Implication of Health Care Reform on Hospitals National Capitol Healthcare Executives Falls Church, VA Ashley Thompson October 2, 2010

Why Health Reform? 51 million uninsured Insurance premiums have risen 131% over 10 yrs Annual premiums > $13,000 for family of four U.S. ranks 1 st in health care spending… but 38 th in health outcomes (in 2000) Current system rewards volume over value Care is provided across silos; it is not coordinated We have a “sick care” system, rather than a “health care” system

It’s the law – March 23, 2010

What’s In It? Coverage & Insurance Reform Insurance Reform Individual Mandate Employer “Play or Pay” Government Subsidies Administrative Simplification Delivery System Reforms Hospital VBP Bundling ACO/Shared Savings Readmissions CMI – Innovation Center Medicare & Medicaid Payment Changes Reductions to Annual Payment Update Reductions to DSH 340B Expansion Wage Index Changes Geographic Variation Adjustment Enhanced Rural Payment Medicare Extenders Workforce and GME Wellness and Prevention Quality Hospital Acquired Conditions Disparities Comparative Effectiveness Research Regulatory Oversight Tax-Exempt Status

Legislation Regulation

“The Secretary shall”

7 Hospitals will be: More Integrated More Accountable More At-Risk

Changing Payment Models Payment system changes encourage greater provider collaboration … Bundling – voluntary pilot program for acute care hospitals, LTCHs, IRFs, doctors, SNF, and HHA to receive bundled Medicare Part A and Part B payments for selected conditions Accountable Care Organizations – allows physicians, hospitals and others to participate in “shared savings” for managing a population Patient-Centered Medical Home – allows capitated payment to interdisciplinary primary care teams Center for Medicare & Medicaid Innovation – $10 billion to test innovative payment and service delivery models

Key Competencies for Forming ACOs Leadership Organizational culture of teamwork Relationships with other providers IT infrastructure for population management/care coordination Infrastructure for managing, monitoring quality Ability to assess and manage financial risk Ability to receive and distribute payments and savings Resources for patient education and support

Key Components: Personal physician Physician directed medical practice Whole person orientation Coordinated or integrated care Quality and safety Enhanced access Additional (capitated) payment Patient-Centered Medical Home

Primary Care Physicians Specialty Care Physicians Outpatient Hospital Care and ASCs Inpatient Hospital Acute Care Long Term Acute Hospital Care Inpatient Rehab Hospital Care Skilled Nursing Facility Care Home Health Care Medical Home Acute Care Bundling Acute Care Episode with PAC Bundling PAC Episode Bundling Models of Service Delivery Accountable Care Organizations

Clinical Integration is Critical Five legal hurdles: - Antitrust - Self referral (Stark) - Civil monetary penalties - Anti-kickback - Internal Revenue Code

Reward Value not Volume Payment system changes encourage patient safety, quality, value …. not volume Value-Based Purchasing – pay hospitals for actual performance on quality measures (not just reporting). Payments reduced 1% growing to 2% over 5 years. Hospital-Acquired Infections – penalizes hospitals with high rates of hospital-acquired conditions (top 25%) with a 1% reduction in Medicare payment for all discharges Readmission Penalties – hospitals with higher-than-expected readmissions will have a 1% (growing to 3%) reduction in Medicare payment for all discharges

Core Competency: Manage quality, patient safety, costs, and patient experience during more of the episode Reach: Connections to other care givers, patients pre- and post- Sharing: Share information on patients, quality, costs; share incentives Integration:Accepting Risk, Managing Care Integration Least Greatest Make CollaborateBuy

Other Implications Lower rates of reimbursement More patient volume (impact on ED?) Stronger focus on quality, patient safety and measurement Enhanced Health Information Technology Workforce shortages ? Focus on wellness & community health Care will be more integrated, coordinated 15

Reform resources Special Bulletin…brief summary Financial calculator Detailed summary Timelines Hospitals as employers Power-point presentations −Consumer audience −Internal hospital audience Member tools

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Tools and Guides

What comes next politically? Democrats −Selling the plan to public −Implementing regulations −Protecting those that took tough votes Republicans − Overall repeal − Constitutional challenges − Incremental efforts to repeal or “de-fund” provisions

“We all know that there is a hurricane coming for the Democrats. We just don’t know if it will be a Category 4 or a Category 5.” Peter D. Hart Democratic Pollster Newsweek September 20, 2010

Senate 2010 GOP Needs 10 House 2010 GOP Needs 39 Governors 2010 Currently 24 GOP Senate GOP House 2010 GOP + 47 Governors GOP

GOP Control of Congress New players on key committees Hearings, investigations and subpoenas Stake in governance Different dynamic on labor issues Efforts to “defund” health care reform Focus on deficit reduction Implications

Marginal control by Democrats No working majority Blue Dogs key swing vote No actions possible without bipartisan support Focus on deficit reduction Implications

Immediate issues (Fall Agenda) Medicare IPPS final rule –Coding offset –CAH provider taxes Health information technology rules…multi-campus Medicare outpatient rule (proposed) –Physician supervision of outpatient therapeutic services Physician payment fix

Positioning for reform Achieve solid hospital-physician (clinical) alignment Measure, report and deliver superior outcomes Attain a favorable cost position Strategic alliances

Implementation Strategic plan and framework Key areas of focus –Health insurance reform –Medicaid/CHIP expansion –Delivery system and payment reforms –Medicare/Medicaid payment changes –Quality –Workforce/Graduate medical education –Reporting information –Prevention and wellness –Program integrity and oversight

“Now is not the end. It is not even the beginning of the end. But, it is, perhaps the end of the beginning. ” Winston Churchill November 1942