Health care reform implications for nursing - aone

Healthcare Reform Implications for Nursinga Perspective from AONE

Presenter

Jo Ann Webb, RN, MHASenior Director, Federal Relations and Policy AONE

Presentation Objectives

• Describe the key provisions of the Affordable Care Act

• Identify major issues, challenges and opportunities healthcare reform presents for nurse leaders

• Identify opportunities for collaboration and strategies to impact healthcare reform and nursing practice

“The legislation provides a road map for healthcare reform, the only problem is that there is no road.” unknown

The Current Status

After more than a year of debate, Congress passed comprehensive health reform:

• Patient Protection and Affordable Care Act (HR 3590 signed March 23, 2010)

• Health Care and Education Reconciliation Act of 2010, (HR 4872 signed March 30, 2010)

• Now known as the Affordable Care Act

What the Bill Does

Expands coverage over the next 3 years (2014) to 32 million people through a combination of public and private sector insurance expansions.

• Provides Medicaid coverage to single childless adults for the first time nationwide.

• Provides subsides for those with limited means.• Puts in place insurance reforms such as:• no lifetime limits on coverage• no exclusions based on pre-existing conditions• no discrimination on health status • no cancellation of insurance coverage . For example will prohibit the cancellation

of a policy when a woman develops breast cancer. • Allows dependents up to age 26 to remain on the parent’s plan

• Will provided pregnancy and newborn care along with vision and dental coverage for children .

• Will increase Medicaid for up to 133% of poverty and will provide subsidies for individuals and families to afford insurance coverage offered through the “exchanges.” For example, a family of 4 with an income of up to $88,000 could qualify for a subsidy.

• Will require individuals to have health care coverage-or pay an income tax penalty. Gives the IRS a role in healthcare.

• Will require employers of 50 or more employees to provide insurance coverage

• Will create state-based benefit exchanges to individuals and small group health insurance purchases to assist small businesses.

• Prohibits copays on preventive services.

Key Nursing and Nursing Workforce Related Provisions

What the New Law does for Nursing• Modernizes Title VIII by significantly expanding education and

training opportunities. • Title VIII remains a discretionary program and funding must

be appropriated annually.• Expands the language to clearly articulate that Title VIII

programs are for graduates of nursing programs who sit for the NCLEX-RN exam.

• Expands the definition to include accelerated degree programs, bridge, or degree-completion programs for Title VIII funding.


Advanced Education Nursing (AEN) GrantsSupports projects that enhance advanced nursing education and practice in

master’s and doctoral programs Law eliminates the 10 % cap on doctoral programs Funds now can go directly to students Extends participation to programs accredited by the American College of

Nurse –Midwives Accreditation Commission for Midwifery EducationNurse Loan Repayment and Scholarship Program

Pays up to 85 % of a student’s loan in return for at least 3 years of service in a designated healthcare facility

Now makes nursing faculty eligible for this program Participation is expanded to include nurses and nursing students who

agree to serve as faculty for two years.


Nurse Education, Practice and Retention Grants • Provides grants to schools of nursing, academic health

centers, nurse-managed health centers, state and local governments and healthcare facilities to strengthen nursing education programs.

• Creates Sec. 831A - a separate section for nurse retention grants

• Expands the career ladder program• Creates a program for nurse internship and residency

programs in collaboration with accredited schools of nursing

Key Nursing and Workforce Related Provisions

Nursing Student Loan Program (NSL)Established in 1964 to address nursing shortages through a

revolving fund for undergraduate and graduate students.• Provides increases to loan amounts from $2500 to $3,300

and from $4,000 to $5,200 for the last two academic years.• The total aggregate amount of the loan will increase from

$13,000 to $17,000.• After FY2011, the loan amounts will be adjusted to provide

for cost of attendance increases.


Nurse Faculty Loan Program (NFLP)Expands the program by creating a “School of Nursing Student

Loan Fund”• Funding priority will be awarded to doctoral nursing students• Provides up to 85% of loan cancellation plus interest if student

agrees to a 4 year teaching commitment in a school of nursing.

• Increases the loan amount from $30,000 to $35,500 for undergraduates, to $40,000 for graduate students and $80,000 for doctoral students


Comprehensive Geriatric EducationAdded to Title VIII as part of the Nurse Reinvestment Act

Legislation to provide grants to nursing schools and partners, such as health care organizations, to develop geriatric training programs for nurses.

• Expands this section to include fellowships for short-term intensive courses on geriatrics, and establishes traineeships for individuals who are preparing for advanced nursing education degrees in geriatric nursing, long-term care, gero-psychiatric nursing or other nursing areas that specialize in the care of elderly populations.


Workforce Diversity GrantsPrepares disadvantaged students to become nurses

• Expands the Workforce Diversity Grant program by creating bridge programs for minority students from ADN and diploma programs to continue their education.

• Expands funding to include scholarships or stipends for accelerated degree programs, pre-entry preparation, advanced education preparation and retention activities

• Includes consultation with the National Coalition of Ethnic Minority Nurse Associations regarding increasing diversity in the nursing profession


Medicare Graduate Nursing Education Demonstration • Establishes a $200 million demonstration program over 4

fiscal years (2012-2015) for 5 hospitals to cover the clinical costs of training advanced practice nurses.

• The grants would be distributed in $50 million increments .• For this demonstration, the term “advanced practice nurse

“includes a clinical nurse specialist, nurse practitioner, certified registered nurse anesthetist, and certified nurse midwife.

• A report to Congress will be conducted and sent to Congress no later than October 17, 2017.


Nurse Managed Health ClinicsNurse Managed Clinics are practice arrangements, managed by nurses that

provide primary care or wellness services to underserved or vulnerable populations. They are associated with school, college or university departments of nursing.

• The law expands the Health Centers program to include grants to Nurse Managed Health Centers. Establishes a funding level at $50 million for FY2010 and such sums that are necessary for FY2011-2014.

School-Based Health Clinics• Establishes a grant program for school-based clinics that serve large

populations of children eligible for Medicaid and also establishes two other grant programs that would authorize construction and equipment for new clinics and also provide for funding to existing school clinics for equipment, training and salaries for personnel.

Other Nursing Related ProvisionPrimary Care, Prevention and Health Promotion

Prevention and Public Health Fund• Establishes a fund to invest in prevention and public health programs to help

restrain the rate of growth in private and public center health costs. National Health Service Corps

• Increases funding to double the Corps and establishes a formula to increase funding based on increased costs of healthcare and the numbers of individuals residing in health profession shortage areas.

• Removes the cap of 2,800 commissioned officers• Reconstitutes the Corps into 2 divisions – the Commissioned Regular Corps and

the Ready Reserve Corps to be activated when necessary.• Establishes a grant program for hospitals, medical schools, PA programs and

others to develop and operate accredited training programs for the provision of primary care. Eligible entities may use grant funds to provide financial aid to students, faculty and develop primary care programs. Gives priority to programs that train students to participate in medical homes, vulnerable populations, federally qualified health centers and clinics that serve these populations.

Other Nursing Related Provisions

Public Health WorkforceEstablishes a loan repayment program to address workforce shortages in

public health agencies. HHS would repay up to 1/3 of loans for employment in a public health agency for 3 years.

Allied Health WorkforceAuthorizes the Allied Health Loan Forgiveness program to eliminate

shortages in this area.Pediatric Health Workforce

Establishes a loan repayment program for individuals willing to practice in a pediatric medical or surgical subspecialty in mental and behavioral health. Eligible recipients also include psychiatric nurses, social workers and professional and school counselors. Loan repayment is $35,000 per year for participation in an accredited subspecialty.


Direct Care ProvidersEstablishes a grant program under which an institution of higher

learning can subsidize training for individuals who are willing to serve as direct care workers in long term care for at least 2 years after completion of the training. The institution must partner with a nursing home, skilled facility or other long term care provider.

Reporting of ExpendituresRequires cost reports for Skilled Nursing Facilities to report

expenditures for wages and benefits for direct care staff and report the break out of RNs, LPNs, CNAs and other medical and therapy staff.


Medicare Payment IncentiveProvides a 10 % bonus payment to primary care practitioners,

including nurse practitioners, clinical nurse specialists, and physician assistants including general surgeons working in health professional shortage areas.

Medicaid Payment IncentiveRequires State Medicaid programs to reimburse primary care

services provided by physicians at no less that 100% of Medicare rates.


Certified Nurse Midwives (CNM)Effective 1/1/2011 requires the CNMs be reimbursed for covered

services from 65% to 100 % of the rate physicians are paid.

Nurse Home Visitation ProgramAuthorizes states to establish nurse home visitation programs for

maternal child health, infant and early childhood purposes.


Medicaid Demonstrations Establishes a “Health Home” demonstration for Medicaid

recipients to coordinate services for individuals with chronic conditions. States would receive 90% of FMAP funding to enroll individuals to test comprehensive care management, coordination, and chronic disease management.

Medicaid Accountable Care Organizations (ACOs) Authorizes a demonstration for Pediatric ACOs that serve State

Medicaid and State Children’s Health Insurance beneficiaries. Incentive payments would be made by HHS to those demonstrations that meet federal guidelines and achieve savings.


Medicare DemonstrationsIndependence at Home Demonstration

Creates a demonstration program for chronically ill Medicare beneficiaries to test payment incentives and service delivery systems utilizing physicians and nurse practitioners. The care will be provided by home-based primary care teams. It will be possible for nurse practitioners and physician assistants to lead home-based primary care teams.

Community-Based Care Transitions ProgramGrants will be awarded to hospitals, community–based partnerships or a

combination of the two to offer transitional services which may include interventional services 24 hours after discharge, post-discharge information and medication review and management. This program is authorized and funded for FY 2011-2015.


Department of Labor Online workforce training programs

Through the Department of Labor’s Workforce Investment Act (WIA) monies will be made available to carry out online

training for healthcare occupations such as nursing, nursing assistants, dentistry, pharmacy, health administration, public health, health information systems, medical assistants and others. $50 million is authorized to be appropriated from

2011 to 2020.

Quality Related Provisions and Nursing

Center for Medicare and Medicaid Innovation within CMSA center will be established to research, develop, test, and

expand innovative payment and delivery arrangements (models) to improve the quality and reduce the cost of care provided to patients in each program. Appropriates $5 million from the Department of Treasury for the design, implementation, and evaluation of models for FY 2010; appropriates $10 billion for Center activities over the next 10 years.

Quality Related Provisions and NursingPatient-Centered Outcomes Research Institute

• Establishes a non-profit institute to synthesize research on comparative effectiveness research. The Agency for Healthcare Research and Quality will be responsible for disseminating the findings and providing training in innovative strategies for quality improvement practices. Authorizes $75 million for the development of quality measures.

Clinical Practice Guidelines• Requires the Secretary to contract with IOM to identify existing

and new clinical practice guidelines. Interagency Working Group on Health Care Quality

• Establishes a working group comprised of Federal agencies to collaborate on development and dissemination of quality initiatives within the Federal government.

Quality Related Provisions and Nursing

Center for Quality Improvement and Patient Safety• Establishes within the Agency for Healthcare Research and

Quality (AHRC) a center to support the identification of best practices and find ways to translate these practices rapidly and effectively into the healthcare system.

New Federal Commissions Boards and Task Forces

• National Health Care Workforce Commission –establishes a 15 member national commission to review the healthcare workforce and projected needs.

• Prevention, Health Promotion and Integrative and Public Health Advisory Group

• Advisory Board on Elder Abuse, Neglect, and Exploitation• Board of Governors for Patient-Centered Outcomes Research

Institute• Personal Care Attendants Workforce Advisory Panel• Commission on National Key Indicators At least 45 Commissions, Boards, Advisory Panels and Task Forces

listed in the law.

Independent Payment Advisory Board (IPAB)

• Most controversial of the Affordable Care Act provisions• Composed of a 15 member board of presidentially appointed individuals

confirmed by the Senate drawn from the healthcare industry, academia, think tanks and consumer groups who will recommend to Congress ways to reduce costs and improve care for Medicare beneficiaries.

• The recommendations of the board will work in a similar manner to the Congressional Base Closure Commissions . Recommendations put before the Congress will go into effect if Congress does not act on them; if the Congress attempts to change the recommendations in a way that will save less money – they will need a 3/5’s majority vote to implement the changes. They can be vetoed by the president but the veto can be overturned by a 2/3’s vote. The recommendations cannot be filibustered. Hospitals have a 5 year exemption from the board but will covered by it in 2018.

• A bill has already been introduced to repeal this section of the law (Healthcare Bureaucrats Elimination Act)

Nursing and Payment Reforms

Hospital Readmission Reduction Program• Beginning in October 2012 adjustments in payments to hospitals will be made

under the Inpatient Prospective Payment System (IPPS) if certain readmission thresholds are exceeded. (Medicare)

Demonstration Project to Evaluate Integrated Care Around Hospitalization• Establishes a bundled payment demonstration under Medicaid in up to 8 states

for a year period from 2012-2019 to look at ways to control costs and provide effective care.

Demonstration Project to Provide Access to Affordable Care• Establishes a 3 year demonstration project in up to 10 states to provide access to

healthcare services to the uninsured at reduced fees .

Each demonstration offers expanded opportunities for nursing to improve outcomes and reduce readmission rates, and participate in the delivery of safe ,cost effective care.

Health Reform and Nursing PracticeWhat Does it All Mean?

New Roles for Nursing? The Nurse as Navigator to provide clinical coordination through the

delivery system of acute inpatient and outpatient care, chronic and transitional care, primary, preventive and home care, and long term and palliative care.

The Nurse in Cost Containment and Access to Care in the expansion of nurse managed clinics, school based clinics, community health clinics, Accountable Care Organizations, and Medicare and Medicaid Demonstrations such as, the Medical Home and the Health Home.

The Nurse as Team Leader will allow nurses and physician assistants to lead home based primary care teams under the Medicare Demonstration, Independence at Home Medical Practice model.

Concepts to Understand and Embrace

Accountable Care Organizations (ACOs)• A network of healthcare providers that manage a full

continuum of care under a bundled payment system that will cover care coordination, medication reconciliation, discharge planning, transitional and other patient-centered services. ACOs will integrate providers and hold them accountable as a group for the value and quality of patient care. ACOs are intended to replace fragmented fee-for-service care and will use payment reductions for misuse or overuse of services.

What is an ACO ?

• It can be an entity with a combination of services such as Hospitals, Physician Groups, SNFs and Home Health Agencies.

• It will cover an episode of care defined as 3 days prior to hospital admission, duration of hospitalization and 30 days post discharge.

• Payment will cover care coordination, medication reconciliation, discharge planning, transitional care and other patient centered services.

• Quality measures will include function status, reduced avoidable hospitalization, readmissions, rates of ER visits, HAIs, and patient satisfaction.

What is a Medical Home?

• This a patient-centered model funded under Medicare to increase primary care access to include women, the elderly, and also provide disease prevention, transitional care and geriatric care.

• Will be composed of interdisciplinary teams which will be paid through a capitated payment system

• Nurse practitioners could possibly be team leaders, they are not specifically excluded from this role by the Affordable Care Act.

What is a Health Home?

• A Health Home equates with the Medical Home; however it is funded through Medicaid.

• It is the federal/state option to provide coordinated care for individuals with chronic conditions.

• It can be a single provider or a team of providers with a nurse coordinator.

• To encourage state participation, states will receive 90% of the federal medical assistance percentage ((FMAP) of each Medicaid beneficiary enrolled in a health home.

What is Happening for Maternal, Infant and Childhood Health?

• The Nurse –Family Partnership has been expanded under the Maternal Child Health Bureau of HHS.

• Requires all states to asses the need for such services and identify at-risk communities.

• Provides for comprehensive services for at risk families.

Other Targeted Programs

National Diabetes Prevention Program • Establishes a national diabetes prevention program targeted

at adults who are high risk with the goal of the program to eliminate the burden of diabetes through community-based prevention services.

Better Diabetes Care• Directs the Secretary of HHS to develop a national report card

on Diabetes to be updated every 2 years.School –Based Health Centers

• Establishes a grant program for eligible entities to support the operation of “school-based health centers.”

The Language of Health Care Reform

Clinical IntegrationCare CoordinationCommunity Care Transitional Care

Pay for Performance/Value Based PaymentsMeaningful Use

BundlingComparative Effectiveness

Medical Loss RatiosReadmissions

ACOs, Medical Homes, Health Homes

What Health care Reform Means for Nursing?

• A watershed moment for Nursing Practice• Restructure role the role of nursing through innovation and

collaboration outside the confines of traditional delivery systems.

• Expands horizons for nursing practice through educational opportunities in the law.

• Provides funding opportunities that will be available to individuals, agencies, hospitals, state and local governments to improve the practice and the profession.

• Offers opportunities to be connected and involved with your practice, your community and with professional organizations.

Congress Today

The November Elections

The Fiscal Year 2011 Appropriations Process

The National Commission on Fiscal Responsibility

Questions???

Health care reform implications for nursing - aone

Health & Medicine

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