1

Patient Protection and Affordable Care Act (ACA)

Individual mandate (2014) State insurance exchanges Expansion of Medicaid program Changes to private insurance Employer requirements mandates Medicare changes

2

Untruthful Assertions Cuts Medicare by $1000 per person

Both ACA and the Ryan plan reduce increases in spending in the future by over $700 billion over 10 years

Establishes death panels Payment to physicians for holding advance care

planning discussions was cut from the Act

3

U.S. spending much more for older ages

Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009. 

4

5

Medicare Reduce payments to Medicare Advantage

MA plans were paid 113% of FFS Some bonuses for high quality programs

Balance payments to high/low areas Establishes an “Independent Payment

Advisory Board” Early donut hole relief – eventual elimination Coverage for prevention services

6

7

Independent Payment Advisory Board Recommend cost savings Produce public reports – access, quality, costs Make recommendations to President and

Congress Prohibited from “rationing” or “changing

benefits or eligibility” or “Medicare premiums” Hospitals and hospices not subject to

recommendations until 2019

8

Donut Hole Relief 2011 $250 rebate

255, 996 FL seniors received the rebate Total amount to FL seniors - $63,999,000

Part D coverage gap discounts 252,989 Ave. per senior - $600 Total amount - $151, 807,700

Kff.org, 1/7/13

9

Prevention & Wellness in FL Free preventive services

1,662,014 FL seniors received free services 70% of FL Part B enrollees (65.5% US)

Annual wellness visit 151,133 FL seniors had an annual wellness visit 6.9% of FL Part B enrollees (5.4% US)

Kff.org, 1/7/13

10

Older Adult Workforce Funds Geriatric Education Centers Expand Geriatric Academic Career Award to

other disciplines (nursing, pharmacy, etc.) New Geriatrics Career Incentive Award

Advanced training opportunities Professionals Direct care workers

11

Elder Justice Create an Elder Justice Coordinating Council

Report published in May 2013 http://www.aoa.gov/AoA_programs/Elder_Rights/

EJCC/Meetings/docs/2013_05_13_EJCC-Proposals.pdf

$400 million for Adult Protective Services $100 million for state demonstration grants

$26 million to create Elder Abuse, Neglect and Exploitation Forensic Centers

12

New Models of Care Innovation Center at CMS

Foster patient-centered care & coordination Models

Accountable Care Organizations Bundled payments Medicare Coordinated Care Partnerships for patients Comprehensive Primary Care

13

Problems with Medical Payments Fee-for-service

Provider (not the consumer) decides what is needed Insurance (not the consumer) pays the fees Provider is incentivized to do more

Capitation (“by the head”) Insurer decides what is needed Insurer pays provider regardless of use Provider is incentivized to do less

14

Accountable Care Organizations (ACO) An organization of physicians and hospitals that

agree to cost and quality targets Strong primary care base Payment is linked to quality (instead of volume) Savings are achieved through improvements in

care Savings are shared between providers and CMS

15

Bundled Payments “Bundling” expenses that used to be separate

Hospital admission and after care Surgery and a “warranty”

Considerations Hard to predict costs Difficult cases may be avoided Doesn’t discourage unnecessary care

16

Medicare Coordinated Care Funds coordinated care for people with chronic

conditions 15 programs

Face-to-face meetings with client Helped with medications Facilitated communications (“hub”) Helped with transitions

8%-33% reduction in hospitalizations Cost neutral

17

Comprehensive Primary Care 4 states (OR, CO, AK, NY) Components

Risk adjustment Access and continuity

Non-visit services & fees

Planned care for chronic conditions Patient and caregiver engagement Coordination od care

18

Partnerships for Patients Reduce hospital-acquired conditions and

readmissions Elements

Hospital Engagement Networks (TMH) Care Transitions (5 sites in FL) Patient and family engagement

Provides resources to health care providers to better educate staff and patients/families

19

Elephant in the Room - LTC Nursing homes - $100,000/year

Many become impoverished and go on Medicaid Low satisfaction CLASS act – (part of ACA) – would have

established a national LTC insurance Dropped by Democrats

Are some interesting new models Eden Alternative, Greenhouse Model

20

21

1 2 3 4 5

1 – Affordability & Access - 35

2 – Choice of setting & provider - 41

3 – Quality of life & quality of care - 43

4 – Support of family caregivers - 40

5 – Effective transitions - 14

State Scorecard on LTSS Commonwealth/AARP 2014

22

Few Good Things in LTSS in ACA National panel of LTC experts

Report issued Sept. 2013 Funding for LTC Ombudsman Program Funding for LTC training and recruitment Nursing home transparency Some financing options

Money follows the person Home health and HCBS

23

Nursing Home Transparency Disclose ownership, financers, etc. Take steps to reduce violations Establish quality assurance programs Provide dementia care training Data collection requirements Pilot program – extend to all states a national

criminal background check system

24

Good Resources Kaiser Family Foundation

http://kff.org CMS Innovation Center

http://innovation.cms.gov/initiatives/#views=models Eden Alternative

http://www.edenalt.org Greenhouse Project

http://thegreenhouseproject.org Autumn Blossoms

http://autumnblossoms.org