of Accountable CareOrganizations (ACOs), brining together groups ofMedicare providers that voluntarily meet qualitythresholds and standards and allowing the ACO

providers to share in collective cost savings forthe patients they serve.



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EstablishesPediatricAccountableCare

Organizations

Establishes a demonstration project for pediatric

ACOs.



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ProvidesIn HomeCareforHighNeed

MedicarePatients

Creates an Independence at Home demonstration

program to provide inhome primary careservices for highneed Medicare patients. Allows

providers to share in cost savings.



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CreatesNationalPrevention,Health

ImprovementandPublicHealthCouncils

Establishes National Prevention, Health Promotionand Public Health Councils to coordinate federal

public health activities; fund prevention and public

health programs; and develop evidencebased

recommendations on the use of clinical and

community preventive services.



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CreatesOfficeofWomensHealth

Establishes an Office of Womens Health with amandate for helping improve health care inAmerica for women.



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CreatesOfficeofMinorityHealth

Establishes programs to improve health and

care for minority populations.



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CreatesNationalEmergencyCareCorps

Establishes a Regular Corps and a Ready

Reserve Corps of trained caregivers available

and ready to serve in national emergencies.



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CreatesFundToInvestInPublicHealth

ImprovementPrograms

Establishes a Prevention and Public Health Fund (PPHF)

to invest in prevention and public health programs with

the goal of improving health and slowing the rate of

growth in health care costs.



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EliminatesCost SharingforPreventive

Services

Eliminates costsharing for a defined list ofmedically appropriate preventive services.



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ProvidesGrantsforTobaccoCessation,

Weight

Control,

Health

Participation

Awards grants to states for programs that

incentivize Medicaid beneficiary participation intobacco cessation, weight control, and other

health promotion programs to help prevent or

manage chronic disease.



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CreatesaProgramtoStabilizePatients

withEmergencyPsychiatricConditions

Creates a Medicaid demonstration program

requiring states to reimburse qualified mental

health care institutions for services to stabilize

Medicaid beneficiaries experiencing an

emergency psychiatric condition.



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RequiresHospitalCommunityNeeds

Assessments

Requires nonprofit hospitals to conduct

community needs assessments, taking intoaccount input from the community served by the

hospital, and adopt implementation strategies to

meet identified needs.



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PromotesEmployer BasedWellness

Programs

Promotes employerbased wellness

programs by providing technical assistance,implementation support, and grants to smallemployers.



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IncreasesFundingforCommunity

HealthCenters,SchoolHealthCosts

Increases funding and provides direction to

the National Health Service Corps, communityhealth centers, schoolbased health centers,and nursemanaged clinics.



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StreamlinesAccesstoLongTermCarefor

ElderlywithDisabilities

Supports Aging and Disability Resource Centers

aimed at streamlining access to longterm carefor the elderly and people with physical, mental,

or developmental disabilities.



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Evidence BasedCancerProgram

Creates an evidencebased national education

campaign to increase awareness about breast

cancer prevention and treatment.



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CreatesDeliveryModelInnovations

Creates a new Center for Medicare and Medicaid

Innovation (CMMI) within CMS to test and

evaluate payment and service delivery models that

reduce costs and maintain or improve quality of

care.



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PromotesandEvaluatesMedicalHomes

Patientcentered medical homes will be evaluated inprimary care settings with the goal of providing

coordinated team care to patients with multiplehealth conditions.



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CreatesDirectContractingPilots

Creates pilot programs to test direct contractingmodels with providers, services and suppliers to

reduce the costs of care and make the unit costsof care more affordable.



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TestsComprehensiveCarePlansand

GeriatricAssessmentTools

Creates pilot programs to test the effectiveness

of utilizing geriatric assessments andcomprehensive care plans to coordinate care for

patients with multiple chronic conditions.



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Salary BasedCareGiverPilotPrograms

Promoting care coordination between providers

and suppliers to facilitate the transition away

from pure feeforservice reimbursement andtoward salarybased payment approaches for

key caregivers.



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CreatesCareSupportToolsBuiltOnHealthCareITCapabilities

Pilot will test supporting care coordination for

chronically ill patients through the use of healthITenabled provider networks, including care

coordinators, a chronic disease registry, layers of

caregiver/patient connectivity and home

telehealth technology.



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TestsPaymentModelsBasedon

Appropriateness

of

Service

Adjusts payment methodologies to

physicians ordering diagnostic imagingservices based on the medical

appropriateness of the service ordered.



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EvaluatesTherapyManagementApproaches

Establishes programs to evaluate medication therapymanagement services intended to improve patientuse of medication.



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AssistingPrimaryCareDoctorswith

ChronicCareManagement

Establishing communitybased health teams that

function to assist primary care providers inchronic care management for patients whose

medical conditions require team care.



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FacilitatesBetterInformedPatient

Choices

Establishes pilot programs to assist patients in

making informed health care choices by payingproviders for using patient decisionsupport tools.



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AllowsStateInnovationforDual

EligiblePrograms

Allows states to test and evaluate models for the

integration of care for dual eligibles.



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TestsAllPayerFeeApproaches

ACA allowing states to test and evaluate systems

of allpayer payment reform.



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PromotesEvidence BasedCancerCareApproaches

Promotes the alignment of evidencebasedguidelines of cancer care with payment incentivesfor professional treatment planning and optimalfollowup care.



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CoordinatesPostAcuteCare

Establishes pilots to improve postacute carethrough continuingcare hospitals, longtermcare hospitals, home health, and skilled nursing

care to improve patient health status after ahospital discharge.


ACA PROVISION RELATING TO CARE


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HomeHealthforChronicCare

Sets up pilots to fund home health providers ofchronic care management services to help

improve team care for chronic care patients.




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SupportsElectronicMonitoringby

Specialists

Supports improvements in inpatient care through

the use of modern, patient focused electronicmonitoring by specialists.




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SupportsDirectReferralsforOutpatient

Services

Pilot will test efficiency and access to outpatient

services though models that do not require aproviders referral for the service.




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TestsHealthcareInnovationZone

PaymentApproaches

Establishes Healthcare Innovation Zone payment

pilots teaching hospitals, groups of providers, and

other clinical entities that, through their structure,deliver integrated and comprehensive health

services while incorporating innovative methods for

the clinical training of future healthcareprofessionals.




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EstablishesNewTherapiesTaxCredit

Provides an Encouraging Investment in New

Therapies tax credit to encourage investments in

new therapies to prevent and diagnose acuteand chronic diseases.




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CreatesCuresAccelerationNetwork

Establishes the Cures Acceleration Network in

the Office of the Director of NIH that will award

grants and contracts to accelerate thedevelopment of products and therapies to cure

certain highneed conditions.




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FostersTeamManagementofMedications

Award grants and contracts to implement

collaborative medication management services,

where pharmacists and other providers would

formulate treatment plans, prevent adverse drug

interactions, and educate patients and caregivers

on the management of chronic diseases.




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CreatesBiosimilarLicensing

Establishes a formal licensing process for

approving biosimilar therapeutics, with data

exclusivity periods.




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EncouragesMalpracticeLitigation

Alternatives

Awards fiveyear demonstration grants to states

to develop, evaluate, and implement alternativesto current medical malpractice litigation.

C OV S O G O C



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CreatesComparativeDatabasefor

PhysicianPerformance

Creates Physician Compare, a webaccessible

database of performance, effectiveness, safety andother assessments of providers who participate in

Medicare Physician Quality Reporting Initiative.



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RequiresFinancialDisclosureswith

ProvidersandSuppliers

Requires open disclosure of financial

relationships between hospitals, providers, andmanufacturers and distributors of drugs andmedical devices.



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CreatesOwnershipTransparency

Requirements

Requires Medicare and Medicaid nursing

facilities to disclose ownership, expenditure andcertification information.



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CreatesEnhancedDatabaseonPatient

Populations

Requires enhanced collection and reporting ofpatient population data on race, ethnicity, sex,

primary language and disability status in allfederally conducted or supported health care orpublic health programs.



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CreatesNationalOfficeofHealth

InformationTechnology

Formally establishes the Office of the National

Coordinator for Health Information Technologyto oversee development and support for a

national health information network.



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StrengthensDataPrivacy

Strengthens health information privacy and

security standards.



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ProvidesFinancialSupportforHealth

CareITAdoption

Authorizes grants to assist state and local

governments and health care providers inadopting and using health IT.



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CreatesMeaningfulUse RequirementsforHealthCareIT

Provides financial incentives under Medicare andMedicaid to encourage hospitals, physicians andhealth professionals to become meaningful users

of health IT by using certified electronic healthrecord technology in ways that allow theelectronic exchange of information to improvehealth care delivery competency and quality.



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CreatesHealthCareWorkforceCommission

Establishes a national Health Care WorkforceCommission of 15 members, appointed by the U.S.Government Accountability Office, to develop a

national health care workforce strategy.



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IncreasestheNumberofNurses

Increases the nurse workforce though training

programs, loan repayment and retention grants.



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RefocusesGraduateMedicalEducation

Priorities

Redistributes unused Graduate Medical

Education training positions toward primarycare, general surgery, and medicallyunderserved geographic areas.



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SupportsRecruitmentofProviderstoRuralAreas

Provides bonus payments and grants forrecruitment and training of providers to serve inrural and underserved areas.



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SupportsDeliveryReformInitiatives

Supports development of training programs

focused on prevention, public health, primary

care, medical homes, team management ofdisease, and integration of mental and physical

health services.

StageOneGuaranteedIssue


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BillCreatesImmediateAccesstoGuaranteedCoverageforHighRiskPatients

inEveryState

Guaranteed coverage can be a quality of careissue. Every state now has in place a PCIP (pre

existing condition insurance program) run by thestate or the federal government. No one inAmerica is uninsurable right now. High risk

patients can now get coverage therebyimproving the likelihood that high risk patientswill receive better care.


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Stage Two Guaranteed Issue

Stage Two for insurance access willhappen in 2014 when all health planswho sell individual coverage will be

open to all applicants.


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Most of the provisions of the Affordable

Care Act deal with the provision of care.

Less than 25 percent of the provisions dealwith the role and function of insurance.

The two sets of provisions are related

because care will not be affordable until itis improved, and people without coverage

can not get access to quality care.

health care shalls in the affordable care act

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