Title: The Health Reform Edition
1- The Health Reform Edition
2The 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.
3Question 1.
- The March 2010 health reform Bill has how many
pages?
4Answer
- 1,990 pages and more than 400,000 words
52. 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
7Cost
8Losing Ground on US Competitiveness
9(No Transcript)
10Coverage
11Insurance Issues
- Lifetime limits
- Pre-existing conditions
- Cancelling coverage
12Uninsured
- 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.
14Bedlam Derm Clinic 2009
15Bedlam Derm Clinic 2009
16Clinicians
17US 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
18Care Quality and Efficiency
19Chronic Disease Re-admissions
- Congestive Health Failure
- COPD
- Diabetes
- Psychiatric Illness
- Schizophrenia
- Bipolar Disorder
20(No Transcript)
21Oklahoma has a very high rate of Heart Disease
223. 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
23COMMONWEALTH FUND State Scorecard Summary of
Health System Performance
24Although Oklahoma health status is very poor,
health spending per capita is in the top
quartile.
Dartmouth Health Atlas 2009
25Not OK!!
264. How many major Federal health reform bills are
active?a. 1b. 2c. 3d. 4
273 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
28Federal 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
295. Beyond increasing health care coverage to the
uninsured and insurance industry regulation.
name 8 additional areas covered in the March 2010
health reform bill?
30Health Reform Basic Areas
- Health Care Coverage 32 million now covered.
50 through Medicaid. In Tulsa, 100,000 newly
insured. - Insurance Reform limits on limits.
- Workforce Initiatives expand public health,
nursing, PAs, nursing, primary care, FQHCs as
teaching sites. - Access to Care primary expansion through FQHCs.
- Quality of Care reimbursement based on
reporting, performance. - Efficiency of Care lower payments per visit,
more patients in need. - Reimbursement Changes bundled care, risk
pushed to providers. - Greater detection of fraud, waste and abuse
more OIG agents. Not practicing evidenced based
medicine is waste and abuse. - Faster transitions from research to patient care.
- 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.
356. 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.
37FQHC Distribution
38FQHC utilization
397. Do the health reform and other major Federal
bills allow opportunities for community-driven
creativity in redesigning health care delivery
?a. Nob. Yes
40Creative Communities
- Beacon Communities Grant health information
exchange - Center for Medicare and Medicaid Innovation
- Health Workforce Planning grants
- 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.
427. 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).
479. Where are the new areas for profit post
health reform ?
48Delivering 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
49By 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
5010. Why do people hate the health reform
legislation?
51Why hate the health reform legislation ?
- Higher taxes
- Lower reimbursement for some clinical services
- Forced insurance coverage
- Forced mandates on States
- 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.
532009 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
54All 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.
55Community 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
57LEAN Initiative Savings (July-06 to June-09)
58Wellness for those with major medical illness and
chronic disease
59Clinical 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
60OU Wayman Tisdale Specialty Health Center OU
Cancer Center, OU Diabetes Center, diagnostic
testing, urgent / cardiac care in the heart of an
underserved area
61We Can Fight Everything or We Can Build Something
Great.