1. D EPARTMENT of F AMILY M EDICINE The Patient Protection and Affordable Care Act: Public Law 111:148 Will it cure our rural & Ag health problems? Signed into Law March 23, 2010 Paul James MD

2. D EPARTMENT of F AMILY M EDICINE Is Health Reform Important?

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7. D EPARTMENT of F AMILY M EDICINE What did we hope that it would improve for rural Americans?  Improve Accessibility  Improve Affordability  Provide higher quality health care

8. D EPARTMENT of F AMILY M EDICINE Consumer Provisions (Insurance Reform): 6 months after enactment  Bars insurance from denying coverage to children with pre- existing conditions  Prohibits insurers from dropping coverage when individuals get sick.  Bans insurers from placing lifetime caps on coverage.  Extends age for children on parents’ plan to 26 years old.

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10. D EPARTMENT of F AMILY M EDICINE Consumer Provisions: January 1, 2014  Insurance Mandate: Individuals must purchase health insurance or face tax unless financial hardship  State Insurance Exchanges: enables consumers to purchase based on large group experience  Individual Tax Credits: for low income individuals to purchase through state exchanges  Insurance can no longer deny coverage to adults for pre-existing conditions, premium variation cannot exceed 3:1 based on age, geography, family size & tobacco use

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12. D EPARTMENT of F AMILY M EDICINE Preventative Health Services 6 months after enactment  All new plans must cover prevention services. These include:  Evidence-based services with “A” or “B” rating from USPSTF  Immunizations recommended by ACIP of CDC  HRSA preventative guidelines for women and children preventative care

13. D EPARTMENT of F AMILY M EDICINE Primary Care Provisions  Medicare payments: 10% bonus payment for primary care services for 5 years beginning in 2011 or if individual furnishes 60% of allowed charges for select Medicare (E&M) codes  2 year experiment beginning in 2013 that guarantees Medicaid pays primary care physicians at least as much as Medicare, including immunizations  Misvalued physician payment codes: Secretary will identify misvalued services & make appropriate adjustments. CMS will also be given more authority to adjust payments

14. D EPARTMENT of F AMILY M EDICINE Innovative Programs January 1, 2011  Allows states to create Patient Centered Medical Homes for patients with chronic illnesses and will be tested by the CMS Innovation Center (Medicare/Medicaid)  The purpose of the Innovation Center is to test payment and delivery models  Payment Bundle Pilot: 5 yr. pilot for patients with 1 or more of 10 conditions during an episode of care  allows for expansion

15. D EPARTMENT of F AMILY M EDICINE Medical Education Provisions  Reauthorizes Title VII Section 747 to support primary care education (2010-2014)  Provision to support schools to recruit students most likely to practice in rural underserved communities, provide rural-focused training & increase # of graduates who practice in rural communities  Developmental grants for Teaching Health Centers to expand primary care residencies

16. D EPARTMENT of F AMILY M EDICINE GME Provisions  Re-allocation of 65% of available residency slots to primary care and general surgery. Complex redistribution dependent upon many variables. Based on cost reporting after 7/1/2011  Volunteer Preceptor/Didactic training, sick, vacation & other leave: modifies DGME & IGME to count costs incurred at non- hospital setting (2010)

17. D EPARTMENT of F AMILY M EDICINE Primary Care Extension Program  Establishes this program to support and assist primary care providers to improved linkage to community health (PCMH)  State hubs and local extension programs may be created  Primary care departments may apply for funding  FY11 & 12: $120 Million. FY 13 & 14 (as much as is needed)

18. D EPARTMENT of F AMILY M EDICINE HealthCare Workforce Commissions/Committees  Establishes Medicaid & CHIP Payment and Advisory Commission (MACPAC) to consult with MedPAC  Establishes National Healthcare Workforce Commission that must provide “analysis of, and recommendations for, eliminating the barriers to entering and staying in primary care, including provider compensation.” (Sept. 30, 2010)  MedPAC Study on Adequacy of Medicare Payments for providers serving rural areas- due January 1, 2011

19. D EPARTMENT of F AMILY M EDICINE Quality Measure Reporting January 1, 2011  Additional 0.5% Medicare payment bonus if report quality measures to CMS through qualified maintenance program  Public reporting of performance using “Physician Compare” website with public viewing beginning 2013  In 2019, a pilot program will test financial incentives to beneficiaries who choose “high quality” physician providers  Medicare claims will be allowed to release provider performance measures

20. D EPARTMENT of F AMILY M EDICINE Accountable Care Organizations January 1, 2012  Organizations must meet performance criteria and can share in savings from high quality, low cost care  Provides flexibility to Secretary to implement innovative payment models, including those in private sector

21. D EPARTMENT of F AMILY M EDICINE Patient Centered Outcomes Research Institute (FY 2010)  Will be run by governing board composed of director of AHRQ & NIH with appointed stakeholders  Will be a non-profit corporation  Identify research priorities, establish project agenda & study how health problems can be studied and managed  Funded through a Trust Fund without appropriation

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23. D EPARTMENT of F AMILY M EDICINE Medical Liability?  Not much here  Allows state demonstration programs to evaluate alternatives. Suggests that it is the Senate’s desire that “states should be encouraged to develop alternatives to existing litigation systems.”  Provides extension of medical malpractice coverage to free clinics (FY 2011)

24. D EPARTMENT of F AMILY M EDICINE Law’s Impact on Patients  Begins to close the Medicare Part D coverage gap in prescription drug coverage  Establishes 59 state-administered insurance marketplaces to allow small businesses and those without employer sponsored coverage to buy insurance that meets federal standards  Expands Medicaid to cover all who earn less than 133% of federal poverty level ($29,327 for family of 4)

25. D EPARTMENT of F AMILY M EDICINE Impact on Medical Practice  Standardize health insurance claims processing requirements between 2013-2016. Will simplify tracking claims and improve revenue cycle  Physician employees will benefit from small business tax credits for health insurance contributing 50% of costs of coverage

26. D EPARTMENT of F AMILY M EDICINE Impact on Physician Payment  Sustainable Growth Rate adjustment remains flawed  5% incentive payment for mental health services  Geographic payment differentials were adjusted to benefit physicians in rural and low cost areas

27. D EPARTMENT of F AMILY M EDICINE Impact on Small Business  Creates state pools (exchanges) to reduce insurance costs. At least 2 multi-state plan options must be available (1 must be not-for-profit)  Insurance can no longer deny coverage or raise rates b/c of health status, age or pre-existing conditions  Businesses with over 50 employees with at least 1 full time with benefits must provide health insurance. 96% of small businesses exempt  Provides $40 billion in tax credits to small businesses for health insurance: instituted in 2 phases, 2010 & 2014

28. D EPARTMENT of F AMILY M EDICINE National Health Service Corps FY 2010-2015  Large expansion: from $320 million in FY10 to $1.15 billion by 2015  Will allow part-time service  Will encourage clinical teaching through THC’s (Teaching Health Centers)  Establishes a “Ready Reserve Corps”

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30. D EPARTMENT of F AMILY M EDICINE Community Living Assistance Services and Support Act: (CLASS Act)  Law favors home and community-based services with federal matching funds  Expands protections against spousal impoverishment for Medicaid patients receiving home and community services  But we don’t know whether premiums will be too expensive for average rural family

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32. D EPARTMENT of F AMILY M EDICINE Will the Rx solve our rural & Agricultural health problems?  Maybe Yes:  It will expand insurance coverage  It will support small businesses to offer health insurance  But will more doctors and nurses move to rural communities and will more primary care doctors be trained?  Will rural hospitals be supported?

33. D EPARTMENT of F AMILY M EDICINE Will the Rx solve our rural & Agricultural health problems?  Maybe Not:  If costs are not controlled and health care is reduced in size without planning for access issues  If market forces that favor urban economies of scale are allowed to continue

34. D EPARTMENT of F AMILY M EDICINE Reference  http://www.kff.org/healthreform/8061.cfm http://www.kff.org/healthreform/8061.cfm  The Henry J. Kaiser Family Foundation  AAFP  Medical Education Futures