innovation, health system transformation and the affordable...
TRANSCRIPT
Innovation, Health System Transformation and the Affordable Care Act
Barbara Connors, D.O.,M.P.H.
Chief Medical Officer, Region III
ACA Provisions:
Quality and Efficiency of Care
• Emphasize Prevention and Promote Primary Care • Expand quality measurement including outcomes and efficiency • Expand settings covered by quality reporting and public reporting programs • Value Based Purchasing
– Base payment in part on quality • Hospital Value Based Purchasing • Physician Value Modifier
• Address specific quality issues – Hospital readmissions – Health disparities – Health Care Associated Conditions
• Introduce New Care Models – ACO – program – Multiple Demonstrations and pilots (CMMI)
• Bundled payment • Medical Home
– Pays for care that rewards better value, patient outcomes, and innovations,
instead of just volume of services
Key Messages About Value Based Purchasing
A major, overarching theme in the Affordable Care Act is one of measurement, transparency, and altering payment to reinforce, not simply volume of services, but the quality of the affects of those services.
Instead of payment that asks “How much did you do?” the
Affordable Care Act clearly moves us toward payment that asks, “How well did you do?” and more importantly, “How well did the patient do?”
-- Don Berwick, April 11, 2011
Value-Based Purchasing
• Goal is to reward providers and health systems that deliver better outcomes in health and health care at lower cost to the beneficiaries and communities they serve.
• Hospital value-based purchasing program shifts approximately $1 billion based on performance
• Five Principles
- Define the end goal, not the process for achieving it
- All providers’ incentives must be aligned
- Right measure must be developed and implemented in rapid cycle
- CMS must actively support quality improvement
- Clinical community and patients must be actively engaged
VanLare JM, Conway PH. Value-Based Purchasing – National Programs to Move from Volume to Value. NEJM July 26, 2012
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Transformation of Health Care at the Front Line
• At least six components
– Quality measurement
– Aligned payment incentives
– Comparative effectiveness and evidence available
– Health information technology
– Quality improvement collaboratives and learning networks
– Training of clinicians and multi-disciplinary teams
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Source: P.H. Conway and Clancy C. Transformation of Health Care at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5
CMS framework for measurement maps to the six national priorities
Greatest commonality of measure concepts across domains
– Measures should be patient-centered and outcome-oriented whenever possible
– Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures
Person- and Caregiver- centered experience and
engagment
•CAHPS or equivalent measures for each settings •Shared decision-making
Efficiency and cost reduction
•Spend per beneficiary measures •Episode cost measures •Quality to cost measures
Care coordination
•Transition of care measures •Admission and readmission measures •Other measures of care coordination
Clinical quality of care
•HHS primary care and CV quality measures •Prevention measures •Setting-specific measures •Specialty-specific measures
Population/community health
•Measures that assess health of the community •Measures that reduce health disparities •Access to care and equitability measures
Safety
•Healthcare Acquired Infections •Healthcare acquired conditions • Harm
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Hospital Quality
•Medicare and Medicaid EHR Incentive Program
•PPS-Exempt Cancer Hospitals
•Inpatient Psychiatric Facilities
•Inpatient Quality Reporting
•HAC payment reduction program
•Readmission reduction program
•Outpatient Quality Reporting
•Ambulatory Surgical Centers
Physician Quality Reporting
• Medicare and Medicaid EHR Incentive Program
• PQRS
• eRx quality reporting
• Value Based Modifier
• Physician Compare
PAC and Other Setting Quality Reporting
• Inpatient Rehabilitation Facility
• Nursing Home Compare Measures
• LTCH Quality Reporting
• Hospice Quality Reporting
• Home Health Quality Reporting
Payment Model Reporting
• Medicare Shared Savings Program
• Hospital Value-based Purchasing
• Physician Feedback/Value-based Modifier*
• ESRD QIP
“Population” Quality Reporting
•Medicaid Adult Quality Reporting*
• CHIPRA Quality Reporting*
• Health Insurance Exchange Quality Reporting*
• Medicare Part C*
• Medicare Part D*
CMS has a variety of quality reporting and performance programs
Tools CMS is Using to Motivate Hospital Quality Improvement
• Beginning 2013, hospitals will receive payment reduction if excess 30 day readmission for MI, CHF, pneumonia
• Beginning 2015, hospitals with high rates of HACs will receive further payment reductions
• By 2015, most hospitals will face payment reductions if they do not meaningfully use health information technology
• Partnership for Patients. CMS will provide $1 billion in support to improve care within hospitals, and to improve care transitions
500M through Community Based Care Transitions
Up to 500 M from CMS Innovation Center for demonstrations to reduce HACs
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Hospital VBP Program
• Required by the Affordable Care Act
• Built on the Hospital Inpatient Quality Reporting measure reporting infrastructure
• Next step in promoting higher quality care for Medicare beneficiaries
• Rewards better value, patient outcomes, and innovations, instead of just volume of services
• Funded by a 1.25% withhold from participating hospitals’ Diagnosis-Related Group payments (FY2014)(-->2.0% by FY2017)
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12 Clinical Process of Care Measures 8 Patient Experience of
Care Dimensions
1. Nurse Communication
2. Doctor Communication
3. Hospital Staff Responsiveness
4. Pain Management
5. Medicine Communication
6. Hospital Cleanliness & Quietness
7. Discharge Information
8. Overall Hospital Rating
1. AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
2. AMI-8 Primary PCI Received Within 90 Minutes of Hospital Arrival
3. HF-1 Discharge Instructions
4. PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
5. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient
6. SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
7. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
8. SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
10. SCIP–Inf–9 Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2.
11. SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
12. SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours
5 Outcome Measures
1. MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day mortality rate
2. MORT-30-HF Heart Failure (HF) 30-day mortality rate
3. MORT-30-PN Pneumonia (PN) 30-day mortality rate
4. PSI-90 Patient safety for selected indicators (composite)
5. CLABSI Central Line-Associated Blood Stream Infection
Represents a new measure for the FY 2015 program not in the FY 2014 program.
Domain Weights
Clinical Process of Care, 20%
Patient Experience of
Care, 30%
Outcome, 30%
Efficiency, 20%
1 Efficiency Measure
1. MSPB-1 Medicare Spending per Beneficiary measure
FY 2015 Finalized Domains and Measures/Dimensions
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Hospital-Acquired Condition (HAC) Reduction Program
• Public reporting of each hospital’s HAC rates in Hospital Compare by 2015
• Adjustment to payments for HAC, FY 2015 – Section 3008 of the Affordable Care Act
– 1% decrease for high rates (risk adjusted)
– top quartile compared to national average
• Methodology in FY2014 IPPS Final Rule – (CMS-1599-F , Federal Register 08/19/2013 )
Hospital Readmissions Reduction Program
• Required by Section 3025 of the 2010 Affordable Care Act • Requires Secretary to establish a Hospital Readmissions
Reduction Program which – Reduces Inpatient Prospective Payment System (IPPS)
payments to hospitals for excess readmissions – For discharges on or after October 1, 2012 (Fiscal Year
[FY] 2013) • Requires initial adoption of the National Quality Forum-
endorsed 30-day Risk-Standardized Readmission measures: – acute myocardial infarction (AMI), – heart failure (HF), – pneumonia
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Payment Adjustment
• Based on readmissions for AMI, HF and Pneumonia
• In FY2015, 2 conditions will be added (COPD, Total Hip/Knee Arthroplasty)
• Applies to hospital’s base DRG payments for Medicare discharges starting October 1, 2012 – FY 2013 no more than 1% reduction – FY 2014 no more than 2% reduction – FY 2015 no more than 3% reduction – Calculation methodology finalized in rule-making
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• Publicly-reported (NQF endorsed)—Since July 2009
• Acute myocardial infarction • Heart failure • Pneumonia 2015: COPD, Total Hip/Knee Arthroplasty
• Development completed
• Percutaneous coronary intervention (registry) • Stroke • Vascular procedures • Hospital-wide readmission
• In development
• Coronary artery bypass graft
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Current CMS Readmission Measures
William Osler, M.D. (1849 – 1919)
“We know more and enjoy larger opportunities and with them have greater responsibilities, but could Hippocrates return he would find no change in those essential duties in which he is still our great exemplar.”
THE EVOLUTION OF INTERNAL MEDICINE. IN MODERN MEDICINE: ITS THEORY AND PRACTICE. PHILADELPHIA: LEA BROTHERS, 1907:34.
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• PQRS
• HITECH incentive payments
• Physician Value Modifier
• Medical Home
Comprehensive Primary Care Initiative (CPCI)
• Multi-Payer Advanced Primary Care Practice Model (MAPCP)
• ACO’s
• Federally Qualified Health Center Advanced Primary Care Demonstration
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Physician/Provider Value Based Purchasing
Eligibility 19
PQRS Value Modifier EHR Incentive Program
Eligible for
Incentive
Subject to
Payment
Adjustment
Included in
Definition
of “Group” (1)
Subject to
VM (2)
Eligible for
Medicare
Incentive(3)
Eligible for
Medicaid
Incentive (4,5)
Subject to Medicare
Payment
Adjustment (7,8)
Medicare Physicians
Doctor of Medicine X X X X X X X
Doctor of Osteopathy X X X X X X X
Doctor of Podiatric Medicine X X X X X X
Doctor of Optometry X X X X X X
Doctor of Oral Surgery X X X X X X X
Doctor of Dental Medicine X X X X X X X
Doctor of Chiropractic X X X X X X
Practitioners
Physician Assistant X X X X (6)
Nurse Practitioner X X X X
Clinical Nurse Specialist X X X
Certified Registered Nurse
Anesthetist (10) X X X
Certified Nurse Midwife X X X X
Clinical Social Worker X X X
Clinical Psychologist X X X
Registered Dietician X X X
Nutrition Professional X X X
Audiologists X X X
Therapists
Physical Therapist X X X
Occupational Therapist X X X
Qualified Speech-Language
Therapist X X X
2014 Incentives and 2016 Payment Adjustments 20
PQRS Value Modifier
EHR Incentive Program
Incentive Pay Adj. Groups of 10+
EPs Medicare
Inc. Medicaid
Inc. Medicare Pay Adj.
Practitioners
Physician Assistant
0.5% of MPFS
-2.0% of MPFS
EPs included in the definition of “group” to determine group size for application of the value modifier in 2016 (10 or more EPs); VM only applied to reimbursement of physicians in the group
N/A
$8,500 or $21,250 (based on when EP did A/I/U)
N/A
Nurse Practitioner
Clinical Nurse Specialist N/A
Certified Registered Nurse Anesthetist
Certified Nurse Midwife $8,500 or $21,250 (based on when EP did A/I/U)
Clinical Social Worker
N/A
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologits
Therapists
Physical Therapist 0.5% of MPFS
-2.0% of MPFS
See above
N/A N/A N/A Occupational Therapist
Qualified Speech-Language Therapist
PQRS Measures
• Smoking Cessation Adults and Adolescents
• Asthma Measures
• COPD Measures
• COPD Measures Group
• Sleep Apnea Measures Group
• Asthma Measures Group
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Value-Based Payment Modifier (VM)
• Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS)
• VM assesses both quality of care furnished and the cost of that care under the
Medicare Physician Fee Schedule
• For CY 2015, CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs)
• For CY 2016, CMS will apply the VM to groups of physicians with 10 or more EPs • Phase-in to be completed for all physicians by 2017
• Implementation of the VM is based on participation in Physician Quality Reporting
System
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What is Meaningful Use?
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Meaningful Use is using certified EHR technology to
• Improve quality, safety, efficiency, and reduce health
disparities
• Engage patients and families in their health care
• Improve care coordination
• Improve population and public health
• All the while maintaining privacy and security
Meaningful Use mandated in law to receive
incentives
Meaningful Use Core Objectives
1. Use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders
2. Generate and transmit permissible prescriptions electronically (eRx)
3. Record demographic information
4. Record and chart changes in vital signs
5. Record smoking status for patients 13 years or older
6. Use clinical decision support to improve performance on high-priority health conditions
7. Provide patients the ability to view online, download and transmit their health information (PATIENT ENGAGEMENT)
8. Provide clinical summaries for patients for each office visit
9. Protect electronic health information created or maintained by Certified EHR Technology
10. Incorporate clinical lab-test results into Certified EHR Technology
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach
12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care
13. Use certified EHR technology to identify patient-specific education resources
14. Perform medication reconciliation
15. Provide summary of care record for each transition of care or referral (ELECTONIC EXCHANGE)
16. Submit electronic data to immunization registries
17. Use secure electronic messaging to communicate with patients on relevant health information (PATIENT ENGAGEMENT)
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Meaningful Use Core Objectives
1. Use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders
2. Generate and transmit permissible prescriptions electronically (eRx)
3. Record demographic information
4. Record and chart changes in vital signs
5. Record smoking status for patients 13 years or older
6. Use clinical decision support to improve performance on high-priority health conditions
7. Provide patients the ability to view online, download and transmit their health information (PATIENT ENGAGEMENT)
8. Provide clinical summaries for patients for each office visit
9. Protect electronic health information created or maintained by Certified EHR Technology
10. Incorporate clinical lab-test results into Certified EHR Technology
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach
12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care
13. Use certified EHR technology to identify patient-specific education resources
14. Perform medication reconciliation
15. Provide summary of care record for each transition of care or referral (ELECTONIC EXCHNAGE)
16. Submit electronic data to immunization registries
17. Use secure electronic messaging to communicate with patients on relevant health information (PATIENT ENGAGEMENT)
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Support research and development of testing, user tools, and best practices related to health IT safety and its safe use
Incorporate safety into certification
Use Meaningful Use to improve patient safety
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2 • Improving: Targeting resources and
corrective actions to improve health IT safety and patient safety
William Edwards Deming (1900 – 1993)
“If you can't describe what you are doing as a process, you don't know what you're doing.”
The purpose of the [Center] is to test innovative
payment and service delivery models to reduce
program expenditures…while preserving or
enhancing the quality of care furnished to
individuals under such titles.
- The Affordable Care Act
The CMS Innovation Center
Identify, Test, Evaluate, Scale
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Innovation is happening broadly across the country
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CMS Innovations Portfolio
Accountable Care Organizations (ACOs)
• Medicare Shared Savings Program (Center for
Medicare)
• Pioneer ACO Model
• Advance Payment ACO Model
• Comprehensive ERSD Care Initiative
Primary Care Transformation
• Comprehensive Primary Care Initiative (CPC)
• Multi-Payer Advanced Primary Care Practice (MAPCP)
Demonstration
• Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice Demonstration
• Independence at Home Demonstration
• Graduate Nurse Education Demonstration
Bundled Payment for Care Improvement
• Model 1: Retrospective Acute Care
• Model 2: Retrospective Acute Care & Post Acute
• Model 3: Retrospective Post Acute Care
• Model 4: Prospective Acute Care
Capacity to Spread Innovation
• Partnership for Patients
• Community-Based Care Transitions Program
• Million Hearts
Health Care Innovation Awards (Rounds 1 & 2)
State Innovation Models Initiative
Initiatives Focused on the Medicaid Population
• Medicaid Emergency Psychiatric Demonstration
• Medicaid Incentives for Prevention of Chronic Diseases
• Strong Start Initiative
Medicare-Medicaid Enrollees
• Financial Alignment Initiative
• Initiative to Reduce Avoidable Hospitalizations of
Nursing Facility Residents
Heart disease and strokes are leading killers in the U.S.
• Cause 1 of every 3 deaths
• Over 2 million heart attacks and strokes each year
– 800,000 deaths
– Leading cause of preventable death in people < 65
• Treatment accounts for ~ $1 of every $6 spent
• Greatest expression of racial disparities in life
expectancy
Status of the ABCS for CAD Prevention
Aspirin People at increased risk of cardiovascular
disease who are taking aspirin
47%
Blood pressure
People with hypertension who have
adequately controlled blood pressure
46%
Cholesterol
People with high cholesterol who have
adequately controlled hyperlipidemia
33%
Smoking People trying to quit smoking who get help
23%
Source: MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, 2011, Early Release, Vol. 60
New Payment Models for Primary Care
• Patient Care Models – The right care at the right time, in the right setting – every time
• Seamless Coordinated Care Models – Coordinating care to improve health outcomes for patients
• Community and Population Health Models – Keeping families and communities healthy
Bundled Payment Projects
• Testing three types of bundles: acute care, acute and post-acute, post acute alone
• Bundles cost of services for an episode of care with quality measures related to episode
• For example from hospitalization to 30/60/90 days post episode or some models are just bundled price for all hospitalization costs
• One of several CMMI projects to test innovative methods of care delivery to improve quality and reduce cost across episodes of care
• Test new payment models that have potential to reduce costs and improve quality for Medicare fee-for-service beneficiaries
• Offer a range of alternatives to determine market interest and meet providers where they are
• Drive redesign of acute and post-acute care to reduce variation in utilization
• Build operating capacity for CMS and providers to process episode-based payments
Goals of Bundled Payments for Care Improvement
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Primary Care
• Comprehensive Primary Care (CPC) Initiative
• Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
• Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
• Independence at Home
• Graduate Nurse Education Demonstration
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Bundled Payments for Care Improvement
Aligns payment for care as patients experience care
Removes barriers and provides opportunity for partnerships with providers and other stakeholders
Includes four distinct models for acute care, acute and post-acute care, and
post-acute care alone
Gives providers flexibility to determine conditions, length of episode, target
price/discount, other components of the initiative
Bundled Payments for Care Improvement
Initiative
Comprehensive primary care
Aim: Better health, Better care, Lower cost
Continuous improvement driven by data
Comprehensive primary care functions:
Risk-stratified care management
Access and continuity
Planned care for chronic conditions and preventive care
Patient and caregiver engagement
Coordination of care across the medical neighborhood
Enhanced, accountable payment
Optimal use of health IT
Su
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Practice and Payment Redesign through the CPC initiative
Graduate Nurse Education Demonstration
GOAL: To increase the provision of qualified training supply of to Advanced Practice Registered Nursing (APRN) students in order to provide access to primary care services for the increasing number of Medicare beneficiaries.
• 4 year demonstration where participating hospitals will be paid for the reasonable costs of the non-hospital community- based care setting clinical training component of the APRN degree requirements
• Hospitals must partner with schools of nursing and community-based care settings and can partner with other hospitals
• 5 hospitals participating
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Clinical Practice Leaders Have Already Charted the Pathway to Practice Transformation
Traditional Approach Patient’s chief complaints or reasons for visit determines care.
Care is determined by today’s problem and time available today.
Care varies by scheduled time and memory/skill of the doctor.
Patients are responsible for coordinating their own care.
Clinicians know they deliver high quality care because they are well trained.
It is up to the patient to tell us what happened to them.
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Transformed Practice We systematically assess all our patients’ health needs to plan care.
Care is determined by a proactive plan to meet patient needs.
Care is standardized according to evidence-based guidelines.
A prepared team of professionals coordinates a patient’s care.
Clinicians know they deliver high quality care because they measure it and make rapid changes to improve.
You can track tests, consults, and follow-up after the ED and hospital.
Adapted from Duffy, D. (2014). School of Community Medicine, Tulsa, OK.
Transforming Clinical Practice Initiative Model
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• Aligns with the criteria for innovative models set forth in the Affordable Care Act: – Promoting broad payment and practice reform in primary care and
specialty care
– Promoting care coordination between providers of services and suppliers
– Establishing community-based health teams to support chronic care management
– Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation
• Support clinician practices through 5 stages of practice transformation – Via Practice Transformation Networks, Support & Alignment Networks and
Quality Improvement Organizations
Transforming Clinical Practice Goals
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Support more than 150,000 clinicians in their practice transformation work
Improve health outcomes for millions of Medicare, Medicaid and CHIP beneficiaries and other patients
Reduce unnecessary hospitalizations for 5 million patients Generate $1 to $4 billion in savings to the federal government and commercial payers
Sustain efficient care delivery by reducing unnecessary testing and procedures
Build the evidence base on practice transformation so that effective solutions can be scaled
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Who might be a…
Practice Transformation Network (PTN)?
• Health Systems
• State Organizations
• Regional Extension Centers
• Quality Improvement Organizations
• Primary Care and/or Specialty Care Practices
• Small/Rural/Medically Underserved Practices
• And more!
Support and Alignment Network (SAN)?
• Medical Associations
• Professional Societies
• Foundations
• Patient and Consumer Advocacy Organizations
• University Consortiums
• And more!
43 Any entities with existing federal contracts, grants, or cooperative agreements would need to satisfy
both conflict of interest and duplication of effort specifications.
Marketplace
The Health Insurance Marketplace
• Mandated by the Affordable Care Act
• Provides a new avenue to coverage for individuals and small businesses
• Expands opportunity to provide primary care
– More people will be enrolled in private and public plans
– Increased access to preventive services for patients
• Protects physician ability to deliver essential care across patient populations
Coverage ACA
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The ACA requires individuals to have health insurance starting January 1, 2014 and prohibits insurers from denying coverage based on factors such as health status. Tobacco users can be charged up to 50% more for health insurance premiums than non-tobacco users in the individual or small group market ACA requires insurers in the small group market to waive the higher premium if smokers participate in a smoking cessation program.
Requirements for Qualified Health
Plans
Essential Health Benefits • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care
a. CMS website.[7]
Increased Contact Opportunity via
Preventive Services
Preventive Services Under the Affordable Care Act • Viewed as vital to mitigating high costs of preventable conditions
• New health insurance plans now required to cover recommended services without cost sharing (September 23, 2010)
– Annual wellness visits
– Other regularly scheduled recommended checks
• No cost sharing for preventive services under Medicare (January 1, 2011)
• No or low-cost preventive services for Medicaid beneficiaries (January 1, 2013)
a. HealthCare.gov.website.[17]
Coverage for Tobacco Cessation
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Tobacco cessation must be provided at no cost under most types of health insurance as of January 1, 2014. However, there is no single definition of tobacco cessation so the scope of coverage is likely to vary by state, by type of insurance (e.g., Medicare, Medicaid, private insurance), and by the insurance provider (e.g., Aetna, Blue Cross, etc.) For example, insurance may provide coverage for only some of the following elements: • Counseling: in-person (individual or group), via phone, or via the internet • Prescription cessation medications such as varenicline (Chantix) and buproprion (Zyban) • Over-the-counter nicotine replacement therapies (NRTs), such as nicotine patches or gum
ACA Compliance
• Non-grandfathered plans must cover preventive services that have received an A or B grade from the U.S Preventive Services Task Force. These services include tobacco cessation interventions.
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Compliance With ACA Requirement to Cover Tobacco
• Screening of all patients for tobacco use
• For enrollees who use tobacco products:
• at least two tobacco-cessation attempts per year, with coverage of each quit attempt including four cessation counseling sessions each 10 minutes long
• Any FDA approved tobacco cessation medications (whether prescription of over the counter) for a 90 day treatment regimen when prescribed by a health care provider
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Medicare and Medicaid Preventive Services
• In states with newly expanded Medicaid, new enrollees
• Traditional Medicaid must cover tobacco cessation for pregnant women
• Eliminates cost sharing for cessation treatments covered by Medicare
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Programs to Help Reduce Chronic Diseases
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• The Prevention and Public Health Fund– an investment of up to $2 billion per year in prevention, wellness, and public health activities including community-based tobacco prevention programs and the CDC’s Tips From Former Smokers campaign.
• The National Prevention Strategy – released by the National Prevention Council in 2011, the Strategy includes tobacco-free living as one of the seven main priorities.
• The Medicaid Incentives for Chronic Disease Prevention Program – through this grant program, states can apply for funds to incentivize Medicaid recipients to prevent chronic disease. Six states currently receive funding for tobacco cessation programs: California, Connecticut, New Hampshire, New York, Texas, and Wisconsin.
CMS Measures of Success
• Better care and lowers costs: Beneficiaries receive high quality, coordinated, effective, efficient care. As a result, health care costs are reduced.
• Improved prevention and population health: All Americans are healthier and their care is less costly because of improved health status resulting from use of preventive benefits and necessary health services
• Expanded health care coverage: All Americans have access to affordable health insurance options that protect them from financial hardship and ensure quality health care coverage.
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Contact Information
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Barbara J. Connors, DO, MPH Chief Medical Officer; Region III, CMS The Public Ledger Bldg. Rm. 272 650 Chestnut St. Philadelphia, Pa. 19106 (215) 861-4218 [email protected]