The document provides a history of healthcare reform in the United States from the 1800s to present day. It discusses the shift from home care to hospital care over time and key acts like the Hill-Burton Act and Medicare. It then summarizes provisions of the Affordable Care Act including essential health benefits, exchanges, the individual and employer mandates, and ways to deliver care like accountable care organizations.
Modern American Health Care: Balancing Performance and Compliance in the Curr...Craig B. Garner
This presentation provides an overview of the Affordable Care Act three years after its passage. It explains how the landmark legislation evolved, what provisions are in place today, and what can we expect in the years to come. The implications for patients, providers and payers are massive, and this presentation is designed to provide a comprehensive overview for anyone interested to learn about health care reform.
Did you have time to read the 1,990 page healthcare bill that was recently passed through Congress? Have you since wondered about the impact that massive bill will have on the average American, health insurance providers, business owners and YOU? If yes, then join the Young Professionals of Chicago as we host a panel of diverse health care professionals that will be discussing current healthcare reform and taking questions on the impact of the United States' new healthcare policy. The distinguished panelists will also provide some insight and clarity into what this massive bill means for individuals like you. There will also be an opportunity for open networking with other young professionals before and after the discussion.
Obamacare - The Patient Protection and Affordable Care Act - ACAAndrew F. Bennett
This short presentation will help bring you up to speed on the Affordable Healthcare act, eligibility requirements to buy in the online marketplace, and coverage that will be available.
Obamacare in Pictures: Visualizing the Effects of the Patient Protection and ...The Heritage Foundation
“Obamacare in Pictures: Visualizing the Effects of the Patient Protection and Affordable Care Act” shows in detail the impact of the sweeping health care law for Americans.
Modern American Health Care: Balancing Performance and Compliance in the Curr...Craig B. Garner
This presentation provides an overview of the Affordable Care Act three years after its passage. It explains how the landmark legislation evolved, what provisions are in place today, and what can we expect in the years to come. The implications for patients, providers and payers are massive, and this presentation is designed to provide a comprehensive overview for anyone interested to learn about health care reform.
Did you have time to read the 1,990 page healthcare bill that was recently passed through Congress? Have you since wondered about the impact that massive bill will have on the average American, health insurance providers, business owners and YOU? If yes, then join the Young Professionals of Chicago as we host a panel of diverse health care professionals that will be discussing current healthcare reform and taking questions on the impact of the United States' new healthcare policy. The distinguished panelists will also provide some insight and clarity into what this massive bill means for individuals like you. There will also be an opportunity for open networking with other young professionals before and after the discussion.
Obamacare - The Patient Protection and Affordable Care Act - ACAAndrew F. Bennett
This short presentation will help bring you up to speed on the Affordable Healthcare act, eligibility requirements to buy in the online marketplace, and coverage that will be available.
Obamacare in Pictures: Visualizing the Effects of the Patient Protection and ...The Heritage Foundation
“Obamacare in Pictures: Visualizing the Effects of the Patient Protection and Affordable Care Act” shows in detail the impact of the sweeping health care law for Americans.
CRFB Webinar - Unpacking the Latest COVID Relief Package - April 22, 2020CRFBGraphics
Earlier this week, the Senate passed the Paycheck Protection Program and Health Care Enhancement Act – the fourth piece of legislation aimed at providing economic relief in the wake of the COVID-19 outbreak.
On Wednesday, the Committee for a Responsible Federal Budget hosted a webinar in which Senior Vice President and Senior Policy Director Marc Goldwein broke down and answered questions regarding the bill and recent actions taken by Congress, the Executive Branch, and the Federal Reserve in response to the COVID-19 crisis.
Delegate Jeannie Haddaway-Riccio's Health Care Presentation 09/16/09Karena Dixon
Presentation on Health Care Reform as presented by Delegate Jeannie Haddaway-Riccio at the Talbot GOP Health Care Forum on Wednesday, September 16th, 2009.
May also be viewed at:
www.votehaddaway.com
This presentation discusses the impact of health reform. It begins by defining the problem, then provides an overview of legislation and the impact on business. It provides a contrarian view of the subject and explains why health reform is really insurance reform. It also introduces the concept of consumer sovereignty,
Health Reform in America: An Overview of the Patient Protection and Affordabl...Adam Dougherty
A lecture to the UC Davis School of Medicine community covering the basics of the health reform law passed in early 2010. Presented by Adam Dougherty, MPH, MS1
CRFB Webinar - Unpacking the Latest COVID Relief Package - April 22, 2020CRFBGraphics
Earlier this week, the Senate passed the Paycheck Protection Program and Health Care Enhancement Act – the fourth piece of legislation aimed at providing economic relief in the wake of the COVID-19 outbreak.
On Wednesday, the Committee for a Responsible Federal Budget hosted a webinar in which Senior Vice President and Senior Policy Director Marc Goldwein broke down and answered questions regarding the bill and recent actions taken by Congress, the Executive Branch, and the Federal Reserve in response to the COVID-19 crisis.
Delegate Jeannie Haddaway-Riccio's Health Care Presentation 09/16/09Karena Dixon
Presentation on Health Care Reform as presented by Delegate Jeannie Haddaway-Riccio at the Talbot GOP Health Care Forum on Wednesday, September 16th, 2009.
May also be viewed at:
www.votehaddaway.com
This presentation discusses the impact of health reform. It begins by defining the problem, then provides an overview of legislation and the impact on business. It provides a contrarian view of the subject and explains why health reform is really insurance reform. It also introduces the concept of consumer sovereignty,
Health Reform in America: An Overview of the Patient Protection and Affordabl...Adam Dougherty
A lecture to the UC Davis School of Medicine community covering the basics of the health reform law passed in early 2010. Presented by Adam Dougherty, MPH, MS1
The Affordable Care Act and Its Impact on Workers’ CompensationCognizant
While the Affordable Care Act (ACA) is expected to reduce the number of uninsured and improve personal wellness in the U.S., the law's changes in workforce definitions will significantly impact workforce dynamics, employee hiring, employers' benefits strategies and wellness programs -- requiring a reevaluation of how workers' compensation is accounted for and delivered.
hCentive Health Insurance Exchange PlatformAlisha North
Take advantage of hCentive's deep expertise in the healthcare insurance industry. Browse through or download our white papers to get an in-depth understanding of the industry.
This gives a good base knowledge of where the current insurance industry is, a timeline of when certain mandates go into effect and a simplified description of the mandats being launched on Sept 23, 2010.
This is Andrew Busch's PPT for Laboratory Products Association annual conference from October 2016. In it, he covers the US economy, the 2016 US Presidential election candidate's policy proposals (Donald Trump and Hillary Clinton) and what lies ahead for future growth of the industry.
Affordable Care Act Summary Provisions of the act are phased.docxnettletondevon
Affordable Care Act Summary
Provisions of the act are phased in over ten years.
2010
National temporary high risk pool for those denied coverage.
>82,000 previously uninsured persons gained coverage including more than 250 in Nebraska
Young adults up to 26 y.o. covered under parents’ plans.
>3 million previously uninsured young adults covered, including 18,000 in Nebraska
No lifetime or annual limits on coverage
105 million people benefit, including 700,000 in Nebraska
No denial by insurers of children for pre-existing conditions
No co-payments for preventive care
10-12 million have accessed preventive care, including approximately 360,000 in Nebraska
Tax credits for small employers (<25 employees) to provide health care coverage.
An estimated 360,000 small businesses with 2 million employees benefited in 2011
$250 rebate for Medicare beneficiaries in Part D coverage gap (doughnut hole)
4 million seniors benefited in 2010 including 26,072 in Nebraska
Scholarships and loan forgiveness programs for health professionals choosing primary care
Primary care & other health professions training grants
A number of grants have been made to Nebraska institutions
Comparative Effectiveness Research Grants
Prevention Research and Service Grants
A number of these grants have also been made to Nebraska institutions.
2011
Grants to employ and train primary care nurse practitioners
No co-pay for Medicare preventive services including comprehensive risk assessment and prevention plan
In 2011, an estimated 32.5 million people with traditional Medicare or Medicare Advantage received one
or more preventive benefits free of charge. In 2012 alone, >25 million people with traditional Medicare,
including nearly ~250,000 in Nebraska, have received at least one preventive service at no cost to
them.
Requires insurers to maintain Medical loss ratios or 80 (small group) or 85% (large group). Provides for states
to review and approve premium rate increases
12.8 million subscribers received insurance rebates totaling >$1 billion, including $4.8 million for 22,500
Nebraska families. Insurance rate reviews have saved consumers another $1 billion in premium costs.
50% discount on brand name prescriptions filled during Part D coverage gap
Since inception 5.4 million seniors have saved $4.1 billion; in Nebraska seniors have saved $27.5
million since 2010 because of donut hole rebates or discounts.
10% Medicare & Medicaid bonus for primary care physicians and general surgeons in shortage areas
Increase Medicare payments to hospitals in low cost areas
Increased funding for Community Health Centers
Nebraska Community Health Centers have received >$19 million in additional funding
2012
Bonus payments to high quality Medicare Advantage plans
Incentive Medicare and Medicaid payments to Accountable Care Organizations that demonstrate quality and
efficiency. ACOs have been demonstrated to lower annual health c.
The same year Amazon celebrated its first birthday, Google was born and Hotmail was launched, Congress passed the 1996 Health Insurance Portability and Accountability act (“HIPAA”). Twenty-one years later, federal and state legislators still struggle to comport the tenets of HIPAA and its progeny with modern-day technology while advancing the national push toward that elusive electronic health record. Whether HIPAA can survive remains to be seen, but with its marked inflexibility, unnecessary complexity, inherent disparity and a cadre of draconian punishments for even the slightest transgressions, the real question is whether or not HIPAA should remain. This program will explore the evolution of HIPAA over the past 21 years and the issues that question the effectiveness of patient privacy laws today.
Better Crazy Than Sick: Regulating Mental Health With or Without the Affordab...Craig B. Garner
This presentation offers and overview of the mental health system in California, from psychiatric acute care hospitals to drug and alcohol rehabilitation centers.
Who's Minding the Store? What Happens When the U.S. Supreme Court Accidentall...Craig B. Garner
The recent Supreme Court decision North Carolina State Board of Dental Examiners v. Federal Trade Commission affirmed an FTC decision targeting anticompetitive conduct of the North Carolina Dental Board. Targeting trade group self-governance, the Supreme Court held that sovereign immunity does not apply if the states fail to exercise appropriate oversight.
The implications of this decision on entities like the Medical and Dental Boards of California, not to mention the State Bar of California, remain to be seen. In an industry like health care where mergers and acquisitions continue with no end in sight, and California law prohibiting the corporate practice of medicine is a fundamental tenet in health care, who will be left to monitor compliance? The implications extend beyond health care, but also into any self-governing, professional trade group. As a result, regulatory oversight will shift from the state level and into the hands of the federal government, and in particular the FTC, which will only monitor when issues of competition arise.
California’s Department of Consumer Affairs oversees 35 professional boards and bureaus, ranging from automotive repair to guide dogs to the medical board to real estate. With the self-governance of each now called into question by the Supreme Court, who will mind the store on behalf of these industries?
The 2010 Affordable Care Act has transformed our nation’s
health care system, creating myriad opportunities for
attorneys and professionals along the way. Now more than ever, attorneys in most fields of practice are
destined to overlap with health care law.
Interested in making the switch from another specialty,
or expanding your health law practice?
Pandemic or Panacea? The Financial Impact of the ACA on the Modern Health Ca...Craig B. Garner
Four years into its evolution, the political debates surrounding the Affordable Care Act continue to engage the nation. From its inception, the impact of the ACA on the changes in health care for individuals has held center stage. However, what will be the fiscal ramifications for the health care industry as a whole? With a revamped emphasis on efficiency and quality of service on the part of providers, transparency for payers and the notion of patient responsibility, how will the industry fare as it transitions from its cost-based legacy toward a performance-based model? Like it or not, America’s new health care structure is here to stay, and so we must be mindful of the collateral damages faced by the industry as the ACA works through its growing pains, while paying special attention to the burdens placed on smaller systems, hospitals and providers who find themselves ill-prepared to weather such storms. This panel will discuss the impact of the ACA on the financial wellbeing of California’s hospitals and physicians.
The Latest Paradigm Shift in Health Care: Providers, Patients and Payers Play...Craig B. Garner
The presentation discusses recent paradigm shifts impacting disputes between providers, payers and patients. The role of alternative dispute resolution in the Affordable Care Act, including compliance
programs and Medicare is included, as well as the enforceability and use of mandatory arbitration agreements.
For attorneys who must litigate the Affordable Care Act, familiarization of its rules can be daunting and unforgiving. Personal instinct and legal experience in fields outside of health law can often be of little value, as contemporary health care law often appears to contradict business law. Drawing from a variety of legal concepts, this seminar will explain what happens when the worlds of health care and litigation collide. The lessons to be learned are to proceed with caution, and remember to honor and obey the newly laid hierarchy at the heart of this epic (and very long) reform law.
The Modern Day Health Care Compliance ProgramCraig B. Garner
An HCCA Web Conference
Identify the impending changes to the core of our nation’s health care structure as a result of the shift toward performance-based initiatives.
Familiarize participants with both safe harbors and potentially costly provisions monitoring fraud and waste, including Stark laws, anti-kickback statutes, RACS, MACs, MICs, and ZPICS.
Demonstrate the positive effect on your bottom line through understanding the benefits of a well-executed compliance program.
In a country of more than 313 million people, the pressures placed on the health care system in the United States are both enormous and complex, as Americans expect a fundamental right to first rate health care without much regard for its cost.
However, the Federal and California governments are mindful of this expense and
take pride in their important role in regulating health care on the West Coast. This is a guide for responding to these investigations.
As the effects of reform continue to implement changes to our nation’s health care structure, providers find themselves forced to act quickly amidst the resultant chaos. Nowhere is the confusion more apparent than when it comes to issues of compliance.
Contact Craig Garner for more information (craig (at) craiggarner (dot) com) or visit
http://craiggarner.com/compliance/.
This presentation provides an overview (updated through December 2011) of the 2010 Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act (also known as health care reform).
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Health Care Reform Goes Live: Day Three in the Current Climate of Reform
1. Day Three in the Current Climate of Reform
By Craig B. Garner
Health Care Reform Goes Live
1299OceanAvenue,Suite400
SantaMonica,CA90401
Craig@CraigGarner.com
(310)458-1560
www.CraigGarner.com
2. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
INTRODUCTION
2
3. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
Throughout the 1800s, access to the delivery of care rendered by the few elite
hospitals (totaling fewer than 200 in 1873) in cities such as New York, Boston and
Philadelphia went hand-in-hand with one’s status in society. Most medical care took
place in the home.
By the 1920s, the hospital had become a national institution in America, with more
than 5,000 facilities appearing across the country. This trend brought with it
advances in technology, more trained physicians, and greater quality of care.
As conditions in health care improved, the practice of medicine in the United States
shifted from home to hospital. People went to a hospital to get better, benefitting
from medical advances and greater availability of care.
3
ABriefHistoryofHealthCareintheUnitedStates
4. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
In 1946, the Hospital Survey and Construction Act (the Hill Burton Act) disbursed
approximately $3.7 billion to hospitals so they could meet the growing needs of the
nation. The Hill Burton Act sought to create 4.5 hospital beds per 1,000 people
nationwide.
The Hill Burton Act forced hospitals and their communities to work together,
combining federal funds with local monies to cover expenses.
By the 1960s, health care in the United States was at a crossroads. Access to
treatment had increased, but so had the corresponding price tag. With the passage
of Medicare in 1965, our nation solidified its commitment to government sponsored
health care.
4
ABriefHistoryofHealthCare,continued
5. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
On March 23, 2010, President Obama signed the Patient Protection and
Affordable Care Act into law.
The Health Care and Education Reconciliation Act followed a week later.
Together, this landmark legislation became the Affordable Care Act, also
known as the ACA.
5
ThePatientProtectionandAffordableCareAct
6. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform6
Drug manufacturers
Health insurers
Medical device manufacturers (excise tax starting in 2013)
Indoor tanning services
Medicare Payroll Tax increases (starting in 2013)
Businesses that offer high-end "Cadillac" plans (starting in 2018)
Taxpayers, in part through the Individual Mandate (starting in 2014)
Companies, in part through the Business Mandate (starting in 2015)
WhoPaysfortheAffordableCareAct?
7. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
EssentialHealthBenefits
IndividualandGroupMarketReforms
ImprovingCoverage
MedicalLossRatio
IndividualMandate
EmployerMandate
REFORMFROMTHE
PATIENT’SPERSPECTIVE
7
8. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventative and wellness services / chronic disease management
Pediatric services, including oral and vision care
42U.S.C.§18022
8
EssentialHealthBenefits
9. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform9
NearlyEssentialHealthBenefits
Emergency room visits
Ambulance services
Diabetes care management
Kidney dialysis
Physical therapy
Durable medical equipment
Prosthetics
Infertility treatment
Organ and tissue transplantation
InstituteofMedicine,EssentialHealthBenefits
10. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform10
IndividualandGroupMarketReforms
FairHealthInsurancePremiums(42U.S.C.§300gg)
Individual or Family
Rating Area (states will decide)
Age (but not more than 3 to 1 for adults)
Tobacco Use (but not more than 1.5 to 1)
EndofPreexistingConditionExclusion(42U.S.C.§300gg-3)
CoverageforAdultChildUntiltheAgeof26(42U.S.C.§300gg-14)
GuaranteedAvailabilityofCoverage(42U.S.C.§300gg-1)
11. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
WhatAretheLevelsofCoverage?
Bronze (60% of the full actuarial value of the benefits)
Silver (70% of the full actuarial value of the benefits)
Gold (80% of the full actuarial value of the benefits)
Platinum (90% of the full actuarial value of the benefits)
Catastrophic (29 years old or younger or exempt from Section
5000A)
42U.S.C.§18022(d),(e)
11
12. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
Referred to as the “80/20 provision” of the Affordable Care Act, the Medical
Loss Ratio (MLR) applies as follows:
Large group market: An issuer must provide a rebate to enrollees if the
issuer has an MLR of less than 85% (subject to adjustments).
Small group market and individual market: An issuer must provide a
rebate to enrollees if the issuer has an MLR of less than 80% (also subject to
adjustments).
States retain the option to set a higher MLR to ensure that premiums are used for
clinical services and quality improvements.
45 C.F.R. Part 158
12
MinimumMedicalLossRatio
13. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform13
MinimumMedicalLossRatio,continued
“[A]n issuer must rebate a pro rata portion of premium revenue if it does
not meet an 80 percent MLR for the small group market in a State that
has not set a higher MLR. If an issuer has a 75 percent MLR for the
coverage it offers in the small group market in a State that has not set a
higher MLR, the issuer must rebate 5 percent of the premium paid by or
on behalf of the enrollee for the MLR reporting year after subtracting
premium and subtracting taxes and fees. . . . In this example, an enrollee
may have paid $2,000 in premiums for the MLR reporting year. If the
Federal and State taxes and licensing and regulatory fees that may be
excluded from premium revenue . . . are $150 for a premium of $2,000,
then the issuer would subtract $150 from premium revenue, for a base of
$1,850 in premium. The enrollee would be entitled to a rebate of 5
percent of $1,850, or $92.50.”
45 C.F.R. § 158.240(c)(2)
14. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform14
IndividualMandate(HowtoMaintainMinimumEssentialCoverage)
Government sponsored programs (Medicare, Medicaid, CHIP, Tricare,
Veterans, Peace Corps); or
Employer-sponsored plan; or
Plans in the individual market (Exchange, Basic Health Program, CO-
OPs);
Grandfathered health plan; or
Other.
26U.S.C.§5000A
15. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform15
ThePenalty Minimum
Essential
Coverage?
Exception?
1. Religious?
2. Not Present?
3. In Jail?
4. Low Income?
5. Hardship?
6. Indian Tribe?
PENALTY (in 2016)
the greater of
$695 (or less)
Yes
No
No
Yes
not to
exceed
Bronze Level of
Coverage
2.5% of
household income
or
1. Self-funded student coverage
2. Foreign health coverage
3. Refugee medical assistance
4. Medicare Part C
5. State high risk pools
6. AmeriCorp volunteers
NEW WAYS TO QUALIFY (1/30/13)
CollectingthePenalty
Waiver of criminal
penalties
Limitations on
liens and levies
16. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform16
EmployerMandate
DELAYED UNTIL 2015
The ACA does not require employers to offer health insurance coverage
to their employees.
For “large employers” (those with 50 or more full-time employees),
however, the ACA imposes a penalty of $2,000 per employee if any of
their full-time employees qualify for and receive federal subsidies.
This penalty does not apply for the first 30 employees.
26U.S.C.§4980H
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SmallBusinessHealthCareTaxCredits
For small businesses that are not required to provide health coverage, new
tax credits will be available to those with low-paid employees.
Must pay average annual wages below $50,000.
Must have fewer than the equivalent of 25 full-time workers (for example, an
employer with fewer than 50 part-time workers may be eligible).
In 2010 this credit was up to 35% of a small business’ premium costs (25%
for tax-exempt employers). On January 1, 2014, this rate will increase to
50% (35% for tax-exempt employers).
Designed to encourage small businesses to provide qualified health
insurance for their employees.
18. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform18
SmallBusinessHealthCareTaxCredits,continued
In a May 2012 publication, the United States Government Accountability
Office (GAO) concluded:
Fewer small businesses claimed the Small Employer Health Insurance
Tax Credit in 2010 than expected. A total of 170,300 small businesses
claimed the tax credit out of an estimated 1.4 to 4 million eligible
employers.
There were $468 million in credits claimed, although most claims were
limited to partial rather than full percentage credit.
Only 8,100 employers claimed the full credit.
19. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform19
EmployerW-2ReportingRequirements
For 2012, W-2 forms included the total cost of employer-sponsored
health insurance coverage.
Required by the Affordable Care Act, the disclosures are designed to
raise awareness of health care expenses among employees.
These health benefits are still tax free.
The new information appears in Box 12 of the standard W-2 form, with
the two-letter code DD.
20. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform20
HealthReimbursementArrangements(HRAs)
An HRA is an arrangement that is funded solely by an employer. It reimburses
an employee for medical care expenses (Internal Revenue Code § 213(d))
incurred by the employee, or spouse, dependents and any children who, as of
the end of the taxable year, are under 27 years of age.
Up to a maximum dollar amount for a coverage period
Excludable from the employee’s income
Amounts that remain at the end of the year generally can be used to
reimburse expenses incurred in later years
Includes group health plans
21. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform21
HealthFlexibleSpendingArrangements(FSAs)
A benefit designed to reimburse employees for medical care expenses
incurred by the employee, employee’s spouse, dependents and any
children who, as of the end of the taxable year, are under 27 years of age.
Contributions to an FSA offered through a cafeteria plan do not result in
gross income to the employee (subject to other Code provisions).
As of January 1, 2011, the cost of an over-the-counter medication was no
longer reimbursable from FSAs without a prescription, though this does not
apply to insulin, medical devices, eye glasses or contact lenses.
22. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform22
PremiumTaxCredit
The ACA provides for a premium tax credit to help individuals and
families afford health insurance coverage through an Exchange.
An employee is not eligible if offered affordable coverage under an
employer-sponsored plan that provides minimum value, or if the
employee enrolls in an employer-sponsored plan.
An employer sponsored plan is affordable if the employee’s required
contribution does not exceed 9.5% of the employee’s household
income.
23. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform23
HEALTHINSURANCE
EXCHANGES
24. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform24
“TheHealthInsurance
Marketplaceisdesignedtohelp
youfindinsurancethatfitsyour
budget,withlesshassle. No
matterwhereyoulive,you’llbe
abletobuyinsurance.... New
lawsmeanplansmusttreatyou
fairlyandcan’tdenyyou
coveragebecauseofpre-existing
conditions.”
Source: CMSToolkit
25. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
HowDoExchangesWork?
Make comparison shopping easier
Lower barriers for new competition in the insurance market
Provide savings and choice through transparency
Determine individual tax credits/subsidies
Increase competitive advantage for enrollees
Focus on the uninsured
25
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State-BasedExchange
26
EachindividualstateoperatesallExchangeactivities,butastatemayusefederal
governmentservicesforthefollowingareas:
Premium tax credit and cost sharing reduction determination
Exemptions
Risk adjustment program
Reinsurance program
27. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
StatePartnershipExchange
Stateoperatesactivitiesfor:
Plan management (and/or)
Consumer assistance
Statemayelecttooverseedirectly,orinthealternativerelyuponfederalgovernment
servicesforthefollowingactivities:
Reinsurance program
Medicaid and CHIP eligibility assessment or determination
27
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Federally-FacilitatedExchange
OperatedbyHHS,butstatemayelecttoperformcertainactivitiesitself. Itcanusefederal
governmentservicesforthefollowingactivities:
Reinsurance program
Medicaid and CHIP eligibility assessment or determination
28
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ExchangeTransparency
Aspartoftheapplicationprocess,eachstateshouldpostcertainsectionsfromits
applicationontheappropriatestatewebsite,including:
Exchange board and governance structure
Stakeholder consultation plan
Outreach and education plan
Role of agents and brokers
Coordination strategy
Pre-Existing Condition Insurance Plan (PCIP) transition
Long-term operational cost plan
29
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CaliforniaHealthBenefitExchange
TheCaliforniaHealthBenefitExchangepoststhefollowingvision,missionandvalueset
onitswebsite(www.healthexchange.ca.gov):
Consumer-focused
Affordability
Catalyst
Integrity
Partnership
Results
30
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BasicHealthProgram
BeginningJanuary1,2015,stateswillhaveanadditionaloptiontoestablishaBasicHealth
Program (BHP) for certain low-income individuals who would otherwise be eligible to
obtaincoveragethroughtheExchange.
Exists in addition to Exchanges and Medicaid Expansion
Proposed rules published September 25, 2013
Regulations encourage coordination between BHP rules and existing
rules for Exchanges, Medicaid or CHIP
Final rules forthcoming
31
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DELIVERING
MEDICALCARE
AccountableCareOrganizations
BundledPaymentsforCareImprovementInitiative
Patient-CenteredMedicalHomes
33. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
AccountableCareOrganizations
An ACO is a shared savings program that promotes accountability for a
patient population, coordinates items and services under Medicare parts A
and B, and encourages investment in infrastructure and redesigned care
processes for high quality and efficient services.
42 U.S.C. § 1395jjj: “Not later than January 1, 2012, the Secretary shall
establish a shared savings program (in this section referred to as the
‘‘program’’) that promotes accountability for a patient population and
coordinates items and services under parts A and B, and encourages
investment in infrastructure and redesigned care processes for high quality
and efficient service delivery.”
33
34. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
AccountableCareOrganizations,continued
By aligning health care providers that focus on improvement, efficiency, and
experience within a particular patient demographic, ACOs connect
reimbursement with quality, outcomes, and resource utilization. This is a
significant departure from the traditional fee-for-service model that for years
has been the standard in American health care.
January 10, 2013 -- 106 new ACOs approved by CMS.
July 9, 2012 -- 87 new ACOs approved by CMS.
April 10, 2012 -- 27 new ACOs approved by CMS.
34
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ACOApplication (July2012)
[S]ubmit a narrative describing how the ACO will . . . implement its quality
assurance and improvement program including but not limited to the ACO’s
processes to promote evidence-based medicine, beneficiary engagement,
coordination of care, and internal reporting on cost and quality. Please
include a description of remedial processes and penalties (including the
potential for expulsion) that would apply for non-compliance.
Submit a narrative describing how the ACO defines, establishes,
implements, evaluates, and periodically updates its process and
infrastructure to support internal reporting on quality and cost metrics that
lets the ACO monitor, give feedback, and evaluate ACO participant and
ACO provider/supplier performance.
35
36. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
Submit a narrative describing how the ACO defines, establishes,
implements, evaluates, and periodically updates its process to promote
patient engagement.
Evaluate the health needs of its assigned beneficiary population
(including consideration of diversity in its patient population) and
develop a plan to address the needs of its population.
Communicate clinical knowledge/evidence-based medicine to
beneficiaries in a way they can understand.
Engage beneficiaries in shared decision-making in ways that consider
beneficiaries’ unique needs, preferences, values and priorities.
Establish written standards for beneficiary access and communication,
as well as a process for beneficiaries to access their medical records.
36
ACOApplication,continued
37. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
CMS will measure quality of care using nationally recognized measures in four
keydomains:
Patient/caregiver experience (7 measures)
Care coordination/patient safety (6 measures)
Preventive health (8 measures)
37
ACOQualityMeasures
At-risk population:
Diabetes (6 measures)
Hypertension (1 measure)
Ischemic Vascular Disease (2 measures)
Heart Failure (1 measure)
Coronary Artery Disease (2 measures)
38. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
OtherACORequirements
Eligibility
Governance and Leadership
Compliance Plan
Data Submission
Public Reporting and Transparency
Audits and Monitoring
Assignment of Beneficiaries
Data Sharing
October 2011 Revisions*
38
39. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
BundledPaymentsforCareImprovementInitiative
Model 1: Retrospective Acute Care Hospital Stay Only
Episode of care is defined as the inpatient stay.
Physicians paid separately.
Some gainsharing permitted.
Model 2: Retrospective Acute Care Stay plus Post-Acute Care
Episode will end either 30, 60 or 90 days after discharge.
May include up to 48 different clinical condition episodes.
39
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BundledPaymentsforCareImprovementInitiative,continued
Model 3: Retrospective Post-Acute Care Only
Triggered by acute care hospital stay and begins at initiation of
post-acute care services with a participating skilled nursing facility.
Post-acute care services must begin within 30 days of discharge
and end either 30, 60 or 90 days after the initiation of episode.
May include up to 48 different clinical condition episodes.
40
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BundledPaymentsforCareImprovementInitiative,continued
Model 4: Acute Care Hospital Stay Only
CMS makes a single, prospectively determined bundled payment to the
hospital that would encompass all services furnished during the hospital
stay by the hospital, physicians and other practitioners.
Related admission for 30 days after discharge is included.
May include up to 48 different clinical condition episodes.
41
42. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
IncludedEpisodes
Major joint upper extremity; Amputation; Urinary tract infection; Stroke; Chronic obstructive
pulmonary disease, bronchitis/asthma; Coronary artery bypass graft surgery; Major joint
replacement of the lower extremity; Percutaneous coronary intervention; Pacemaker; Cardiac
defibrillator; Pacemaker device replacement or revision; Automatic implantable cardiac
defibrillator generator or lead; Congestive heart failure; Acute myocardial infarction; Cardiac
arrhythmia; Cardiac valve; Other vascular surgery; Major cardiovascular procedure;
Gastrointestinal hemorrhage; Major bowel; Fractures of femur and hip/pelvis; Medical non-
infectious orthopedic; Double joint replacement of the lower extremity; Revision of the hip or
knee; Spinal fusion (non-cervical); Hip and femur procedures except major joint; Cervical
spinal fusion; Other knee procedures; Complex non-cervical spinal fusion; Combined anterior
posterior spinal fusion; Back and neck except spinal fusion; Lower extremity and humerus
procedure except hip, foot, and femur; Removal of orthopedic devices; Sepsis; Diabetes;
Simple pneumonia and respiratory infections; Other respiratory issues; Chest pain; Medical
peripheral vascular disorders; Atherosclerosis; Gastrointestinal obstruction; Syncope and
collapse; Renal failure; Nutritional and metabolic disorders; Cellulitis; Red blood cell
disorders; Transient ischemia; Esophagitis, gastroenteritis and other digestive disorders.
42
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Patient-CenteredMedicalHomes
Comprehensive Team of Care Providers
Physical and mental health needs
Physicians, advanced practice nurses, physician assistants, nurses,
pharmacists, nutritionists, social workers, educators and care coordinators
Built around the community
Patient Centered (partnering with patients and their families)
43
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Patient-CenteredMedicalHomes,continued
Coordinated Care During Transitions
Specialty care
Hospitals
Home health care
Community Services
Accessible Services
Shorter waiting times for urgent needs
Enhanced in-person hours
24 hour telephone or electronic access to team member
Quality and Safety
Evidence-based medicine
Patient satisfaction
Sharing data
44
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MEDICAIDEXPANSION
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WhatIsMedicaid?
Medicaid is health insurance for individuals who qualify financially, as well
as families with dependent children, the aged, blind or disabled.
Medi-Cal
KanCare
SoonerCare
Hoosier Healthwise
MassHealth
SALUD!
TennCare
46
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MedicaidExpansion
77FederalRegister17144(Mar.23,2012)
Implemented provisions of the Affordable Care Act related to Medicaid
eligibility, enrollment and coordination with the Exchanges, CHIP, and
other programs.
Simplified the eligibility rules in Medicaid and CHIP.
Set the minimum Medicaid income eligibility level of 133 percent of the
Federal Poverty Level for most non-disabled adults under age 65.
47
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MedicaidExpansion,continued
AdditionalRegulations(Jan.14,2013)
Reflects new statutory eligibility provisions.
Proposes changes to provide states more flexibility to coordinate
Medicaid and CHIP eligibility, appeals and other administrative
procedures.
Modernizes and streamlines existing rules.
48
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Medi-Cal
Created in California during its 1975 Second Extraordinary Session.
CAL. WELF. & INST. CODE § 14000:
“The purpose [of Medi-Cal] is to afford to qualifying health care and related remedial
or preventative services, including related social services which are necessary for
thosereceivinghealthcareunder[Medi-Cal].”
49
Includes 25% of California’s population.
50. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
MedicaidExpansionandtheSupremeCourt
The United States Supreme Court held that Congress has the authority to
offer funding for states to expand Medicaid by 2014 without imposing
retroactive financial conditions. National Fed. of Indep. Bus. v. Sebelius, 132
S. Ct. 2566, 2606-07 (2012).
Congress never dreamed that any State would refuse to go along with the
expansion of Medicaid. Congress well understood that refusal was not a
practical option. (Id. at 2665 (Scalia, Kennedy, Thomas and Alito, JJ,
dissenting).
50
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Alabama
Alaska
Georgia
Idaho
Indiana
Kansas (undecided)
Louisiana
Maine (undecided)
Mississippi
Nebraska
North Carolina
51
StatusOpposingMedicaidExpansion(asofSept.16,2013)
Oklahoma
Pennsylvania (undecided)
South Carolina
South Dakota
Tennessee (undecided)
Texas
Utah (undecided)
Virginia
Wisconsin
Wyoming
52. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
MedicaidExpansionbytheNumbers
The Federal Government will pay 100% of added expenses for newly eligible
beneficiaries through 2016, 95% in 2017, 94% in 2018, 93% in 2019 and 90% in
2020 and thereafter.
States must pay “qualified” physicians Medicaid fees at least equal to Medicare
rates starting in 2013.
Pay increase applies to family physicians, internists and pediatricians (and in
some instances specialists) provided (1) they are Board-certified or (2) at least
60% of the Medicaid codes they billed in the previous year were primary care
codes identified in the Affordable Care Act.
52
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PERFORMANCE
BASED
REIMBURSEMENT
HospitalValue-BasedPurchasing
PhysicianValue-BasedPurchasing
HospitalReadmissionsReductionProgram
HospitalAcquiredConditions
HospitalAssociatedInfections
54. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
HospitalValue-BasedPurchasing(VBP)Program
The DRG system will begin to include value-based purchasing.
CMS will start paying hospitals Medicare “bonuses” based upon overall
performance, adherence to quality measures and patient satisfaction.
This epic change is designed to transform a system that has historically
been based on cost into one that focuses primarily on quality and
performance.
Funding for value-based purchasing comes from base operating DRG
reductions (1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016,
and 2% thereafter).
Hospitals with poor performance ratings may be excluded from bonus
opportunities.
54
55. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
HospitalVBP,continued
The VBP Program is based on a hospital’s total performance score (TPS),
which includes, in part, 12 Clinical Process of Care measures (70% of the
TPS) in the following categories:
Acute Myocardial Infarction
Heart Failure
Pneumonia
Surgical Care Improvement Project
55
56. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
HospitalVBP,continued
The TPS also includes 8 Patient Experience of Care dimensions (30% of TPS)
from the Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey:
Communication with doctors
Communication with nurses
Responsiveness of hospital staff
Pain management
Communication about medication
Cleanliness and quietness
Discharge information
Overall rating
56
57. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
FormOverSubstance
FollowHCAHPSQualityAssuranceGuidelines
Hospitals must continuously collect and submit HCAHPS data in
accordance with the current HCAHPS Quality Assurance Guidelines
and within the quarterly data submission deadlines.
To participate in the collection of HCAHPS data, a hospital must either
(1) contract with an approved HCAHPS survey vendor or (2) self-
administer the survey, provided the hospital attends HCAHPS training
and meets Minimum Survey Requirements.
Four approved methods of administering the CAHPS Hospital Survey:
(1) mail; (2) telephone; (3) mixed (mail followed by telephone); and (4)
active interactive voice response.
57
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PhysicianVBP
For groups with 25 or more physicians, CMS recommends that the following
outcome measures be used in the calculation:
30-day post discharge visits
All cause readmissions
Composite of acute prevention quality indicators (pneumonia, UTI,
dehydration)
Composite of chronic prevention quality indicators (COPD, heart failure,
diabetes)
58
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Combine each quality measure into
a quality composite and each cost
measure into a cost composite
using the following domains:
59
PhysicianValueModifierAmount
60. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
HospitalReadmissionsReductionProgram
Starting October 1, 2012, the Hospital Readmissions Reduction Program
(HRRP) reduces a hospital’s base operating Medicare diagnosis-related group
(DRG) payments with respect to readmissions for three conditions, including: (1)
acute myocardial infarction (AMI); (2) heart failure (HF); and (3) pneumonia
(PN).
Adjustment Factor: A hospital’s “adjustment factor” or readmission payment
adjustment is the greater of (1) the ratio of a hospital’s aggregate dollars for
excess readmissions to their aggregate dollars for all discharges or (b) the
statutory adjustment maximum for the Fiscal Year (FY). For FY 2013, the number
cannot exceed 0.99 (i.e., a 1% reduction). The statutory floor adjustment factor is
0.98 for FY 2014 and 0.97 for FY 2015 and subsequent years.
60
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HospitalReadmissionsReductionProgram,continued
61
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Hospital-AcquiredConditions
The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in
Medicare Severity Diagnosis Related Group (MS-DRG) payments for certain
hospital acquired conditions. CMS has titled the provision “Hospital-
Acquired Conditions and Present on Admission Indicator Reporting” (HAC &
POA).
Hospitals do not receive the higher payment for cases when one of the
selected conditions is acquired during hospitalization (i.e., was not
present on admission).
The case is paid as though the secondary diagnosis is not present.
62
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Hospital-AcquiredConditions,continued
The Inpatient Prospective Payment System (IPPS) Fiscal Year 2013 Final Rule
sets forth the applicable HACs:
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III & IV
Falls and Trauma (fracture, dislocation, head injury, burn, etc.)
Catheter-Associated Urinary Tract Infection
63
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Hospital-AcquiredConditions,continued
Additional HACs:
Vascular Catheter-Associated Infection
Manifestations of Poor Glycemic Control
Surgical Site Infections Following Coronary Artery Bypass Graft and
Certain Orthopedic Procedures (spine, neck, shoulder, elbow) as well as
Bariatric Surgery and Implantation of Cardiac Electronic Device
Deep Vein Thrombosis and Pulmonary Embolism Following Certain
Orthopedic Procedures (total knee and hip replacements)
Latrogenic Pneumothorax with Venous Catheterization
64
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OTHER
PROVISIONS
Innovation
Prevention
FraudandAbuse
66. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform66
InnovationandPrevention
To reduce patient health care expenditures, the Affordable Care Act must
rely upon innovation and prevention, hoping to improve upon the delivery
of health care in the United States. Some examples include:
Center for Medicare & Medicaid Innovation ($10 billion each decade)
School-Based Health Center Grants ($50 million)
Prevention and Public Health Fund ($11 billion through 2022)
Education and Outreach Campaign for Preventative Benefits
Community Transformation Grants
Patient-Centered Outcomes Research Institute (PCORI)
67. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform67
FraudandAbuse
The Affordable Care Act increases
the Federal Government’s arsenal
to combat health care fraud, abuse
and waste.
Some examples include:
Mandatory Compliance Programs
60 Days to Pay
Physician Owned Hospitals
Medicaid RACs
Physician Payment Sunshine Act
68. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform68
MandatoryCompliancePrograms
Section 6401(a)(7) of the Affordable Care Act requires all providers and suppliers
who participate in Medicare to adopt a compliance program as a condition
precedent.
The Office of the Inspector General (OIG) has encouraged the industry “to
exercise due diligence to prevent and detect criminal conduct and otherwise
promote an organizational culture that encourages ethical conduct and a
commitment to compliance with the law” consistent with the Federal Sentencing
Guidelines for Organizations (FSGO).
Section 6102 of the Affordable Care Act specifically requires nursing homes to
establish “a compliance and ethics program that is effective in preventing and
detecting criminal, civil, and administrative violations” by March 23, 2013.
69. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform69
60DaystoPay
Last year the Federal Government made it clear that health care providers must
return federal overpayments within 60 days from the time the overpayment was
first identified.
Failure to follow this new requirement set forth in Section 6402(a) of the
Affordable Care Act throughout any ten-year “look-back” period creates potential
liability under the False Claims Act.
Providers are held to a standard of actual knowledge or “reckless disregard or
deliberate ignorance” for purposes of identifying an overpayment under the new
regulations.
70. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform70
Physician-OwnedHospitals
Section 6001 of the Affordable Care Act limits the “whole hospital exception” under
the physician self-referral prohibitions, more commonly known as the Stark Laws.
This exception applies only to physician-owned hospitals that had physician
ownership as of March 23, 2010, and had obtained a Medicare provider number
by the end of 2010.
Subsequent regulations clarified requirements for and restrictions on
physician-owned hospitals, including but not limited to:
Requirements for “grandfathered facilities”
Clarification that “physician ownership” can change but never increase
Limitations on physical expansion (i.e., total number of beds)
71. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform71
MedicaidRACs
The 2003 legislation that began the Recovery Audit Contractor (RAC) program to
detect and correct improper payments within Medicare has since expanded under
the Affordable Care Act.
Section 6411 of the Affordable Care Act requires each state to establish its own
recovery audit program for Medicaid.
Clarified through November 2010 regulations, the burden to succeed placed on
these Medicaid RACs is certain to increase exponentially in 2014 when Medicaid
Expansion officially begins.
72. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform72
PhysicianPaymentSunshineAct
Enacted in February 2013, Section 6002 of the Affordable Care Act (the Physician
Payment Sunshine Act) deals primarily with transparency and public disclosure.
It requires disclosures by certain manufacturers of drugs, devices, and biological
or medical supplies, as well as group purchasing organizations (GPOs),
including but not limited to: (a) certain physician ownership or investment
interests; and (b) certain payment information made by these entities to
physicians.
The deadline to collect this information is August 1, 2013, and the reporting
deadline is March 31, 2014.
73. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform73
CHALLENGES
ContraceptionControversy
DebtCeiling,FiscalCliffandSequestration
HIPAA,HITECHandGINA
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TheContraceptionControversy
When first announced in August 2011, the inclusion of contraceptive care as a
mandatory component in the employer promotion of preventative services
sparked a First Amendment debate.
Regulations in February 2012 created a temporary enforcement safe harbor for
objecting employers.
The February 2013 regulations set the new threshold, allowing employers
to:
Oppose providing coverage for some or all of the previously required
contraceptive services on the basis of religious grounds;
Exist as a nonprofit entity; and
Represent themselves as a religious entity.
75. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform75
DebtCeiling,FiscalCliffandSequestration
How will the nation’s financial challenges impact the Affordable Care
Act?
How many percentage points will it take before a hospital collapses?
The debt ceiling compromise proved to be the final blow to the
Community Living Assistance Services and Supports (CLASS) Program.
The fiscal cliff disrupted a major portion of the funding for the Consumer
Operated and Oriented Plans (CO-OPs).
Will sequestration prove to be another catalyst for the reduction of
provider reimbursement?
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HIPAA(HealthInsurancePortabilityandAccountabilityAct)and
HITECH(HealthInformationTechnologyforEconomicandClinicalHealthAct)
The most recent privacy regulations were released in January 2013, affecting
almost 700,000 health care entities.
The costs involved include:
Breach notifications -- as much as $14.5 million (in 2011), not including
the estimated initial expense of $3.9 million to set up the toll-free
notification lines.
Business associates -- as high as $150 million, including security rule
compliance documentation and BAAs.
Notification to patients of privacy practices (for providers, health insurers
and third party administrators -- as much as $56 million.
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TheDigitalMedicalRecord
Existing privacy laws require practically every health
care related electronic device to employ encryption
algorithms, from a home facsimile or copy machine to
all institutional servers.
Laptops and other portable devices must default to
unreadable ciphertext, a protocol far beyond the
ordinary login password.
Last year’s release of the Medicare and Medicaid Programs’ Electronic Health
Record Incentives specified hospital stage two (out of three stages) criteria to
qualify for electronic health record incentive payments.
Physicians’ Medicare incentive payments can be as high as $44,000, but the
future penalty for not participating is up to 3% of all Medicare payments starting in
2017.
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TheGeneticInformationNondiscriminationActof2008(GINA)
GINA is the leading federal protection of genetic information, but it only prohibits
genetic discrimination in health insurance and employment.
GINA does not regulate access, security or disclosure of genetic or whole genome
sequence information across all potential users, nor does it protect against
discrimination in other contexts.
State laws vary for similar protections.
Genetic information protections are only briefly mentioned in the Affordable Care
Act (42 U.S.C. § 300gg-3(b)(1)(B) (Treatment of Genetic Information)): “Genetic
information shall not be treated as a condition . . . in the absence of a diagnosis of
the condition related to such information.”
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TAXES
ANDREFORM
PointsofIntersection
AdditionalMedicareTax
OtherTaxes
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PointsofIntersection
The ACA has become inextricably connected to the laws of federal and state
taxation. These points of intersection include:
Disclosure or Use of Information by Tax Return Preparers
Medical Loss Ratio (MLR)
Reporting Employer Provided Health Coverage in Form W-2
Net Investment Income Tax
Additional Medicare Tax
Minimum Value
Small Business Health Care Tax Credit
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PointsofIntersection,continued
Health Flexible Spending Arrangements
Medical Device Excise Tax
Health Insurance Premium Tax Credit
Individual Shared Responsibility Provision
Health Coverage for Older Children
Excise Tax on Indoor Tanning Services
Adoption Credit
Transitional Reinsurance Program
Medicare Shared Savings Program
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PointsofIntersection,continued
Qualified Therapeutic Discovery Project Program
Group Health Plan Requirements
Annual Fee on Health Insurance Providers
Tax-Exempt 501(c)(29) Qualified Nonprofit Health Insurance Issuers
Additional Requirements for Tax-Exempt Hospitals
Annual Fee on Branded Prescription Pharmaceuticals
Employer Shared Responsibility Payment
Excise Tax on “Cadillac” Plans
Patient-Centered Outcomes Research Institute
Retiree Drug Subsidies
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AdditionalMedicareTax
As of 2013, the 0.9% Additional Medicare Tax applies to income that
exceeds a threshold amount of $250,000 for married taxpayers filing
jointly and $125,000 if filing separately.
A $200,000 threshold applies for all other taxpayers.
An employer is responsible for withholding the Additional Medicare
Tax from wages or compensation it pays in excess of these limits
within a calendar year.
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NetInvestmentIncomeTax
As of 2013, the 3.8% Net Investment Income Tax applies to
individuals, estates and trusts that have certain investment income
above threshold amounts.
IndoorTanningServicesTax
As of July 1, 2010, a 10% excise tax on indoor UV tanning services
went into effect.
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MedicalDeviceExciseTax
As of January 1, 2013, manufacturers and importers paid a new 2.3%
medical device excise tax on sales of certain medical devices.
FeeonBrandedPrescriptionPharmaceuticalManufacturers andImporters
Beginning in 2011, the ACA requires an annual fee from certain
manufacturers and importers of brand name pharmaceuticals.
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AdditionalResources
www.healthcare.gov(U.S.Government)
www.healthreform.kff.org(TheHenryJ.KaiserFoundation)
www.hhs.gov(TheU.S.DepartmentofHealthandHumanServices)
www.cms.gov(CentersforMedicare&MedicaidServices)
www.oshpd.ca.gov/reform(OfficeofStatewideHealthPlanning&Development)
www.chhs.ca.gov(CaliforniaHealth&HumanServices Agency)
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87. PAGE: Health Care Reform Goes Live : Day Three in the Current Climate of Reform
CraigB.Garner
Craig is an attorney and health care consultant, specializing in issues pertaining to
modern American health care and the ways it should be managed in its current climate of
reform.
Craig’s law practice focuses on health care mergers and acquisitions, regulatory
compliance and counseling for providers. Craig is also an adjunct professor of law at
Pepperdine University School of Law, where he teaches courses on Hospital Law and the
Affordable Care Act.
Between 2002 and 2011, Craig was the Chief Executive Officer of Coast Plaza Hospital in
Norwalk, California. Craig is also a Fellow Designate with the American College of
Healthcare Executives, a Member of the State Bar of California, Business Law Section,
Health Law Committee and a Vice Chair of the Healthcare Reform Educational Task Force
of the American Health Lawyers Association.
Additional information can be found at www.craiggarner.com.
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