1. 1 Patient Protection and Affordable Care Act (ACA)  Individual mandate (2014)  State insurance exchanges  Expansion of Medicaid program  Changes to private insurance  Employer requirements mandates  Medicare changes

2. 2 Untruthful Assertions  Cuts Medicare by $1000 per person Both ACA and the Ryan plan reduce increases in spending in the future by over $700 billion over 10 years  Establishes death panels Payment to physicians for holding advance care planning discussions was cut from the Act

3. 3 U.S. spending much more for older ages Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009.

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5. 5 Medicare  Reduce payments to Medicare Advantage MA plans were paid 113% of FFS Some bonuses for high quality programs  Balance payments to high/low areas  Establishes an “Independent Payment Advisory Board”  Early donut hole relief – eventual elimination  Coverage for prevention services

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7. 7 Independent Payment Advisory Board  Recommend cost savings  Produce public reports – access, quality, costs  Make recommendations to President and Congress  Prohibited from “rationing” or “changing benefits or eligibility” or “Medicare premiums”  Hospitals and hospices not subject to recommendations until 2019

8. 8 Donut Hole Relief 2011  $250 rebate 255, 996 FL seniors received the rebate Total amount to FL seniors - $63,999,000  Part D coverage gap discounts 252,989 Ave. per senior - $600 Total amount - $151, 807,700 Kff.org, 1/7/13

9. 9 Prevention & Wellness in FL  Free preventive services 1,662,014 FL seniors received free services 70% of FL Part B enrollees (65.5% US)  Annual wellness visit 151,133 FL seniors had an annual wellness visit 6.9% of FL Part B enrollees (5.4% US) Kff.org, 1/7/13

10. 10 Older Adult Workforce  Funds Geriatric Education Centers  Expand Geriatric Academic Career Award to other disciplines (nursing, pharmacy, etc.) New Geriatrics Career Incentive Award  Advanced training opportunities Professionals Direct care workers

11. 11 Elder Justice  Create an Elder Justice Coordinating Council Report published in May 2013 http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/ Meetings/docs/2013_05_13_EJCC-Proposals.pdf http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/ Meetings/docs/2013_05_13_EJCC-Proposals.pdf  $400 million for Adult Protective Services $100 million for state demonstration grants  $26 million to create Elder Abuse, Neglect and Exploitation Forensic Centers

12. 12 New Models of Care  Innovation Center at CMS Foster patient-centered care & coordination  Models Accountable Care Organizations Bundled payments Medicare Coordinated Care Partnerships for patients Comprehensive Primary Care

13. 13 Problems with Medical Payments  Fee-for-service Provider (not the consumer) decides what is needed Insurance (not the consumer) pays the fees Provider is incentivized to do more  Capitation (“by the head”) Insurer decides what is needed Insurer pays provider regardless of use Provider is incentivized to do less

14. 14 Accountable Care Organizations (ACO)  An organization of physicians and hospitals that agree to cost and quality targets  Strong primary care base  Payment is linked to quality (instead of volume)  Savings are achieved through improvements in care  Savings are shared between providers and CMS

15. 15 Bundled Payments  “Bundling” expenses that used to be separate Hospital admission and after care Surgery and a “warranty”  Considerations Hard to predict costs Difficult cases may be avoided Doesn’t discourage unnecessary care

16. 16 Medicare Coordinated Care  Funds coordinated care for people with chronic conditions  15 programs Face-to-face meetings with client Helped with medications Facilitated communications (“hub”) Helped with transitions  8%-33% reduction in hospitalizations  Cost neutral

17. 17 Comprehensive Primary Care  4 states (OR, CO, AK, NY)  Components Risk adjustment Access and continuity  Non-visit services & fees Planned care for chronic conditions Patient and caregiver engagement Coordination od care

18. 18 Partnerships for Patients  Reduce hospital-acquired conditions and readmissions  Elements Hospital Engagement Networks (TMH) Care Transitions (5 sites in FL) Patient and family engagement  Provides resources to health care providers to better educate staff and patients/families

19. 19 Elephant in the Room - LTC  Nursing homes - $100,000/year Many become impoverished and go on Medicaid  Low satisfaction  CLASS act – (part of ACA) – would have established a national LTC insurance Dropped by Democrats  Are some interesting new models Eden Alternative, Greenhouse Model

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21. 21 1 23 4 5 1 – Affordability & Access - 35 2 – Choice of setting & provider - 41 3 – Quality of life & quality of care - 43 4 – Support of family caregivers - 40 5 – Effective transitions - 14 State Scorecard on LTSS Commonwealth/AARP 2014

22. 22 Few Good Things in LTSS in ACA  National panel of LTC experts Report issued Sept. 2013  Funding for LTC Ombudsman Program  Funding for LTC training and recruitment  Nursing home transparency  Some financing options Money follows the person Home health and HCBS

23. 23 Nursing Home Transparency  Disclose ownership, financers, etc.  Take steps to reduce violations  Establish quality assurance programs  Provide dementia care training  Data collection requirements  Pilot program – extend to all states a national criminal background check system

24. 24 Good Resources  Kaiser Family Foundation http://kff.org  CMS Innovation Center http://innovation.cms.gov/initiatives/#views=models  Eden Alternative http://www.edenalt.org  Greenhouse Project http://thegreenhouseproject.org  Autumn Blossoms http://autumnblossoms.org