Healthcare Reform & Role of the Nurse: Preparing for the Brave New World

Transcription

1 Healthcare Reform & Role of the Nurse: Preparing for the Brave New World Nena Bonuel, PhD, RN, CCRN-E, CNS, ACNS-BC Director, Nursing Strategic Initiatives, Harris Health System, Ambulatory Care Services Nurse Education Specialist II, Center for Professional Excellence, Houston Methodist Hospital

2 Effective January 1, 2014 Nearly all Americans will be required to have a health insurance as mandated by the Affordable Care Act

3 Affordable Health Care Act Is a law designed to provide affordable, quality health care to all Americans and reduce the cost of health care to individuals and to the government. Signed into law by President Obama, March 2010 The most significant government expansion and regulatory overhaul of the US health care system since the passage of Medicare and Medicaid in 1965

4 Affordable Care Act Impact: The Uninsured Those without health insurance will be required to have it or buy it by Jan.1, 2014 or face penalty Penalty: $285 per family or 1% of income by 2014 $2,085 per family or 2.5 % of income by 2016 U.S. Census Bureau: 40 million Americans lack insurance Oct. 1, 2013: Uninsured will shop for insurance through a new, state-run insurance exchanges created by ACA.

5 INSURANCE EXCHANGES Wellpoint AETNA HUMANA

6 OPTION # INSURANCE EXCHANGES OPTION # OPTION #

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8 Americans who qualifies for government subsidies Low-to-middle income Income between 133 and 400 % of the federal poverty level* 2013 federal poverty level definition: an income of $23,550/year for a family of 4 Family of 4 earning $88,000 per year also qualifies The closer to the poverty level a family falls, the larger the subsidy Families making less than 133% of the federal poverty level will be funneled into Medicaid: no need to purchase insurance through the exchange

9 Individual States can opt not to go along with 133 % eligibility expansion which will take effect on Jan. 1, 2014 but instead can continue receiving existing levels of Medicaid funding from the federal government TEXAS CHOSE to continue with its current funding levels and eligibility standards. Texas uninsured rate at 28.8 % ( Gallup poll, March 2013) If TEXAS had said YES to the Medicaid expansion an additional 1.5 million TEXANS would be covered by Medicaid by 2017 The States who agree with Medicaid expansion, Federal government will pay 100% of the cost of Medicaid expansion from 2014 to 2016 and ratchet its share down gradually to 90% by 2020, with states picking up the difference.

10 Health Insurance for senior citizen: UNCHANGED under the ACA Senior ages 65 and above receive Medicare, and may choose to purchase supplemental insurance if they wish

11 Affordable Care Act Impact: The Already Insured Insurance companies are no longer allowed to set an individual s premium cost based on gender or health status Insurance companies cannot drop coverage nor cap coverage for people who develop longterm illnesses or disabilities Policies purchased through a health exchange are allowed, to cost three times more for an older person than a younger person Insurance companies need to cover the children of insured parents up to age 26 ( has been in effect since 2010, the year the act was signed as law)

12 Affordable Care Act Impact: People with Pre-Existing Conditions By 2014: It is illegal for any health insurance plan to use pre-existing conditions to exclude, limit, or set unrealistic premium rates on coverage for adults The requirement to cover children under age 19 for pre-existing conditions began in 2010.

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14 Affordable Care Act Impact: The EMPLOYERS Business with 50 or more employees :required to provide health insurance coverage or face fines Goes into effect by January 1, 2014 but on July 2, Obama Administration push it back for a year. Business with 50 or fewer employees: exempted from providing health insurance to its employees or less

15 Affordable Care Act Impact: The INSURERS INSURANCE COMPANY MUST SPEND: 85% of premium on your medical care 15% on other things: advertising and administrative costs IF THEY EXCEED THESE THRESHOLD: THEY HAVE TO REBATE THE EXCESS TO THEIR CUSTOMERS

16 Affordable Care Act Impact: The INSURERS FACTORS that DRIVE UP PREMIUM COSTS: Requirement to issue policies to high-risk individuals The elimination of male and female gender pricing Limiting the amount an older person pays for his or her policy to no more than 3 times the amount a younger person pays (compared to the current 4 or 5 times more)

17 Affordable Care Act Impact: RESTAURANTS Larger chain of restaurants must list calories under every menu item

18 Affordable Care Act Impact: PHYSICIANS HOSPITALISTS and PRIMARY CARE PROVIDERS

19 NET COST of Affordable Care Act = total of $1.36 trillion in the next decade Expect HIGHER TAXES if your are in a high-income bracket Who also bear the greater TAX LOAD: Pharmaceutical, Medical device, and Insurance companies Who is CHARGED of IMPROVING the way CARE is delivered: HEALTH CARE PROVIDERS

20 NURSING: What is it for me? Accountable Care Organizations (ACOs) - A new approach to healthcare delivery that are designed to provide consistently high-quality care to a specific population of patients while controlling costs.

21 History of ACOs 2001 IOM Report : Crossing the Quality Chasm Do no Harm 2007 Institute of healthcare Improvement (IHI) launched the triple AIM: Improve the health of the population Enhance patients experience of care ( including quality, access, and reliability) Control or reduce the cost of care ACO Pilot sites ( high-performance delivery systems )- they found to promote higher performance through: -information continuity -patient engagement -care coordination -team-oriented care delivery -continuous innovation, and -convenient access to care delivery.

22 History of ACOs Concept of ACO was incorporated into the Affordable Care Act, Healthcare organizations can apply to the federal government to be an ACOs for Medicare enrollees ACOs are to capture the essence of the TRIPLE AIM organizations that were trailblazers in the move towards a reformed and high performance health care system,

23 Accountable Care Organizations Is define as groups of physicians, hospitals and other healthcare providers who come together, on a voluntary basis, to give coordinated high quality care to their patients on Medicare. Coordinated care: get the right care, at the right time, with a goal of avoiding medical errors and unnecessary duplication of services.

24 ACOs composition: Demystifying ACOs Inpatient facilities and services ( such as one or more hospitals, skilled nursing facilities, long-term care facilities, hospice facilities, psychiatric hospitals) A collection of physicians and providers (such as physicians and providers (such as independent primary physicians and specialists, faculty group practices, physicians organizations, federally qualified health centers, nurse practitioners groups) Outpatient facilities, programs and services ( such as urgent care clinics, ambulatory surgical centers, dialysis centers)

25 Population Health ACO will agree to manage all the healthcare needs of at least 5,000 Medicare patients for at least 3 years Patient-Centered Care is the essence of ACO CARE INTEGRATION will be a CORE design principle and major focus of ACOs ACO Focus on patient s needs and how they will be treated Patient Cohorts Care Requirements (what patient s needs to remain well or stable if living with a chronic health condition) Customer s needs Acute care, chronic care, end-of-life care Current State Focusing on patient s specific conditions Clinical diagnosis Provider s needs Neurology, urology, cardiology etc

26 Six Requirements for ACOs Information Continuity Care Coordination and managed transition System Accountability Peer view and teamwork for high-value care Continuous Innovation Easy access for appropriate care

27 PRIMARY CARE Primary care become a centerpiece Patient-Centered Health Homes will be patient s entry way into the entire healthcare system Patient-Centered Health Homes will be an integrated system of health care providers (physicians, APNs, Care Coordinators, Social workers, public health population analysts, nutritionists, clinical nurse educators, home health aides, promotoras (community health workers), psychologists, clinical pharmacists, and information technologists. Patient Navigators manage a care itinerary Care Delivery will be guided by common care pathways, and protocol designed to ensure high quality, cost effective care delivery.

28 CARE PATHWAYS Success of ACOs depends on the design and use of care pathways Care Coordination is integral to ensure population-based care Care Coordinators will most likely be NURSES

29 Patient-Centered Care In ACOs, fragmentation of care will be discourage Physicians, nurses and others work together in closely knit teams to improve care delivery and coordination. Leadership will be critical in achieving greater patient centeredness. Collective accountability must be develop Responsible experimentation of care delivery will be the norm

30 Role for Nurses Need for APNs will intensify Care Coordination will likely become a new specialty Patient navigators will be important for ACOs Leadership positions for nurses should abounds in ACOs Nurses with expertise in Quality Improvement and Patient Safety will be essential Nurse Informaticists will be in demand Nurse Innovators/Strategists will be an important new role and is critical to the future of high-performing care delivery systems.

31 GOVERNMENT SHUTDOWN! Most of the ACA provisions are expected to be protected. Health Exchanges are slated to launch as scheduled Health and Human Services (HHS) : CMS would continue large portion of ACA activities

32 Gov t Shutdown: Affected Staffing: HHS would furlough 40, 512 of its 78,198 employees Disease monitoring: CDC would suspend its seasonal influenza program, reduce its outbreak detection effort, and stop helping states with infectious disease monitoring. Fraud and abuse control: CMS would suspend certain health care fraud detection efforts, such as high profile strike force. Ongoing safety efforts: FDA would halt some activities, including routine inspections, import monitoring and laboratory research needed to inform public health decision making; and Routine oversight: Medicare and Medicaid providers would complete fewer certifications and entry surveys, which CMS says could put beneficiaries at risk of quality of care deficiencies

33 Gov t Shutdown: Untouched Health Insurance Exchanges: Done deal Public health insurance programs: Medicare would continue to provide coverage, and state would continue to receive federal payments for Medicaid and CHIP Clinical trials: NIH would continue patient care for current clinical center patients.

34 OBAMA CARE bvao19tzwdi7m89ov&bctid=

35 References Green, A (2013). Accountable Care Organization. CE Direct Envisioning the National Healthcare Quality Report, Institute of Medicine, National Academy Press Accessed at: The DAILY Briefing. What does a government shutdown mean for health care? Accessed at -does-a-government-shutdown Vivian Ho ( 2013). The Affordable Health care Act: What to Expect in 2014.Symposium presentation hosted by Rice s Baker Institute for Public Policy