WINTER 2014 Thursday Course Series HEALTH REFORM AT THE CROSSROADS: HOW WE GOT TO THE ACA AND WHERE WE GO FROM HERE Date: Thursday, February 27, 2014, 7:00 pm 8:30 pm Topic: MAKING IT WORK: PUBLIC AND PRIVATE EFFORTS TO IMPLEMENT THE ACA Speakers: Bonnie Preston, MSPH, Outreach and Policy Specialist, US Department of Health and Human Services Region IX Bonnie Preston, MSPH, has 20 years of experience in health policy, health services research, and health program development in all levels of government and the private sector. Prior to joining HHS she worked as an independent consultant assisting California to prepare for the Affordable Care Act in the areas of workforce development and telehealth. She was Director of a Nationwide R&D Fund for the Permanente Medical Groups for six years where she developed new approaches to meeting the needs of Kaiser members with a $10 million seed funding. She launched strategic initiatives in care to the elderly, preventive services and pharmacy care. Prior to Kaiser, Bonnie worked in Washington D.C. for six years in health policy and research for the National Governor s Association, the Office of Technology Assessment and SysteMetrics. Early in her career she worked as a health planner in community clinics and hospitals implementing payment and organizational reforms in the Bay Area, Arizona and Ohio. She earned her B.A. with honors in political science from UC Berkeley and her MSPH from the University of North Carolina, Chapel Hill. Jeffrey Rideout, MD, MA, Senior Medical Advisor, Covered California Jeffrey Rideout, MD, MA, is currently Senior Medical Advisor for Covered California, the Health Insurance Exchange for the State of California. In this role Dr. Rideout oversees all clinical quality, network management and delivery system reform objectives for Covered California as outlined in its model contract with partner health plans and their physician and hospital partners. Previously Dr. Rideout was SVP, Chief Medical Officer for The TriZetto Group and also served as the Chief Medical Officer and global leader of the healthcare division for Cisco Systems Internet Business Solutions Group. While at Cisco, Dr. Rideout also served as a member of the American Health Information Community (AHIC s) Chronic Care Workgroup for the US Department of Health and Human Services. Prior to Cisco, Dr. Rideout was Chief Medical Officer and SVP for Blue Shield of California and head of Quality Management for Blue Cross of California/WellPoint. Dr. Rideout is a volunteer physician and Board of Directors member for Medical Teams International, an international medical relief organization. He is also currently on the board of Contra Costa Interfaith Housing, which provides permanent housing to low income families in the Contra Costa County in California. He also serves on the board of the Pacific Business Group on Health and the Integrated Healthcare Association. Dr. Rideout is also a faculty member at the UC Berkeley Haas
School of Business, teaching on topics related to healthcare technology, services and innovation. Dr. Rideout completed his residency training in internal medicine at University of California, San Francisco. He received his medical degree from Harvard Medical School and his undergraduate degree from Stanford University. He also holds a master s degree in Philosophy, Politics, and Economics from Oxford University where he studied as a Rhodes Scholar. Andrew B. Bindman, MD, Professor of Medicine, Health Policy, Epidemiology & Biostatistics, UCSF Andy Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics, at the University of California San Francisco (UCSF). He is Director of the University of California Medicaid Research Institute and Director of UCSF s Primary Care Research Fellowship. He is also a senior advisor in the Office of the Assistant Secretary for Planning and Evaluation within the US Department of Health and Human Services where he works on issues related to the health care workforce, graduate medical education, and Medicaid. During 2009-2010, Dr. Bindman was a Robert Wood Johnson Health Policy Fellow on the staff of the US House of Representatives Energy and Commerce Committee chaired by Congressman Henry Waxman. In that role he actively participated in the policy process that resulted in federal health reform through the passage of the Patient Protection and Affordable Care Act. Dr. Bindman received his MD from Mt. Sinai School of Medicine in New York. Joanne Spetz, PhD, Professor of Health Policy Studies Family and Community Medicine, and Social and Behavioral Sciences, UCSF Joanne Spetz, PhD, is a Professor at the Institute for Health Policy Studies and in the Department of Family and Community Medicine and the School of Nursing at the University of California, San Francisco. She is the Associate Director for Research Strategy at the UCSF Center for the Health Professions and the Director of the UCSF Health Workforce Research Center. Her fields of specialty are labor economics, public finance, and econometrics. She has led research on the health care workforce, organization of the hospital industry, impact of health information technology, effect of medical marijuana policy on youth substance use, and quality of patient care. Joanne's teaching is in the areas of quantitative research methods, health care financial management, and health economics Joanne is a member of the Institute of Medicine Standing Committee on Credentialing Research in Nursing and was a consultant to the Institute of Medicine Committee on the Future of Nursing. She frequently provides testimony and technical assistance to state and federal agencies and policymakers. Joanne received her Ph.D. in economics from Stanford University after studying economics at the Massachusetts Institute of Technology. She is an Honorary Fellow of the American Academy of Nursing. Moderator: Janet Coffman, MPP, PhD, Associate Professor, Philip R. Lee Institute for Health Policy Studies, UCSF Janet Coffman, MPP, PhD, is an Associate Adjunct Professor at the Philip R. Lee Institute for Health Policy Studies and the Department of Family and Community
Medicine at the University of California, San Francisco. Her research interests include the health care workforce, health insurance policy, and access to care for vulnerable populations. Dr. Coffman is a member of the California Health Benefits Review Program s faculty task force. In this capacity, she analyzes legislation introduced in the California State Legislature regarding health insurance benefit mandates. She has published a paper for the California Program on Access to Care on the impact of the Affordable Care Act on California s health workforce needs. Dr. Coffman is currently working on several projects that assess access to physicians for Californians enrolled in Medicaid. She previously served on the staffs of the UCSF Center for the Health Professions, the San Francisco Department of Public Health, and the United States Senate Committee on Veterans Affairs.
2/26/2014 Medicaid Coverage Expansion in California California Medicaid = Medi Cal Medicaid is nation s public insurance program for the poor Andrew B. Bindman, MD Professor, UCSF School of Medicine Director, California Medicaid Research Institute Medi Cal is largest state Medicaid program in country Federal, State, and County contributions February 27, 2014 $66 billion in 2012 2013 Potential Expansion Through ACA All US citizens <138% FPL New eligibility group childless adults Increases income eligibility of low income parents Federal government pays 100% for 3 years and tapers over time to no less than 90% 1
2/26/2014 Challenges in Expanding Medi Cal Like re modeling a house while living in it Diverse complicated patient population Enrollment increasing even without ACA Transforming care delivery through managed care Expanding into rural counties Broadening types of beneficiaries Medi Cal Enrollment Trends, 2003 2013 AVERAGE MONTHLY ENROLLMENT (In Millions) 8.75 6.48 6.49 6.56 6.54 6.55 6.72 7.09 7.40 7.59 7.61 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2
2/26/2014 Bridging to Reform Enrollment California early adopter of option to expand Medicaid Federal waiver to create Low Income Health Program (LIHP) County by county enrollment in Medi Cal lite prior to ACA implementation January 2014 Federal financial match for county contribution Identified those who would become newly eligible and linked them to providers primarily in safety net Not all who are eligible for Medi Cal will enroll Among those eligible but not enrolled prior to ACA expect that 250,000 500,000 to now enroll because of mandate Anticipate 1.4 million newly eligible of which 750,000 900,000 will enroll Enrollment increased by 650,000 in January 2014 (total of 9.4 million Medi Cal beneficiaries) Majority through passive enrollment from LIHP Age Distribution of Transitional LIHP Population By Gender 14,000 12,000 10,000 Number of 8,000 Eligibles 6,000 4,000 2,000 Females (Median Age = 51) Males (Median Age = 44) 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 Age of Eligible The mean age for the combined population was 44.23 years, and the median age was 47 years. Female members of the transitional LIHP population were older on average than their male counterparts. Females had a mean age of 46.24 and a median age of 51. Male members of the transitional LIHP population had a mean age of 42.41 and a median age of 44. LIHP Distribution By Ethnicity Other 33,392 5% Asian 63,506 10% African American 103,061 16% Missing 29,288 5% Hispanic 222,403 36% Caucasian, Non Hispanic 172,465 28% About 36% of the transitional LIHP population newly enrolled in Medi Cal in January was identified as Hispanic; 28% Caucasian, non Hispanic; 16% African American; and 10% Asian. 11 12 3
2/26/2014 Issues to Monitor Some Future Policy Considerations Expansion of Medi Cal enrollment beyond LIHP transition Whether coverage expansion translates into access Number of individuals who churn between Medi Cal and Covered California and if this results in disruptions in continuity with their providers Whether uninsured who gain Medi Cal remain in the safety net and if that impacts capacity of those institutions to serve those who remain uninsured Increasing Medi Cal payments to ensure an adequate supply of providers to meet increased demand for care A statewide Basic Health Plan to for individuals up to 200% FPL to reduce churn between Medi Cal and Covered California A state based insurance Exchange for immigrants ineligible to participate in Covered California 4
2/24/2014 Affordable Care Act: Main Components Health Reform and The Health Workforce Joanne Spetz, PhD, FAAN Philip R. Lee Institute for Health Policy Studies & Center for the Health Professions University of California, San Francisco Insurance changes Individual mandate, employer mandate Expansions of Medicaid Health insurance exchanges & subsidies Insurance protections Preventive care is free Funds to Community Health Centers Center for Medicare and Medicaid Innovation Value-based purchasing program Accountable Care Organizations Bundled payments for episodes of care February 2014 Very few items are labeled workforce items Incentives to expand number of primary care doctors, nurses, and physician assistants Loan forgiveness Scholarships Higher payments to rural health providers Higher Medicaid payments for primary care doctors (2013) National Health Workforce Commission But many provisions will impact health workforce Increasing numbers of insured people Free preventive care Funds to Community Health Centers States can offer home/community based services to disabled people Community Care Transitions program for seniors Value-based purchasing program Bundled payment program for Medicare Integrated health systems (Accountable Care Organizations) 1
2/24/2014 Increasing numbers of insured people 46 million uninsured in 2009 People with insurance demand more care In Massachusetts, after health reform Widespread shortages of primary care providers Drop in share of family-medicine doctors offices accepting new patients In Oregon Health Insurance Experiment found increase in ED visits in year following new enrollment In California Health Care Coverage Initiative found decrease in ED visits Job Growth Projections, 2010-2020 Overall percentage growth Percentage growth due to ACA Number of new jobs by 2020 Offices of 36.4% 10.1% 1,391,400 practitioners Private hospitals 18.7% 0.1% 878,300 Outpatient 36.6% -0.5% 394,100 Drug stores 36.1% 2.8% 257,400 Medical devices 1.6% -0.4% 4,900 Long-term care 26.3% -4.9% 822,000 Home health 80.7% -1.4% 871,800 Growth in the Largest Occupations Forecasted new jobs in California by 2021 Dental hygienists Physical therapists EMTs/paramedics Pharmacists Dental asst's Health care managers Clin lab techs Pharmacy techs Recreation workers Diagnostic techs Medical assistants Support techs Social workers Physicians LPNs Personal care aides Home health aides Nursing aides RNs 37.7% 39.0% 33.3% 25.4% 30.9% 22.4% 13.0% 32.4% 19.0% 29.9% 30.9% 29.6% 24.8% 24.4% 22.4% 20.1% 26.0% 70.5% 69.4% 0% 20% 40% 60% 80% 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0-10,000 Non-ACA growth S 8 2
2/24/2014 Baseline: Unmet needs for Primary Care Physicians Source: HRSA/AAFP But physicians don t have to provide all the care Preventive care can come from NPs, PAs, RNs Law recognizes importance of other workers in primary care Full Medicare payments to any provider of preventive services Grants to support nurse-managed health clinics Health promotion and public health Grants to promote positive health behaviors through the use of community health workers Home & community based services: RNs, certified nursing assistants, personal care assistants Center for Medicare & Medicaid Innovation (CMMI) Develops & tests new health care delivery & payment models Accountable Care Bundled Payments for Care Improvement Primary Care Transformation Initiatives Focused on the Medicaid and CHIP Population Initiatives Focused on the Medicare-Medicaid Enrollees Initiatives to Speed the Adoption of Best Practices Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models CMMI models & workforce Bundled payments Manage transitions of care Manage post-hospitalization care Manage chronic care Accountable Care Organizations Incentives to save money while producing good patient care & outcomes Innovation Awards $1 billion Projects from delivery systems, educators, advocates Evaluation is required 11 12 3
2/24/2014 Example: Care team integration of the home-based workforce California Long-Term Care Education Center Multiple education & care partners UCSF Center for the Health Professions (evaluator) Focus on Medicaid personal care services beneficiaries (in-home support services IHSS) Train 6900 Personal Care Attendants Health monitoring, coaching, navigating, + care aide Reduce ER visits & hospital admissions by 23% over 3 years, reduce nursing home stay lengths Funding Amount: $11,831,445 Estimated 3-Year Savings: $24,957,836 A Goal for National Planning National Health Workforce Commission Appointed in September 2012 Never funded Never met National Center for Health Workforce Analysis (HHS) Collect and analyze data Support work of national commission and state planning Funded 3 Health Workforce Research Centers + 1 Health Workforce Technical Assistance Center 13 4