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The Health Reform Edition

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Title: The Health Reform Edition


1
  • The Health Reform Edition

2
The Game Show..that is not a game
  • Rules
  • Question on health reform is asked.
  • Joes (audience) allowed to provide an answer,
    then.
  • Pros (Dr. Clancy) allowed to provide an answer.
  • Lightning Round not enough time for debate as I
    think I am right and you are wrong.

3
Question 1.
  • The March 2010 health reform Bill has how many
    pages?

4
Answer
  • 1,990 pages and more than 400,000 words

5
2. What are the 4 Cs that explain why health
reform was needed?
6
  • The 4 Cs of the Push for Health Reform
  • Cost US health care costs too much
  • Coverage insured and uninsured
  • Clinicians currently practiced, not enough
  • Care Quality / Efficiency not good enough

7
Cost
8
Losing Ground on US Competitiveness
9
(No Transcript)
10
Coverage
11
Insurance Issues
  • Lifetime limits
  • Pre-existing conditions
  • Cancelling coverage

12
Uninsured
  • 47,000,000 uninsured in the US.
  • 650,000 uninsured in Oklahoma,
  • 150,000 uninsured in Tulsa region or 15

13
  • 47 million uninsured in the US - Individuals
    without insurance are 1.4 to 2.6 times more
    likely than the insured to be diagnosed with last
    versus early stage cancer.

14
Bedlam Derm Clinic 2009
15
Bedlam Derm Clinic 2009
16
Clinicians
17
US short by 125,000 - 250,000 physicians in next
10 years AAMC
  • Increase in US population
  • Increase in life expectancy
  • Baby boomer demand
  • Declines in medical school class sizes.
  • Oklahoma 49th in primary care physicians per
    capita. United Health Foundation 2009

18
Care Quality and Efficiency
19
Chronic Disease Re-admissions
  • Congestive Health Failure
  • COPD
  • Diabetes
  • Psychiatric Illness
  • Schizophrenia
  • Bipolar Disorder

20
(No Transcript)
21
Oklahoma has a very high rate of Heart Disease
22
3. Where does Oklahoma rank when quality of care
is plotted against cost of care?
a. Here ?
c. Here ?
Quality of Care
d. Here ?
b. Here ?
Cost of Care
23
COMMONWEALTH FUND State Scorecard Summary of
Health System Performance
24
Although Oklahoma health status is very poor,
health spending per capita is in the top
quartile.
Dartmouth Health Atlas 2009
25
Not OK!!
26
4. How many major Federal health reform bills are
active?a. 1b. 2c. 3d. 4
27
3 Federal Responses alive in 2010..
  • Patient Protection and Affordable Care Act
    March 2010
  • American Recovery and Reconstruction Act
    Stimulus Bill - 2009
  • Public Health Services Act - 1944

28
Federal Health Reform Legislative Process
2010 Federal Health Reform - ACA
2009 Stimulus - ARRA
House, Senate and White House Negotiations
1944 Public Health Services Act - PHSA
  • Agency Policies,
  • Procedures and Rules
  • Health and Human Services
  • Centers for Medicare and Medicaid
  • Agency for Health Research and Quality
  • Centers for Disease Control
  • Health Resources and Services Administration

Passed Into Law
Modified Law ?
Repealed Law?
Practice of Medicine In Community
29
5. Beyond increasing health care coverage to the
uninsured and insurance industry regulation.
name 8 additional areas covered in the March 2010
health reform bill?
30
Health Reform Basic Areas
  1. Health Care Coverage 32 million now covered.
    50 through Medicaid. In Tulsa, 100,000 newly
    insured.
  2. Insurance Reform limits on limits.
  3. Workforce Initiatives expand public health,
    nursing, PAs, nursing, primary care, FQHCs as
    teaching sites.
  4. Access to Care primary expansion through FQHCs.
  5. Quality of Care reimbursement based on
    reporting, performance.
  6. Efficiency of Care lower payments per visit,
    more patients in need.
  7. Reimbursement Changes bundled care, risk
    pushed to providers.
  8. Greater detection of fraud, waste and abuse
    more OIG agents. Not practicing evidenced based
    medicine is waste and abuse.
  9. Faster transitions from research to patient care.
  10. Center for Medicare and Medicaid Innovation
    creativity in health care design and payment.

31
  • Insurance Reform
  • No longer lifetime dollar limits on health care
    coverage, no denying of coverage for pre-existing
    conditions and no cancelling policies because
    someone gets sick.
  • Extending Care - By 2014, plans underway for many
    Americans currently without health care coverage.
  • Expanding eligibility for Medicaid
  • Allowing children to be on parents plans up to
    the age of 26
  • Mandating those in certain income categories to
    purchase health care coverage some subsidized.
  • Creation of insurance exchanges that allow
    individuals to be included with larger groups in
    purchasing private non-profit insurance plans.

32
  • Newly Insured
  • Health insurance expansion will cover an
    estimated 32,000,000 of the 47,000,000 currently
    uninsured in the US.
  • Roughly 16,000,000 will be covered through health
    insurance exchanges and 16,000,000 through
    Medicaid expansion. ROI on insuring more in
    Oklahoma through Medicaid is positive.
  • In the Tulsa region, this will initially be in
    the range of 30,000 newly insured patients and
    may grow to as many as 100,000 patients seeking
    health care and medical homes.

33
  • Workforce and Medical Education
  • Primary Care
  • PAs, NPs
  • Teaching Health Centers resident physician
    expansion family medicine, internal medicine,
    pediatrics, geriatrics, psychiatry, dentistry and
    pediatric dentistry.

34
  • Workforce Planning
  • Loan Payback Programs There is an expansion of
    the National Health Service Corp loan payback
    program, highlighting primary care. Included
    within this program - physicians receiving loan
    payback can split time 50 patient care to the
    underserved and 50 towards medical and resident
    teaching.
  • Patient Centered Medical Home teams Funding
    will become available to expand training in the
    Patient Centered Medical Home team model.
  • Public Health Funding will be available to
    promote Public Health training of medical
    students with a focus on epidemiology, disaster
    and emergency response and team-based patient
    care.

35
6. Access What will be the primary site for
expansion of health care to the newly insured
(currently underserved)?
36
  • FQHC Expansion
  • Continued ramp up in capital, workforce and
    operations support of Federally Qualified Health
    Centers.
  • Peak funding is 2011.
  • 11 Billion over the next 5 years.
  • Morton, Community Health Connections and Indian
    Health Resource Center.

37
FQHC Distribution
38
FQHC utilization
39
7. Do the health reform and other major Federal
bills allow opportunities for community-driven
creativity in redesigning health care delivery
?a. Nob. Yes
40
Creative Communities
  1. Beacon Communities Grant health information
    exchange
  2. Center for Medicare and Medicaid Innovation
  3. Health Workforce Planning grants
  4. Health Information Extension grants Oklahoma
    Foundation Medical Quality

41
  • Center for Medicare and Medicaid Innovation
  • Within CMS, this new center is created which
    allows for communities and organizations to
    create their own programs that improve the
    quality and efficiency of care and lower the cost
    of care.
  •  
  • Bundling of Care Programs for 10 conditions for
    bundling of all care 3 days prior to the primary
    interventions and for 30 days post intervention
    will begin by 1-1-2013.
  • Accountable Care Organizations (ACO) Shared
    governance organizations that are accountable for
    the quality, cost and overall care of Medicare
    patients assigned to a particular ACO.

42
7. How will health reform cover its costs?
43
  • Cost of health reform
  • Decreased Payments - The legislation cuts about
    455 billion over 10 years from projected payment
    increases to hospitals, insurance companies and
    others under Medicare and other government health
    programs.
  • Increased Taxes - Revenue increases over 10 years
    include 210 billion from increasing the
    Medicare payroll tax 107 billion from fees on
    insurance companies, drug makers and medical
    device manufacturers 32 billion from the excise
    tax on high-value insurance plans and 2.7
    billion from a tax on indoor tanning services.

44
  • Decreased Hospital Reimbursement
  • There will be a phased in reduction in the usual
    annual increases in payments for hospital based
    care.
  • There will be a phased in dramatic reduction in
    DSH - payments to hospitals.
  • Hospitals will see penalties for readmission of
    myocardial infarction, congestive heart failure
    and pneumonia patients as well as for hospital
    acquired infections.

45
  • Changes in Physician Reimbursement
  • Primary care gets a 10 bump.
  • From 2011 2014, physician quality of care
    reporting and quality of care reimbursement will
    be implemented.
  • Meaningful use of health information
    technologies will require
  • Use of electronic health records
  • Health information exchange
  • Reporting of quality of care data.
  • Initially, physicians will receive enhanced
    payment for meaningful use.
  • Beginning in 2015, physicians will receive lower
    reimbursement for non-participation in quality
    initiatives and meaningful use.

46
  • Fraud Detection and Compliance
  • Non-Profit Hospital Reporting Non-profit
    hospitals will be required to justify their
    non-profit status as well as their attention to
    community need by
  • Performing and publishing a Community Health
    Needs Assessment and Implementation Strategy
    every 3 years.
  • Publishing and promoting a financial assistance
    policy for patients unable to pay their hospital
    bills.
  • Publishing and promoting their emergency care
    policies.
  • Limiting charges to uninsured patients to the
    same levels as insured patients.
  • Fraud, Waste, Abuse Will see increase in
    funding for fraud detection ( 150,000,000 for
    2011), new powers for OIG, closer monitoring for
    kickback, promotion of whistle blowers and
    reporting of clinicians to National Practitioners
    Data Bank.
  • Sunshine Act Requires physicians to report all
    relationships and payments from industry
    (pharmaceutical, biological, device and IT).

47
9. Where are the new areas for profit post
health reform ?
48
Delivering Health Care
  • Today Curve
  • Volume
  • Procedures
  • Specialty Care
  • Hospital Care
  • Cost based payment

Tomorrow Curve
Revenue
  • Quality
  • Efficiency
  • Performance
  • Bundling
  • Reduce expenses

2010 2012 2014 2016
49
By 2014, you must learn how to make money at
Medicare payment levels
Revenue per patient
Cost per patient
2010 Dollars
Medicare 100
Commercial
Medicaid
Medicare
Uninsured
Payor Source
50
10. Why do people hate the health reform
legislation?
51
Why hate the health reform legislation ?
  1. Higher taxes
  2. Lower reimbursement for some clinical services
  3. Forced insurance coverage
  4. Forced mandates on States
  5. Big change in how we do things

52
  • 11. Is there a way to organize all of this in
    your head so that the emerging future makes
    some sense ?
  • No
  • Yes
  • Maybe

  • Does not matter, it is all going to be repealed
    starting in November.

53
2009 2018 A time of great change..
  • Pre-health reform ? Implement health reform
  • Uninsured ? Many newly insured
  • Physician centered care ? Patient centered
    medical home
  • Individual practitioners ? Team care
  • Paper ? EMR ? Health information exchange
  • Volume based care ? Performance, quality,
    efficiency focus
  • Fee for service ? Bundled payment
  • Primary care focused GME ? add specialty GME
  • Distant relationship with payors ? All In
    partnerships

54
All In
  • All In In poker, the all in strategy involves
    betting all of your chips on a single hand and
    declaring I am going all in. Other players must
    respond by also going all in, or folding. It is
    a risky move but often used when a player is
    losing ground and must catch up to stay in the
    game.
  • A similar analogy is playing out in communities
    across the US. Health disparities are so severe
    in some of these regions, that these at-risk
    communities cannot economically compete.

55
Community Medicine is far more than the medical
school..
  • Workforce
  • Expanded, dedicated, diverse, culturally
  • competent, team-oriented skills to promote
    quality,
  • efficiency and equity
  • Facile with health Information technologies
  • Safety, Quality and Efficiency
  • New system promotes
  • high quality - efficient care
  • with no errors, team care
  • Leverages health information
  • technology
  • Access to Care
  • Right clinician at right
  • location at right time
  • Community
  • embedded

All In Integrated Model for High Performance
Health Systems for the Underserved
  • Linked to Broader
  • Determinants of Health
  • Education, urban design,
  • economic development, safety
  • Health literacy, early childhood
  • Payment Models
  • Promote safety, quality, efficiency,
  • access for all, physician retention for
  • care of the underserved

56
  • Workforce
  • Partnership with TU
  • SCM Track and Recruitment
  • Summer Institute
  • PA program initiated
  • Bedlam L team-care
  • EMR sophistication
  • Public Health certificates / MPH
  • Preventive Medicine fellowships
  • Safety, Quality and Efficiency
  • LEAN
  • Patient Centered Medical Home
  • and IMPACT Outreach Teams
  • Doc 2 Doc
  • Health Access Network
  • Greater THAN
  • Health Information
  • Access to Care
  • Bedlam E / L
  • FQHC expansion
  • School-based Clinics
  • Tulsa Housing Auth. Clinics
  • North Tulsa Regional Ctr
  • Tisdale Specialty Clinic

Tulsa All In Integrated Model for High
Performance Health Systems for the Underserved
  • Linked to Broader
  • Determinants of Health
  • Educare and
  • Promise Neighborhoods
  • OU Urban Design - CHED
  • OU Pharmacy - health literacy
  • OU Social Work Turley
  • YMCA Wellness and LIVESTRONG
  • OU Community Engagement Center and
  • Public Schools
  • Payment Models
  • Loan payback programs
  • PMPM and case rates for team care
  • Bumps for EMR and e-prescribing
  • Preparing for quality reporting
  • Direct to employer contracts
  • Summit on Urban Health
  • Center for Medicare and Medicaid
  • Innovation, HRSA

57
LEAN Initiative Savings (July-06 to June-09)
58
Wellness for those with major medical illness and
chronic disease
59
Clinical Services Network Supported by Medical
Education346 clinicians, 98 specialized programs
at 52 sites of practice
  • Traditional Hospital-Based Services
  • (5 hospitals, 18 programs)
  • St. John 24 / 7/ 365 Internal Medicine
    hospitalist teams, ICU team, geriatrics team,
    general surgery teams, orthopedics trauma
    fellowship, dialysis team, procedures team,
    palliative care, vascular team.
  • Hillcrest Medical Center 24 / 7/ 365 Family
    Medicine hospitalists, in-house OB Gyn 24 / 7 /
    365 services, Maternal Fetal Medicine program.
  • Saint Francis Hospital Emergency Medicine
    faculty and residents, 24 / 7/ 365 OU Peds
    hospitalist teams, Psychiatry consultation team.
  • Laureate Psychiatric Hospital 24 / 7/ 365
    Inpatient psychiatry care
  • Jane Phillips Hospital inpatient Family
    Medicine hospitalist and ob care.
  • Resident Moonlighting St. John, Saint Francis,
    Hillcrest. General medicine, OB.
  • Traditional OU Clinics
  • (5 OU Clinics, 37 specialized programs)
  • Schusterman Center green card ER referral
    from hospitals, general medicine clinic,
    geriatrics, HIV / Hepatitis, dermatology,
    geriatric psychiatry, psychiatry, adult diabetes,
    pediatric diabetes, gestational diabetes, general
    pediatrics, pediatric pulmonology, pediatric
    urology, OB, gynecology, perinatology,
    hypertension, headache, nephrology, Flu Clinics,
    student and employee health, OU Pharmacy, pain
    management, patient centered medical home teams.
  • OU Family Medicine Center green card ER
    referrals from hospitals, family medicine, sports
    medicine, physical therapy, STEP Pharmacy,
    patient centered medical home teams.
  • Warren Clinic peds behavioral health, peds GI
  • St. John Bernsen Center green card ER
    referrals from hospitals, OU Surgery Clinic, OU
    Vascular Clinic, OU Neurology Clinic.
  • Community Health Clinics (27 clinic sites and
    programs)
  • Primary Care - 2 Bedlam Evening Clinics / week,
    6 Bedlam Chronic Care / Longitudinal Clinics /
    week patient centered medical home teams,
    Family and Childrens Services Primary Care
    Clinic in a mental health center, 2 Tulsa Housing
    Authority Apartment Clinics, 19 School-Based
    Clinics, Mobile Sooner Schooner II Clinics,
    Neighbors Along the Line Clinic, Day Center for
    the Homeless PA Clinic 5 days per week.
  • Specialty Care - Bedlam Surgery Clinic, Bedlam
    Womens Clinic, Bedlam Dermatology Clinic,
    Shriners Telemedicine Clinics, Bedlam Pharmacy
    Network, Bedlam Case Management, Bedlam Pharmacy
    Consultation, Web-based Visits, Web-based
    Consultations, Bedlam Specialist Referral
    Network, Xavier Breast Clinics, Optometry / Wound
    Care, Bedlam HIV and Hepatitis Clinic,
  • Specialized Community Health Teams (20 programs)
  • IMPACT Mobile Psychiatric Team, Community Health
    Connections and Morton Obstetrics Clinics, Porter
    and Hominy Obstetrics Outreach, Margaret Hudson
    High School Clinic, Neighbor for Neighbor and
    Morton Heart Intervention Program, Child Abuse
    Network severe child abuse intervention team,
    Oklahoma Bio-ethics Center, Oklahoma Institute
    for Disaster and Emergency Medicine, Greater
    Tulsa Health Access Network (Greater THAN),
    Indian Health Resource Center Psychiatry - OB
    Programs, Youth Services of Tulsa Clinic team,
    Youth Services of Tulsa outreach clinic, Laura
    Dester child abuse shelter, OU Nursing Prenatal
    Outreach Inter-conception Care. Harvard Center
    for Child Development partnership. Tulsa Health
    Department Dysplasia Clinic, US Probation Office
    Clinic.
  • Coming Soon ER frequent flyer case management
    team, pediatric bone cancer, Wayman Tisdale
    Specialty Health Center

60
OU Wayman Tisdale Specialty Health Center OU
Cancer Center, OU Diabetes Center, diagnostic
testing, urgent / cardiac care in the heart of an
underserved area
61
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