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Health Care Reform and You

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Lean how the Affordable Care Act impacts you and our community.

Lean how the Affordable Care Act impacts you and our community.


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  • Health Care Reform: A fundamental restructuring of the healthcare delivery system by changing how providers are paid.
    Shift from being paid for each service to premiums for the year-so ACA pays not to treat but prevent diseases.
    Why talk about it now? To be fully implemented Jan 2014.
  • Is this good or bad?
    Arthritis (2011): 38.2%
    Hypertension (2011): 51.4% ----- 2009: 42.7%
    Diabetes (2011): 16.0%
    Heart disease (2011): 9.6%
    Overweight/Obese (2011): 34.6% + 14.5% = 49.1% -----------2009: 39.7%
    Caregiving (2009): 23.3% In 2010, there were 7.2 potential caregivers (ages 45-64 or the average age of caregivers) for every person age 80-plus. In 2030, that caregiver ratio will drop to 4 to 1 and by 2050, when all boomers will be in late life, the ratio becomes less than 3 to 1. In 2050, there will be three times as many people age 80-plus as there are today.
  • Death rate: JAMA 7/10/2013
  • Today is a high level overview of the 1,900 page of the ACA.
    Is Patient Protection and Affordable Care Act ALSO KNOWN AS Affordable Care Act AKA Obama Care. But won’t end with this administration.
    WHY??
  • What are the goals of health care reform?
  • CLASS ACT. Put on hold 10/2011
    Payroll deductions: Younger pay less
    Auto enrollment: But could opt out
    Five year vesting: Not pay for first 5 years of enrollment
    Must have been enrolled for 5 years; employed for at least 3 of them.
    Benefit depends on severity of functional limitation
    Used for home care, home modification, transportation, nursing home
  • Managed care approach for everyone.
  • MA plans had been paid 14% more; will reduce benefits.
    Medicare Open Enrollment
    ■ Change from Original Medicare to a Medicare Advantage Plan
    ■ Change from a Medicare Advantage Plan back to Original Medicare.
    ■ Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.
    ■ Switch from a Medicare Advantage Plan that doesn’t offer drug coverage to a Medicare Advantage Plan that offers drug coverage.
    ■ Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn’t offer drug coverage.
    ■ Join a Medicare Prescription Drug Plan.
    ■ Switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug Plan.
    ■ Drop your Medicare prescription drug coverage completely.
    Medicare Advantage Disenrollment: Jan 1 to Feb 14
    If you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. Your Original Medicare coverage will begin the first day of the
    following month.
    ■If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your
    prescription drug coverage will begin the first day of the month after the plan gets your enrollment form.
  • CARE COORDINATION:
    Intent: All providers communicating, reduce redundancies, goal of keeping you as healthy as possible.
    Consequence: Rationing of services to lowest cost
    NARROW NETWORKS
    Intent: Better coordiation
    Consequence: Less choice
    STANDARDIZED BEST PRACTICES
    Intent: Spend money on proven therapies/services
    Consequence: Can’t have access to some rare/unusal services
    PHYSICIAN EXTENDERS:
    Intent: provide you more access
    Consequence: Less access to MD (high cost)
    CHANGING BENEFITS:
    Intent: Insurance available to more, help with cost
    Consequence: Home Depot sending 20,000 PT to exchange, UPS no benefits for employed spouses, Trader Joes ends for PT, others reduce to less than 30 hrs, employers dropping plans that don’t provide essential benefits
    DIFFFERENT MODELS: Group appointments, 9/24 LA Times Concierge (Pacific Heart Institute: Select level ($500) priority appointments for certain treaments (pacemaker maintenance) & Prompt notification of non-urgent results. Premier ($1800) priority scheduling of tests and direct email and phone calls from MD. Concierge ($7500) 24 hr pager, email and cell phone access to MD and emergency night and weekend availability of personal cardiologist.
    FOCUS ON COMMUNITY BASED OPTIONS:
    Intent : This is what we want
    Consequence: Difficult to get into hospital or nursing home
  • Checks and Balances
    Pay for Performance
    READMISSIONS:
    1 out of 5 Medicare pts readmited w/i 30 days.
    2013: Hospital penalized for excessive readmits (AMI, CHF and pneumonia) but reductions for all DC. FY2013 = 1%; FY2013 = 2%; FY2013 = 3%
    VALUE BASED PURCHASING
    Start 10/2012, hospitals rewarded on quality measures for CHF, AMI, pneumonia, surgeries and health care-associated infections. CaHealthline: $1 billion tied to pt satisfaction. In CA: 75% pts said nurses communicated well; less than 75% clean room/br; 50% room quiet.
    11/15/2013: 1451 hospitals’ Medicare payment decreased; 1231 payment increased. Payment up or down 1.25% (equivalent to DRG decrease). Increase to 2% reduction in 2017.
    VBP will extend to (2015) home health agencies, SNF, ambulatory surgery centers, PHYSICIANS, (2016) long-term care facilities, hospice, psychiatric hospitals, rehab hospitals.
    PHYSICIAN QUALITY REPORTING:
    Medicare Physician Quality Reporting System provides financial incentive for reporting quality data.
    2015, incentives eliminated and must report or payment from Medicare reduced. Physician Value-Based Payment Modifier. Will initially apply only to physician groups and some specialists selected by the government, but by 2017 the payment change is supposed to apply to most if not all doctors
    MEDICARE ADVANTAGE PLAN BONUSES
    Since 2012: Bonus payments for at least 3 star rating with bigger bonus for 4 or more stars.
    SELF MANAGEMENT: 70% of health conditions are due to factors we control vs genetics. Self-management is key.
    National Council on Aging: identifying strategies to prevent chronic illnesses and improve self-management is key to controlling health care costs and improving quality of life.
    Includes health literacy – reading insurance forms, understanding prescriptions, knowing what to ask the doctors.
  • Transcript

    • 1. Health Care Reform and You Brandon Leong Community Resources Manager Keiro Senior HealthCare April 27, 2014 1
    • 2. How old are you? A. <50 years old B. 50 – 64 years old C. 65 – 79 years old D. 80 years and older 2 <50 yearsold 50 –64yearsold 65 –79yearsold80 yearsand older 0% 0%0%0%
    • 3. What percent of Japanese-American children are hapa (multi-racial)? A. 25% B. 50% C. 75% D. More than 75% 3 25% 50% 75% M ore than 75% 0% 0%0%0%
    • 4. Our Japanese American Community • Our community is changing • 23.6% is 65+ years old vs. 22.7% Japan vs. 13% U.S. • Population geographically dispersing • 74% of children 0-19 are multi-racial • Generational shift occurring 4
    • 5. Health conditions are mostly a result of: A. Genetics B. Lifestyle choices 5 Genetics Lifestyle choices 0%0%
    • 6. Japanese Americans’ Report Card on Health 日系人の健康診断 6
    • 7. Prevalence: JA in LA/OC – 50+ yrs (UCLA CHIS 2011-12) 7 49% Overweig ht Obese (太り気味・ 肥満) 10% Heart Dis   (心 臓 病) 16% Diabete s (糖尿 病) 24% Care Giving (介 護) 51% High BP ( 高血圧 ) 38% Arthritis (関節炎・ リウマチ)
    • 8. 8 US SPENDS THE MOST $
    • 9. Health Care Reform Patient Protection and Affordable Care Act Signed March 23, 2010 9
    • 10. 10 Everyone has health insurance Triple Aim Care is coordinated
    • 11. What Does ACA Include? • Everyone must have insurance; there is help to pay for insurance • Health Insurance Exchanges • Benefits and Expansions • Employer Requirements 11
    • 12. What Does This Mean for Me? 12
    • 13. Health Care Reform: “I am a senior…” • More coverage for prescription drugs • Preventive services • Medicare Open Enrollment: Oct 15 to Dec 7 – Different than Covered CA Open Enrollment: Oct 1 to Mar 31 13
    • 14. Health Care Reform: “I don’t have insurance…” • Access to health insurance marketplace – subsidies for low-income, tax credit to help pay for premiums • Expansion of Medi-Cal 14
    • 15. Health Care Reform: “I own or work at a small business…” • If 25 or fewer workers, receive tax credits • If 50 or fewer workers, can buy insurance through health insurance marketplace 15
    • 16. Health Care Reform: “I have Medicare and Medi-Cal…” • I can only go to contracted hospitals, doctors and nursing homes – within selected zip codes • My care will be coordinated 16
    • 17. What Should We Expect? • Care coordination • Narrow networks • Standardized best practice guidelines • Physician extenders • Changing benefit structures • Different models of care delivery • Focus on community based options vs. facility based care 17
    • 18. What Should We Expect? • Lifestyle management approaches will keep people at home. SELF-MANAGEMENT 18
    • 19. What percent of U.S. adults are health literate? A. <15% B. 15% - 29% C. 30% - 44% D. 45% - 69% E. 70% - 89% F. 90% - 100% 19 <15% 15% -29% 30% -44% 45% -69% 70% -89% 90% -100% 0% 0% 0%0%0%0%
    • 20. 20
    • 21. Lifelong Learning • Memory Kai: UCLA - 4 weeks • A Matter of Balance: Boston University – 8 weeks • Savvy Caregiver: University of Minnesota – 6 weeks • Healthier Living: Stanford University - 8 weeks • Diabetes Self-Management: Stanford University – 8 weeks • Driver Safety: AARP - 2 x 4 hours 21
    • 22. Coming soon…June 7, 2014… 22 Genki Conference: Caregiver’s Edition in Japanese Wintersburg Presbyterian Church
    • 23. Coming soon…August 23, 2014… 23 Genki Conference:Genki Conference: Veteran’sVeteran’s EditionEdition Southeast Japanese School and Community Center (Norwalk)
    • 24. Coming soon…Women’s Wellness Conference…September 27, 2014 24 Hyatt Regency Long Beach
    • 25. What We All Want Healthy People – Healthy Community 25
    • 26. Did you find the clickers easy to use? A. Yes B. Somewhat C. No 26 Yes Som ew hat No 0% 0%0%
    • 27. Do you like this instant polling? A. Yes B. Somewhat C. No 27 EnterAnsw erText 0% 0%0%