LEADERSHIP IN MEDICINE:POSITIONING THE NCMS FOR THE FUTURE OF HEALTH CARE

Government Affairs and Health Policy, North Carolina Medical Society

CATALYSTS FOR CHANGE

Unsustainable increases in health care costs

Increased numbers of uninsured Premium increases that are

more than 5x the rate of inflation and wage growth

Future viability of Medicare and other public programs

CATALYSTS FOR CHANGE

Both sides of the aisle agree that change to our health care delivery system is needed (even though there is a lack of consensus on specific reforms)

Private sector, including health care providers, health plans, employers, and consumers all recognize the need for change

Increased emphasis on quality, safety, and accountability

Patient Protection and Affordable Care Act (“The Act”) is a reality and unlikely to be changed significantly

MAJOR THEMES OF “THE ACT”

Insurance reformsAccess to care / workforcePayment reformsQuality / health information technology

INSURANCE REFORMS

Insurers cannot rescind coverage of enrollees; deny coverage to kids with pre-existing conditions; place lifetime caps on coverage (all 2010)

New private plans must cover preventive services without cost-sharing (2010)

Insurers must offer COBRA dependent coverage to cover children up to age 26 (2010)

State Insurance Exchange to sell “qualified health plans” to individuals and small businesses (by 2014, or else feds will do it)

Individual and employer mandate takes effect (2014)

MEDICAID

Eligibility expanded to all people under age 65 with incomes up to 133% FPL – FMAP available only for newly eligible (2014) 

States must reimburse PCPs at 100% Medicare (2013-14)

ACCESS TO CARE / WORKFORCE

Increase in the number of insured / covered persons

More health care providers, especially in primary care, will be needed

More medical school and residency slots More limited scope practitioners Increase pressure to expand scope and

recognize new classes of providers Autonomy and fragmentation are

contrary to the general direction of and consensus on health care reform

PAYMENT REFORMS

Medicare Shared Savings Program utilizing Accountable Care Organization (ACO) model—interim step using fee for service as foundation

Increase focus on quality, care coordination, efficiency, and accountability

Numerous pilots, demos, boards, commissions, grants

What is clear: Feds are moving away from passive, volume-based,

purchaser (FFS) to a move active, results-oriented, value-based purchaser

Feds don’t have the answer yet--hence the # of demos, pilots, boards, grants, etc…

QUALITY AND HEALTH INFO TECH

Process and outcomes measures Data collection Meaningful use Patient and caregiver engagement Patient-centeredness Coordination of care Safety Accountability Prevention and wellness Health disparities

HANDOUTS

At least 33 new boards, commissions or task forces established

At least 62 new grant programsAt least 35 pilot programs and demonstration projects created

LESSER-KNOWN PROVISIONS

Medical loss ratio minimums established (80% individual, 85% large group); state can increase: 2010 -2013 (s.1001)

Secretary and States to review “unreasonable premium increases” and require explanation: 2010 (s.1003)

Those in the NC high risk pool will be excluded from all coverage for 6 mos prior to enrollment in federal HRP: 2010 (s.1101)

A qualified health plan may K with provider only if the provider implements mechanisms to improve quality: 2015 (s.1311)

LESSER-KNOWN PROVISIONS

PQRI extended through 2014, with penalties after 2015; meaningful use measures to be incorporated by 2012; Sec shall provide timely feedback re satisfactorily reporting; new informal appeals process added (s. 3002)

Confidential reports to physicians measuring resources used to furnish care. 2012 (s. 3003)

Value-based payment modifier (based on risk adjusted health outcomes) for physician fee schedule ;Jan 2015 – implement for selected physicians (TBD); Jan 2017 – implement for all physicians (s. 3007)

LESSER-KNOWN PROVISIONS

Payment adjustments for hospital-acquired conditions - 2015 (s. 3008) and excess readmissions 10/1/12 (s. 3025)– expand concept to other settings, including clinics (p.258)

National strategy for quality improvement – Jan 2011. (s.3011)

Data collection and public reporting (via website) of aggregated performance data on quality measures: 2010-2014 (s. 3015)

Center for Medicare & Medicaid Innovation (CMI) established to develop and test innovative payment and service delivery models to reduce expenditures: 2011 (s.3021)

Shared Savings Program (ACO) to be implemented: 2012 (s. 3022)

LESSER-KNOWN PROVISIONS

Secretary to periodically review “misvalued” codes in Physician Fee Schedule (s.3134)

Modification of equipment utilization factor for advanced imaging services (expects to save $3 b from 2010-19) (s. 3135)

Independent Physician Advisory Board established to reduce Medicare per capita growth; Sec shall implement recommendations; however, Congress can supersede by enacting legislation: created 2010/ reports and proposals 2014 (s. 3403)

Grant money available to professional societies if they have demonstrated expertise in QI support and assistance (s.934)

LESSER-KNOWN PROVISIONS

Community health team grants for programs to provide capitated payments to be made to primary care practices (s. 3502)

Accessibility standards to be promulgated for physician offices with diagnostic equipment: 2012 (s.4208)

Data collection re race, ethnicity, sex, primary language, disability; provided practicable and funded (s. 4203)

Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services: 2010 (s. 6003)

LESSER-KNOWN PROVISIONS

National Health Care Workforce Commission will recommend (to Congress) changes to meet medical workforce needs: Sept 2010 (s. 5101)

$240 million over 6 years to be spent on increased fraud & abuse and program integrity efforts (s.10606)

Expansion of the RAC program to state Medicaid: Dec 31, 2010 (s. 6411)

Medical Reimbursement Data Centers: physician rates posted on internet (related to medical-loss ratio prv.)

STATE LEGISLATIVE AND REGULATORY ISSUES

Individual Mandate (opposition and support)

Insurance Regulation (massive) Medical Loss Ratio Adjustment High Risk Pool Health Insurance Exchange Medicaid Program Expansion

(500K lives est.)

STATE LEGISLATIVE AND REGULATORY ISSUES

State Option - Medicaid Health Homes State Option - Community First Choice Scope of Practice & Professional Regulation Medical Schools, Health Workforce Funding Medical Facilities Planning Alternatives to Medical Tort Litigation

Demonstration Project (NCMS, NCHA & others are looking at this)

Adapt Laws to New Corporate Forms

BURNING QUESTION

How can NCMS help our members adapt to the changes?

Current strengths: state lobbying; health policy; legal analysis; private sector (health plan) advocacy

New areas of increased focus: Regular updates on health system reform activity Education & training availability re: quality

improvement & measurement Access to effective & affordable health

information technology Federal level advocacy Strategic partnerships Facilitation in development of physician-led ACOs