Geriatric Care Provisions of Health Reform March 12,

Goals Provide background on geriatric care specifics in preparation for June DC meeting Show progress to date in advocacy work Discuss possible future contingencies 2

It’s not about us or our issues 3

IOM study approved by JAHF Board, June 2006 IOM Study begun, January 2007 Obama wins democratic nomination, June 2008 Boxer -Collins “Caring for an Aging America Act of 2008,” April 2008 Senate Special Aging Com. testimony on report, April 2008 Eldercare Workforce Alliance, January March 2010 Kohl “The Retooling the Health Care Workforce for an Aging America Act,” December 2008 IOM releases Retooling report, April 2008 Advocacy coalition formation begins, October 2007 Senate bill passed, December 24,

IOM Recommendations 1. Increase recruitment and retention of geriatric specialists in all health professions (IOM 4.3). 2. Improve all health care workers’ ability to deliver skilled geriatric care including the skills of the direct care, paraprofessional and family care workforce (IOM 4.2). 3. Redesign models of care to integrate and improve services for older patients (IOM 3.1 ). 5

Problems of Geriatric Care – Lack of Primary Care/Prevention – Poor Care Coordination – Unsafe Prescribing – High Rates of Hospital Readmission – 20% within 30 days – Poor Adherence to Guidelines – 33% for geriatric conditions – Regional Variation Unrelated to Guidelines or Outcomes – An Unprepared Workforce - Weak Geriatric Skills – Reimbursement Incentives Work Against Quality 25-33% of health care expenditures are of little value 6

Paradoxical Facts Health Care is 17.6% of GDP (US per capita spending top of OECD, quality average or below) Medicare expenditures - $504 Billion 2010 (15% Federal Budget) % MORE - out of pocket, supplemental, or retiree Medicaid (federal + state) expenditures on Medicare beneficiaries ~ $190 Billion 7

Costs of Care - Role of Older Adults Health Care is 17.6% of GDP $19B US Graduate Medical Education Payments $14,000/year total health care costs per Medicare beneficiary $504B – Medicare 2010 (15% of Federal Budget) + $100B – Out of Pocket, Retiree, Supplemental ~ $190B – Medicaid 2010 (OAs are 46% of $400B federal and state total) 3.2% of Federal Budget A little math => possible savings ≈ $2 - $2.6 Trillion over 10 years 8

Timeline 1/1/2007 IOM Report Begins > Planning for “IOM” advocacy coalition March 2008 Boxer- Collins “Caring for an Aging America Act of 2008” April 2008 IOM Report Released - Retooling April 2008 Senate Special Aging testimony on IOM report December Kohl “Retooling the Health Care Workforce for an Aging America Act” January 2009 Eldercare Workforce Announced (JAHF and AP funding) June 2009 Senate HELP Bill Geriatric Workforce Provisions November 2008 House “Affordable Health Care for America Act” December 2009 Senate “Patient Protection and Affordable Care Act” 9

Health Reform? A Vehicle for Foundation Issues 1.Politics 2.Procedure Policy 10

Health (#115 of 486) 11

Senate/Presidential Legislation Title I – Insurance Regulation, Coverage Title II – Public programs, Coverage (Medicaid) Title III – Quality** Title IV – Prevention Title V – Workforce** Title VI – Reporting, Transparency, Fraud Title VII – Biologics/Medicines Title VIII – CLASS ACT (long-term Care Insurance) Title IX – Taxes and Revenue Title X – Amendments & Additions 12

Provisions Relevant to the Mission of The John A. Hartford Foundation – Improving Health and Health Care for Older Adults Not coverage for uninsured, mandates, federal take over Not very controversial Not very big 13

Important to us, but not much on the minds of others 14

Three Major Categories 1.Provisions Specific to the Geriatric Health Professions, Title V (small) 2.Provisions for the General Health Care Workforce Available/Adaptable for Geriatric Issues, Title V (medium) 3.Provisions Changing Payment and Regulation of Delivery System for Older Adults, Title III (large) 15

Geriatric Specific Workforce TITLE V—HEALTH CARE WORKFORCE Geriatric Workforce Development – 24 new Geriatric Education Centers, expanded focus $10.8M, 5 years (Sec. 5305) Geriatric Career Incentive Awards – non MD awards program (teaching or practice) $10M, 3 years (Sec. 5305) Training Opportunities for Direct Care Workers – grants program for long-term care workers $10M, 3 years (Sec. 5302) Healthcare Workforce Center/Analysis/Commission - national and state level look at workforce $39M, 4 years (Secs. 5103, 5101) 16

General Health Care Workforce TITLE V—HEALTH CARE WORKFORCE 10 % increase in Medicare payment for primary care services provided by MDs, NPs/CNSs, or PAs (includes geriatricians) who receive at least 60% of their income from providing primary care services. (Sec. 5501) Increased provider revenue ~ $3-5 Billion? 17

General Health Care Workforce TITLE V—HEALTH CARE WORKFORCE Sec Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. – GME beyond hospitals $125M/year, 4 years -> geriatrics training in residency Sec Mental and behavioral health education and training grants. – Scholarships in Social Work $8M and Psychology $12M, 4 years -> social work practicum and faculty development programs Sec Nurse education, practice, and retention grants. – Career ladders -> nursing assistants, associate degree, continuing ed. Sec Loan repayment and scholarship program. Sec Nurse faculty loan program. – up to $40,000 for MA, $80,000 PhD -> CGNEs, faculty awards Overall appropriation of $338M for

Delivery System TITLE III – Improving the quality and efficiency of health care – Subtitle A – Transforming the Health Care Delivery System PART III – Encouraging Development of New Patient Care Models...utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions... Establishment of Center for Medicare and Medicaid Innovation within CMS (Sec. 3021) $25M/year for administration and $1B/year for services – Accountable Care Organizations (Sec 3022) – Physician Group Practice Demonstration University of Michigan, Dartmouth, Geisinger – Bundled Payments (Sec. 3023) – 90 day episode capitation – Independence at Home Demonstration Program (Sec. 3024) – Home Hospital, Physician Home Visits – Community-Based Care Transitions Program (Sec. 3026) – Coleman and Naylor, $500M over 5 years 19

Delivery System TITLE III - Improving the quality and efficiency of health care Subtitle F—Health Care Quality Improvements Sec Health care delivery system research; Quality improvement technical assistance, $20M for 5 years, 1:5 private to public match Sec Establishing community health teams to support the patient-centered medical home –> Guided Care Sec Medication management services in treatment of chronic disease –> Partners in Care Medication Management Sec Patient navigator program. 20

Misc Provisions TITLE III Subtitle E (Ensuring Medicare Sustainability) Sec 3403 – Independent Medicare Advisory Board – MedPAC on Steroids TITLE VIII - Community Living Assistance Services and Supports CLASS ACT – long-term care insurance 21

Misc Provisions TITLE X - STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS – Subtitle D – Provisions Relating to Title IV Centers of Excellence for Depression (Sec ) $100-$150M annually for treatment, research and education centers around the country (1:5 private to public match) 22

Future Directions Geriatric Specific Provisions – advise and monitor – use advocacy mechanisms to argue for more General Health Workforce Provisions – inform and organize grantees to compete – capacity building technical assistance Delivery System – Bring Foundation experts and expertise into conversation – Strategically fund convening, planning, and research to influence implementation. 23

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Appendix Additional Provisions 25

TITLE II – Role of Public Programs Subtitle E—New Options for States to Provide Long-Term Services and Supports Sec Community First Choice Option. Sec Removal of barriers to providing home and community-based services. Sec Money Follows the Person Rebalancing Demonstration. Sec Protection for recipients of home and community-based services against spousal impoverishment. Sec Funding to expand State Aging and Disability Resource Centers. Sec Sense of the Senate regarding long-term care. Subtitle H—Improved Coordination for Dual Eligible Beneficiaries Sec year period for demonstration projects. Sec Providing Federal coverage and payment coordination for dual eligible beneficiaries. 26

TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE Subtitle A—Transforming the Health Care Delivery System PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM – Sec Hospital Value-Based purchasing program. – Sec Improvements to the physician quality reporting system. – Sec Improvements to the physician feedback program. – Sec Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs. – Sec Quality reporting for PPS-exempt cancer hospitals. – Sec Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies. – Sec Value-based payment modifier under the physician fee schedule. – Sec Payment adjustment for conditions acquired in hospitals. PART II—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY – Sec National strategy. – Sec Interagency Working Group on Health Care Quality. – Sec Quality measure development. – Sec Quality measurement. – Sec Data collection; public reporting. 27

TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH Subtitle A—Modernizing Disease Prevention and Public Health Systems Subtitle B—Increasing Access to Clinical Preventive Services – Sec Medicare coverage of annual wellness visit providing a personalized prevention plan. – Sec Removal of barriers to preventive services in Medicare. – Sec Evidence-based coverage of preventive services in Medicare. Subtitle C—Creating Healthier Communities – Sec Community transformation grants. – Sec Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries. – Sec Demonstration project concerning individualized wellness plan. Subtitle D—Support for Prevention and Public Health Innovation – Sec Research on optimizing the delivery of public health services. – Sec Advancing research and treatment for pain care management. 28