A briefing for Foundation Trustees and colleagues on the proces and features of the Affordable Care Act related to the John Hartford Foundation\'s mission of improving care for older Americans

1. Geriatric Care Provisions of
Health Reform
March 12, 2010
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2. Goals
• Provide background on geriatric care specifics
in preparation for June DC meeting
• Show progress to date in advocacy work
• Discuss possible future contingencies
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3. It’s not about us or our issues
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4. IOM study approved by JAHF
Board, June 2006
IOM Study begun, January
2007
Obama wins democratic
nomination, June 2008
Boxer -Collins “Caring for
an Aging America Act of
2008,” April 2008
Senate Special Aging
Com. testimony on
report, April 2008
Eldercare Workforce
Alliance, January 2009-
March 2010
Kohl “The Retooling the
Health Care Workforce
for an Aging America
Act,” December 2008
IOM releases Retooling
report, April 2008
Advocacy coalition
formation begins,
October 2007
Senate bill passed, December 24, 2009
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5. IOM Recommendations
1. Increase recruitment and retention of geriatric
specialists in all health professions (IOM 4.3).
2. Improve all health care workers’ ability to deliver
skilled geriatric care including the skills of the
direct care, paraprofessional and family care
workforce (IOM 4.2).
3. Redesign models of care to integrate and improve
services for older patients (IOM 3.1).
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6. Problems of Geriatric Care
– Lack of Primary Care/Prevention
– Poor Care Coordination
– Unsafe Prescribing
– High Rates of Hospital Readmission – 20% within 30 days
– Poor Adherence to Guidelines – 33% for geriatric conditions
– Regional Variation Unrelated to Guidelines or Outcomes
– An Unprepared Workforce - Weak Geriatric Skills
– Reimbursement Incentives Work Against Quality
• 25-33% of health care expenditures are of little
value
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7. Paradoxical Facts
• Health Care is 17.6% of GDP (US per capita
spending top of OECD, quality average or
below)
• Medicare expenditures - $504 Billion 2010
(15% Federal Budget)
• + 25-30% MORE - out of pocket,
supplemental, or retiree
• Medicaid (federal + state) expenditures on
Medicare beneficiaries ~ $190 Billion
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8. Costs of Care - Role of Older Adults
• Health Care is 17.6% of GDP
• $19B US Graduate Medical Education Payments
• $14,000/year total health care costs per Medicare
beneficiary
• $504B – Medicare 2010 (15% of Federal Budget)
• + $100B – Out of Pocket, Retiree, Supplemental
• ~ $190B – Medicaid 2010 (OAs are 46% of $400B
federal and state total) 3.2% of Federal Budget
• A little math => possible savings ≈ $2 - $2.6 Trillion
over 10 years
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9. Timeline
1/1/2007
IOM Report
Begins
2007 ->
Planning
for “IOM”
advocacy
coalition
March
2008
Boxer-
Collins
“Caring
for an
Aging
America
Act of
2008”
April
2008 IOM
Report
Released
-
Retooling
April 2008
Senate
Special
Aging
testimony
on IOM
report
December
2008. Kohl
“Retooling
the Health
Care
Workforce
for an
Aging
America
Act”
January
2009
Eldercare
Workforce
Announced
(JAHF and
AP funding)
June 2009
Senate HELP
Bill Geriatric
Workforce
Provisions
November
2008 House
“Affordable
Health Care
for America
Act”
December
2009 Senate
“Patient
Protection
and
Affordable
Care Act”
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10. Health Reform?
A Vehicle for Foundation Issues
1. Politics
2. Procedure
3. .
4. .
5. .
6. Policy
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11. Health (#115 of 486)
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12. Senate/Presidential Legislation
• Title I – Insurance Regulation, Coverage
• Title II – Public programs, Coverage (Medicaid)
• Title III – Quality**
• Title IV – Prevention
• Title V – Workforce**
• Title VI – Reporting, Transparency, Fraud
• Title VII – Biologics/Medicines
• Title VIII – CLASS ACT (long-term Care Insurance)
• Title IX – Taxes and Revenue
• Title X – Amendments & Additions
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13. Provisions Relevant to the Mission
of The John A. Hartford Foundation
– Improving Health and Health
Care for Older Adults
• Not coverage for uninsured, mandates, federal
take over
• Not very controversial
• Not very big
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14. Important to us, but not much on the minds of others
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15. Three Major Categories
1. Provisions Specific to the Geriatric Health
Professions, Title V (small)
2. Provisions for the General Health Care
Workforce Available/Adaptable for Geriatric
Issues, Title V (medium)
3. Provisions Changing Payment and
Regulation of Delivery System for Older
Adults, Title III (large)
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16. Geriatric Specific Workforce
TITLE V—HEALTH CARE WORKFORCE
• Geriatric Workforce Development – 24 new Geriatric
Education Centers, expanded focus $10.8M, 5 years
(Sec. 5305)
• Geriatric Career Incentive Awards – non MD awards
program (teaching or practice) $10M, 3 years (Sec. 5305)
• Training Opportunities for Direct Care Workers – grants
program for long-term care workers $10M, 3 years (Sec.
5302)
• Healthcare Workforce Center/Analysis/Commission -
national and state level look at workforce $39M, 4 years
(Secs. 5103, 5101)
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17. General Health Care Workforce
TITLE V—HEALTH CARE WORKFORCE
• 10 % increase in Medicare payment for
primary care services provided by MDs,
NPs/CNSs, or PAs (includes geriatricians) who
receive at least 60% of their income from
providing primary care services. (Sec. 5501)
• Increased provider revenue ~ $3-5 Billion?
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18. General Health Care Workforce
TITLE V—HEALTH CARE WORKFORCE
• Sec. 5301. Training in family medicine, general internal medicine,
general pediatrics, and physician assistantship. – GME beyond
hospitals $125M/year, 4 years -> geriatrics training in residency
• Sec. 5306. Mental and behavioral health education and training
grants. – Scholarships in Social Work $8M and Psychology $12M, 4
years -> social work practicum and faculty development programs
• Sec. 5309. Nurse education, practice, and retention grants. – Career
ladders -> nursing assistants, associate degree, continuing ed.
• Sec. 5310. Loan repayment and scholarship program.
• Sec. 5311. Nurse faculty loan program. – up to $40,000 for MA,
$80,000 PhD -> CGNEs, faculty awards
• Overall appropriation of $338M for 2010
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19. Delivery System
TITLE III – Improving the quality and efficiency of health care
– Subtitle A – Transforming the Health Care Delivery System
• PART III – Encouraging Development of New Patient Care Models
. . .utilizing geriatric assessments and comprehensive care plans to coordinate the care
(including through interdisciplinary teams) of applicable individuals with multiple
chronic conditions. . .
Establishment of Center for Medicare and Medicaid Innovation within CMS (Sec. 3021)
$25M/year for administration and $1B/year for services
– Accountable Care Organizations (Sec 3022) – Physician Group Practice
Demonstration University of Michigan, Dartmouth, Geisinger
– Bundled Payments (Sec. 3023) – 90 day episode capitation
– Independence at Home Demonstration Program (Sec. 3024) – Home Hospital,
Physician Home Visits
– Community-Based Care Transitions Program (Sec. 3026) – Coleman and Naylor,
$500M over 5 years
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20. Delivery System
• TITLE III - Improving the quality and efficiency of health care
Subtitle F—Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality
improvement technical assistance, $20M for 5 years,
1:5 private to public match
Sec. 3502. Establishing community health teams to
support the patient-centered medical home –>
Guided Care
Sec. 3503. Medication management services in
treatment of chronic disease –> Partners in Care
Medication Management
Sec. 3510. Patient navigator program.
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21. Misc Provisions
• TITLE III Subtitle E (Ensuring Medicare
Sustainability) Sec 3403 – Independent
Medicare Advisory Board – MedPAC on
Steroids
• TITLE VIII - Community Living Assistance
Services and Supports CLASS ACT – long-term
care insurance
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22. Misc Provisions
• TITLE X - STRENGTHENING QUALITY,
AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
– Subtitle D – Provisions Relating to Title IV
Centers of Excellence for Depression (Sec. 10410)
$100-$150M annually for 20-30 treatment,
research and education centers around the
country (1:5 private to public match)
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23. Future Directions
• Geriatric Specific Provisions
– advise and monitor
– use advocacy mechanisms to argue for more
• General Health Workforce Provisions
– inform and organize grantees to compete
– capacity building technical assistance
• Delivery System
– Bring Foundation experts and expertise into conversation
– Strategically fund convening, planning, and research to
influence implementation.
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24. 24

25. Appendix
Additional Provisions
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26. TITLE II – Role of Public Programs
Subtitle E—New Options for States to Provide Long-Term Services and
Supports
• Sec. 2401. Community First Choice Option.
• Sec. 2402. Removal of barriers to providing home and community-based
services.
• Sec. 2403. Money Follows the Person Rebalancing Demonstration.
• Sec. 2404. Protection for recipients of home and community-based services
against spousal impoverishment.
• Sec. 2405. Funding to expand State Aging and Disability Resource Centers.
• Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries
• Sec. 2601. 5-year period for demonstration projects.
• Sec. 2602. Providing Federal coverage and payment coordination for dual
eligible beneficiaries.
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27. TITLE III—IMPROVING THE QUALITY AND EFFICIENCY
OF HEALTH CARE
Subtitle A—Transforming the Health Care Delivery System
PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM
– Sec. 3001. Hospital Value-Based purchasing program.
– Sec. 3002. Improvements to the physician quality reporting system.
– Sec. 3003. Improvements to the physician feedback program.
– Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals,
and hospice programs.
– Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
– Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home
health agencies.
– Sec. 3007. Value-based payment modifier under the physician fee schedule.
– Sec. 3008. Payment adjustment for conditions acquired in hospitals.
PART II—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY
– Sec. 3011. National strategy.
– Sec. 3012. Interagency Working Group on Health Care Quality.
– Sec. 3013. Quality measure development.
– Sec. 3014. Quality measurement.
– Sec. 3015. Data collection; public reporting.
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28. TITLE IV—PREVENTION OF CHRONIC DISEASE AND
IMPROVING PUBLIC HEALTH
• Subtitle A—Modernizing Disease Prevention and Public Health Systems
• Subtitle B—Increasing Access to Clinical Preventive Services
– Sec. 4103. Medicare coverage of annual wellness visit providing a personalized
prevention plan.
– Sec. 4104. Removal of barriers to preventive services in Medicare.
– Sec. 4105. Evidence-based coverage of preventive services in Medicare.
• Subtitle C—Creating Healthier Communities
– Sec. 4201. Community transformation grants.
– Sec. 4202. Healthy aging, living well; evaluation of community-based
prevention and wellness programs for Medicare beneficiaries.
– Sec. 4206. Demonstration project concerning individualized wellness plan.
• Subtitle D—Support for Prevention and Public Health Innovation
– Sec. 4301. Research on optimizing the delivery of public health services.
– Sec. 4305. Advancing research and treatment for pain care management.
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