Implementation of Health Reform Legislation: Implications for STD Prevention


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Presented by Enrique Martinez-Vidal, Vice President, AcademyHealth and Director Robert Wood Johnson Foundation’s State Coverage Initiative’s Program

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Implementation of Health Reform Legislation: Implications for STD Prevention

  1. 1. Implementation of Health Reform Legislation: Implications for STD Prevention National Chlamydia Coalition Annual Meeting October 29, 2010 Enrique Martinez-Vidal Vice President, AcademyHealth Director, State Coverage Initiatives
  2. 2. About State Coverage Initiatives  The State Coverage Initiatives (SCI) program provides timely, experience-based information and assistance to state leaders in order to help them move health care reform forward at the state level – Supports a community of state officials – Provides unbiased information – Offers responsive policy and technical assistance  National program office of the Robert Wood Johnson Foundation  
  3. 3. Presentation Overview  Essential Benefits Package  Population Health, Prevention and Wellness Provisions in PPACA  Delivery System Reform: Medical Homes  Health Insurance Exchanges  Questions Moving Forward
  4. 4. Essential Benefits Package
  5. 5.  Plans may not discriminate against health care providers who act within the scope of their licenses and State laws  All plans must comply with annual cost- sharing limitations for plans sold in the Exchanges and must include the essential benefits package… Health Insurance Markets: Plan Benefit Requirements PPACA Sec.1201
  6. 6. The scope of benefits to be included in the essential health benefits package has yet to be determined. It must cover the following general categories of service: Health Insurance Markets: Plan Benefit Requirements -Ambulatory patient services -Emergency services -Hospitalization -Maternity and newborn care -Prescription drugs -Preventative and wellness services and chronic diseases management -Mental health and substance abuse disorder services -Rehabilitative and habilitative services and devices -Laboratory services -Pediatric services, including oral and vision care PPACA Sec.1302
  7. 7. PPACA: Screening for Chlamydia Infection Insurance  Full insurance payment for priority preventative screening services recommended by the U.S. Preventive Services Task Force (USPSTF)  Applies only to new private plan years beginning on or after September 23, 2010 Covered Screening Recommendations  All sexually active, non-pregnant women aged 24 and younger and older women who are at increased risk  All pregnant women aged 24 and younger and older pregnant women who are at increased risk
  8. 8. Population Health, Prevention and Wellness Provisions in PPACA
  9. 9. PPACA: Promoting Population Health & Wellness  Implement a National Wellness Plan – The Secretary shall develop and support a broad effort to promote population health and wellness by March 2011.  Prevention Fund – Appropriations rise from $500M in FY10 to $2B in FY15+ – Usable to advance national strategy for prevention and health promotion  Benefit Designs to Promote Wellness – Coverage for preventive services and incentives for wellness are fostered in Medicare, Medicaid and for private coverage.  Encourage Employer Wellness Programs – Employers’ efforts to promote wellness are fostered through multiple vehicles.
  10. 10. Population Health, Prevention and Wellness: State Opportunities in PPACA  Preventive Services Measures (Medicaid/CHIP) – Chronic Disease Incentive Payment Program (§4108) • Grants ($100m) for incentives to join programs that reduce obesity, tobacco, blood pressure, diabetes, etc. – Elimination of exclusion of coverage of drugs that promote smoking cessation, including FDA-approved OTC (§2502) – Medical Homes for Enrollees with Chronic Conditions; Planning Grants (§2703) – Enhanced FMAP for eliminating cost-sharing reqs for clinical preventive services and adult vaccination (§4106) – Coverage of Tobacco Cessation Services for Pregnant Women - Effective October 2010 (§4107) – Extension of CHIP Childhood Obesity Demo (§4306)
  11. 11. Population Health, Prevention and Wellness: State Opportunities in PPACA  Preventive Services Measures (cont) – CDC – Community Transformation Grants - program to promote evidence-based community preventive health activities intended to reduce chronic disease rates, and address health disparities (§4201) – Healthy Aging, Living Well Public Health Grant Program - grants for pilots to provide public health community interventions, referrals, and screenings for heart disease, stroke, and diabetes for individuals between ages 55 and 64 (§4202)
  12. 12. Population Health, Prevention and Wellness: State Opportunities in PPACA  Preventive Services Measures (cont) – CDC – Immunization Coverage Improvement Program - demo grants to improve immunization coverage for children, adolescents, and adults (§4204) – Epidemiology Laboratory Capacity Grants - grants to develop an information exchange and improve surveillance and response to infectious diseases (§4304) – State Authority to Purchase Recommended Vaccines for Adults Program - states may obtain adult vaccines through manufacturers at price negotiated by HHS (§4204)
  13. 13. Population Health, Prevention and Wellness: State Opportunities in PPACA  Preventive Services Measures (Other) – Prevention and Public Health Fund (§4002) – Primary Care Extension Program (§5405) – School-Based Health Centers (§4101) • Grants to provide comprehensive preventive/primary care services – Personal Responsibility Education Grant Program (§2953) • Educate adolescents about abstinence/contraception – Wellness Program Demonstration (§2705) • 10-state health promotion program in Individual Market • Allows 30% premium reduction – Health Plan Coverage of Preventive Health Services - no cost sharing for preventive services - Beginning 9.23.2010 (§2713) – Essential Health Benefits Package in Exchange (§1302) • Preventive services will not be subject to deductibles
  14. 14. Population Health, Prevention and Wellness: State Opportunities in PPACA  Public Health Workforce – Loan Repayment Program for Public Health Professionals (§5204) – Health Care Workforce Development - Planning and Implementation grants (§5102) – Public Health Training for Mid-Career Professionals (§5206) – Promote Community Health Workforce – CDC will award grants to states to use community health workers to promote positive health behaviors and outcomes in medically underserved communities (§5313) – State and Regional Ctrs for Health Workforce Analysis (§5103) – Fellowship Training in Public Health - Activities to address documented workforce shortages in state and local health departments in the areas of applied public health epidemiology, public health laboratory science, and informatics and may expand the Epidemic Intelligence Service (§5314)
  15. 15. Prevention and Wellness Initiatives • Some states have already put some of these ideas into practice: Vermont’s Blueprint pilot programs link public health and health reform by embedding community health teams in community-based primary care practices.
  16. 16. Health IT Framework Global Information Framework Evaluation Framework Operations Blueprint Integrated Pilots Coordinated Health System PCMH PCMH PCMH PCMH Hospitals Public Health Prevention Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Mental Health & Substance Use Disorders
  17. 17. Delivery System Reform Medical Homes
  18. 18. Multi-Payer Medical Home Initiatives (1) • Multi-payer medical home projects bring major insurers in a state together to implement changes in the interaction between primary care providers and patients. • Typically, these changes have meant investing more money into primary care, with the additional funds being tied to various performance measures. • Payers must decide how much reimbursement should be tied to structure and process (use of EMRs) or outcome measures (reduce ER visits).
  19. 19. Multi-Payer Medical Home Initiatives (2) • Funding of extra medical home services was initially achieved by increasing funding to the system, as opposed to using savings from elsewhere in the system. • The economic downturn has forced states to find more creative ways to fund medical home initiatives, including:  Requiring insurers to find cost neutral ways to increase primary care funding without raising premiums (as is done in Rhode Island)  Shared savings models  And other strategies that reward physicians for savings achieved.
  20. 20. Why the Medical Home?  Primary care-oriented health systems generate lower cost, higher quality, fewer disparities (Starfield).  The Chronic Care Model – the chassis for much of the NCQA standards – has been heavily evaluated and found to improve quality. There have been fewer evaluations of cost and utilization impact, but most findings have been positive (Wagner, RAND).  Primary care supply is declining nationwide and shortages will extend without change. – 2% of graduating medical students pursuing Internal Medicine intend to become primary care providers (JAMA, 2008)  Increasing evidence from medical home pilots of effectiveness in improving quality, reducing costs and ER & IP utilization, and/or improving clinician satisfaction.
  21. 21. Eight Distinguishing Characteristics  Personal physician (clinician)  Team-based care  Proactive planned visits instead of reactive, episodic care  Tracking patients and their needed care using special software (patient registry)  Support for self-management of chronic conditions (e.g., asthma, diabetes, heart disease)  Patient involvement in decision making  Coordinated care across all settings  Enhanced access (e.g., secure e-mail)
  22. 22. Current U.S. Medical Home Initiatives  Current initiatives take many different forms, with variation in: – Practice transformation emphasis – Payment design – Sponsorship – Involvement  Tremendous learning underway  Medical Home design issues – Practice Redesign – Consumer Engagement Beyond Primary Care Setting – Incentive Alignment – Evaluation  Risk: moving on to the next new thing (e.g., the ACO) before perfecting the medical home
  23. 23. State Medical Home Initiatives • Over 30 states have engaged in efforts to implement programs to advance Medical Homes in Medicaid/CHIP • States working across payers on Medical Homes Programs include CO, LA, MA, MD, MN, NH, NY, PA, RI, VT, WA, and WV • Three leading initiatives – all state- sponsored: PA, RI and VT – All dealt with anti-trust concerns by having the state take “state action” and play a leadership and facilitative role – Legislation necessary only in VT for an intransigent payer, but can be helpful in defining the role of the state
  24. 24. Payment Reform/Care Coordination: State Opportunities in PPACA  Medicaid – Medical Homes – State Plan Option (§2703) • Enhanced FMAP of 90% for medical home service costs during the first two years of the program • Grants to help develop medical home State Plan amendment – Community Health Teams for PCMHs – Grants (§3502) – Pediatric ACO (§2706) – Primary Care Extension Program (§5405) – Bundled payment for hospital and physician services - Demo (§2704) – Up to 8 states (2012-2016) – Chronic care prevention activities – Grants (§4108)
  25. 25. Health Insurance Exchanges
  26. 26. Health Insurance Exchanges  Minimum Requirements under PPACA  Why Do It?  Defining Goals  Structuring Exchanges  Impact of Current Markets
  27. 27. Minimum Requirements under PPACA: Structural  Primary purpose is to array coverage options for consumers (individuals & employers) – Traditionally has been a lack of information/high search costs – Creates better balance for the purchasing side of the transaction  Operated by state agency or state-established, non-profit entity  Choice of state-wide, subsidiary exchanges across state, or multi-state  Requires an exchange in the individual and small group markets – Exchanges may be combined – Markets may be combined
  28. 28. Minimum Requirements under PPACA: Administrative  Certify, recertify, and decertify qualified health plans based on HHS criteria  Toll-free hotline  Web site with standardized comparative information  Rate qualified health plans per federal standards  Present plan options in standard format (four plan benefit options in standardized manner – bronze; silver; gold; platinum; catastrophic for young adults/exemptions)
  29. 29. Minimum Requirements under PPACA: Administrative  Determine and inform individuals of eligibility for public programs (Medicaid/CHIP/Other State programs) and enroll members  Provide economic calculator for consumers  Determine whether individuals are exempt from individual mandate  Communicate with Treasury Department (eligibles and exempts)  Inform employers regarding changes in coverage of employees
  30. 30. Minimum Requirements under PPACA: Consumer Assistance  Operate a Navigator program – Provide culturally/linguistically appropriate public education – Facilitate enrollment in qualified health plans – Refer consumers with complaints/questions to appropriate agencies  Brokers/agents – States may let brokers/agents sell coverage offered in exchange
  31. 31. Minimum Requirements under PPACA: Accountability  Consultation and stakeholder participation  Accountability to federal government – Annual report to HHS Secretary on activities, receipts, and expenditures  Transparency – Publish average costs of licensing, regulatory fees, administrative costs, monies lost to waste, fraud, abuse, etc.
  32. 32. Potential Value of State-Based Insurance Exchange  Maintain regulatory authority over large share of market  Prevent risk selection issues caused by varying rating/underwriting rules inside/outside the exchange  State is better positioned to coordinate benefits and eligibility across state programs  Powerful state tool to help advance other health care priorities
  33. 33. Potential Risks of State-Based Insurance Exchange Challenges of creating new institutions Must be self-sustaining by 2015 Tension between demands to keep fees low and demands for high quality customer service
  34. 34. What Are A State’s Policy Goals?  Make health insurance and care more like consumer- driven markets?  Increase health insurers’ accountability?  To drive system affordability and cost containment?  To transform the way carriers do business and contract with providers?  To build an easy-to-use shopping tool for consumers?  To help ease the transition for safety-net providers from reliance on disproportionate share payments and other uncompensated care funding to commercial insurance reimbursement?  To moderate premium increases?
  35. 35. How to Structure an Exchange  Market Organizer (e.g., Utah Health Exchange) – Impartial source of information on health plans – Provides structure to market to enable consumers to compare health plans and purchase coverage  Selective Contracting Agent (e.g., Massachusetts Connector) – Market organizer + attempts to influence market and enhance competition • Contracts with limited number of carriers; offers limited number of plans – Provides structure to market to enable consumers to compare health plans and purchase coverage – Does not necessarily negotiate premiums with carriers but can “encourage” carriers to “sharpen their pencils”  Active Purchaser – Plays a more active role in the market (e.g., establishing plan designs; purchasing coverage like a large employer procures health benefits for employees) – May be necessary to get the best prices where competition is limited – Can push insurers to invest in quality improvements and delivery system changes – Can aim to elicit more consumer information to be used to negotiate and remove problematic plans and protect consumers from unexpected barriers
  36. 36. How Local Conditions May Affect Policy Decisions – Part I  How many carriers are in the state? How competitive are the carriers for the non-group and small group market populations?  Should non-group/small group markets be merged?  How competitive are the provider systems? Is physician access currently adequate?  Are there regional variations regarding carriers and providers that require special consideration?
  37. 37. How Local Conditions May Affect Policy Decisions – Part II  What is the nature of insurance market reforms inside/outside the exchange? Should exchange rules be extended outside the exchange?  How will adverse selection be addressed for the exchange? Impact on reinsurance/risk adjustment requirements?  Should the exchange be the sole distribution channel for a market segment such as non-group? (impact on undocumented)  What are the mandated benefits in the state?
  38. 38. PPACA: Opportunities and Challenges Related to STIs  Opportunities: – Increase of individuals who have not had regular health care = increased identification of STIs  Challenges: – Dependents will be permitted to remain on their parents’ insurance plan until their 26th birthday • Includes dependents that no longer live with their parents, are not a dependent on a parent’s tax return, are no longer a student, or are married – What will be the possible issues of confidentiality for a young adult on their parents’ insurance with STIs?
  39. 39. PPACA: More Challenges Related to STIs  Shortages of health care providers to screen and treat for STIs  Individual may still not have the funds to purchase needed medications and follow up care  Due to state and local budget cuts, public health has decreased ability to follow up on STIs to assure individual and their contacts are treated = increase risk of spread of STIs
  40. 40. Questions Moving Forward  How will states ensure that populations that remain without adequate insurance coverage obtain the health care they need?  How will the safety net prepare for the likely changes in benefits that are covered by commercial or public insurers?  How should the public health infrastructure leverage the demonstration projects, grant opportunities, and other features of reform to augment its resources, increase its effectiveness, and enhance its impact?  How will states facilitate the coordination of safety net services in the reformed health care system while identifying both persistent and new unmet needs and coordinating safety net care delivery?  What should be expected of traditional safety net providers in an environment in which more individuals have insurance coverage, and how can the capacity of these providers be leveraged and fostered?