1. The Health Reform Edition

2. The Game Show….. that is not a game Rules: Question on health reform is asked. Joes (audience) allowed to provide an answer, then…. Pros (Dr. Clancy) allowed to provide an answer. Lightning Round – not enough time for debate as I think I am right and you are wrong.

3. Question 1. The March 2010 health reform Bill has how many pages?

4. Answer 1,990 pages and more than 400,000 words

5. 2. What are the 4 Cs that explain why health reform was needed?

6. The 4 C’s of the Push for Health Reform: 1.Cost – US health care costs too much 2.Coverage – insured and uninsured 3.Clinicians – currently practiced, not enough 4.Care Quality / Efficiency – not good enough

7. Cost

8. Losing Ground on US Competitiveness

10. Coverage

11. Insurance Issues Lifetime limits Pre-existing conditions Cancelling coverage

12. Uninsured 47,000,000 uninsured in the US. 650,000 uninsured in Oklahoma, 150,000 uninsured in Tulsa region or 1:5

13. 47 million uninsured in the US - Individuals without insurance are 1.4 to 2.6 times more likely than the insured to be diagnosed with last versus early stage cancer.

14. Bedlam Derm Clinic 2009

16. Clinicians

17. US short by 125,000 - 250,000 physicians in next 10 years AAMC Increase in US population Increase in life expectancy Baby boomer demand Declines in medical school class sizes. Oklahoma 49 th in primary care physicians per capita. United Health Foundation 2009

18. Care Quality and Efficiency

19. Chronic Disease = Re-admissions Congestive Health Failure COPD Diabetes Psychiatric Illness –Schizophrenia –Bipolar Disorder

21. Oklahoma has a very high rate of Heart Disease

22. 3. Where does Oklahoma rank when quality of care is plotted against cost of care? Quality of Care Cost of Care a. Here ? d. Here ? b. Here ? c. Here ?

23. COMMONWEALTH FUND State Scorecard Summary of Health System Performance

24. Although Oklahoma health status is very poor, health spending per capita is in the top quartile. Dartmouth Health Atlas 2009

25. Not OK!!

26. 4. How many major Federal health reform bills are active? a. 1 b. 2 c. 3 d. 4

27. 3 Federal Responses alive in 2010………….. 1.Patient Protection and Affordable Care Act – March 2010 2.American Recovery and Reconstruction Act – Stimulus Bill - 2009 3. Public Health Services Act - 1944

28. Federal Health Reform Legislative Process 2010 Federal Health Reform - ACA 1944 Public Health Services Act - PHSA Agency Policies, Procedures and Rules Health and Human Services Centers for Medicare and Medicaid Agency for Health Research and Quality Centers for Disease Control Health Resources and Services Administration House, Senate and White House Negotiations Passed Into Law 2009 Stimulus - ARRA Practice of Medicine In Community Modified Law ? Repealed Law?

29. 5. Beyond increasing health care coverage to the uninsured and insurance industry regulation…. name 8 additional areas covered in the March 2010 health reform bill?

30. Health Reform Basic Areas: 1.Health Care Coverage – 32 million now covered. 50% through Medicaid. In Tulsa, 100,000 newly insured. 2.Insurance Reform – limits on limits. 3.Workforce Initiatives – expand public health, nursing, PAs, nursing, primary care, FQHCs as teaching sites. 4.Access to Care – primary expansion through FQHCs. 5.Quality of Care – reimbursement based on reporting, performance. 6.Efficiency of Care – lower payments per visit, more patients in need. 7.Reimbursement Changes – bundled care, “risk” pushed to providers. 8.Greater detection of fraud, waste and abuse – more OIG agents. Not practicing evidenced based medicine is “waste and abuse.” 9.Faster transitions from research to patient care. 10.Center for Medicare and Medicaid Innovation – creativity in health care design and payment.

31. Insurance Reform No longer lifetime dollar limits on health care coverage, no denying of coverage for pre-existing conditions and no cancelling policies because someone gets sick. Extending Care - By 2014, plans underway for many Americans currently without health care coverage. Expanding eligibility for Medicaid Allowing children to be on parents plans up to the age of 26 Mandating those in certain income categories to purchase health care coverage – some subsidized. Creation of insurance exchanges that allow individuals to be included with larger groups in purchasing private – non-profit insurance plans.

32. Newly Insured Health insurance expansion will cover an estimated 32,000,000 of the 47,000,000 currently uninsured in the US. Roughly 16,000,000 will be covered through health insurance exchanges and 16,000,000 through Medicaid expansion. ROI on insuring more in Oklahoma through Medicaid is positive…. In the Tulsa region, this will initially be in the range of 30,000 newly insured patients and may grow to as many as 100,000 patients seeking health care and medical homes.

33. Workforce and Medical Education Primary Care PAs, NPs Teaching Health Centers – resident physician expansion family medicine, internal medicine, pediatrics, geriatrics, psychiatry, dentistry and pediatric dentistry.

34. Workforce Planning Loan Payback Programs – There is an expansion of the National Health Service Corp loan payback program, highlighting primary care. Included within this program - physicians receiving loan payback can split time 50% patient care to the underserved and 50% towards medical and resident teaching. Patient Centered Medical Home teams – Funding will become available to expand training in the Patient Centered Medical Home team model. Public Health – Funding will be available to promote Public Health training of medical students with a focus on epidemiology, disaster and emergency response and team-based patient care.

35. 6. Access : What will be the primary site for expansion of health care to the newly insured (currently underserved)?

36. FQHC Expansion: –Continued ramp up in capital, workforce and operations support of Federally Qualified Health Centers. –Peak funding is 2011. –$ 11 Billion over the next 5 years. –Morton, Community Health Connections and Indian Health Resource Center.

37. FQHC Distribution

38. FQHC utilization

39. 7. Do the health reform and other major Federal bills allow opportunities for community-driven creativity in redesigning health care delivery ? a. No b. Yes

40. Creative Communities 1.Beacon Communities Grant – health information exchange 2.Center for Medicare and Medicaid Innovation 3.Health Workforce Planning grants 4.Health Information Extension grants – Oklahoma Foundation Medical Quality

41. Center for Medicare and Medicaid Innovation Within CMS, this new center is created which allows for communities and organizations to create their own programs that improve the quality and efficiency of care and lower the cost of care. Bundling of Care – Programs for 10 conditions for bundling of all care 3 days prior to the primary interventions and for 30 days post intervention will begin by 1-1-2013. Accountable Care Organizations (ACO) – Shared governance organizations that are accountable for the quality, cost and overall care of Medicare patients assigned to a particular ACO.

42. 7. How will health reform cover its costs?

43. Cost of health reform: Decreased Payments - The legislation cuts about $455 billion over 10 years from projected payment increases to hospitals, insurance companies and others under Medicare and other government health programs. Increased Taxes - Revenue increases over 10 years include: $210 billion from increasing the Medicare payroll tax; $107 billion from fees on insurance companies, drug makers and medical device manufacturers; $32 billion from the excise tax on high-value insurance plans; and $2.7 billion from a tax on indoor tanning services.

44. Decreased Hospital Reimbursement There will be a phased in reduction in the usual annual increases in payments for hospital based care. There will be a phased in dramatic reduction in “DSH” - payments to hospitals. Hospitals will see penalties for readmission of myocardial infarction, congestive heart failure and pneumonia patients as well as for hospital acquired infections.

45. Changes in Physician Reimbursement Primary care gets a 10% bump. From 2011 – 2014, physician quality of care reporting and quality of care reimbursement will be implemented. “Meaningful use” of health information technologies will require: –Use of electronic health records –Health information exchange –Reporting of quality of care data. Initially, physicians will receive enhanced payment for “meaningful use.” Beginning in 2015, physicians will receive lower reimbursement for non-participation in quality initiatives and “meaningful use.”

46. Fraud Detection and Compliance Non-Profit Hospital Reporting – Non-profit hospitals will be required to justify their non-profit status as well as their attention to community need by: –Performing and publishing a Community Health Needs Assessment and Implementation Strategy every 3 years. –Publishing and promoting a financial assistance policy for patients unable to pay their hospital bills. –Publishing and promoting their emergency care policies. –Limiting charges to uninsured patients to the same levels as insured patients. Fraud, Waste, Abuse – Will see increase in funding for fraud detection ($ 150,000,000 for 2011), new powers for OIG, closer monitoring for kickback, promotion of whistle blowers and reporting of clinicians to National Practitioners Data Bank. Sunshine Act – Requires physicians to report all relationships and payments from industry (pharmaceutical, biological, device and IT).

47. 9. Where are the new areas for “profit” post health reform ?

48. Delivering Health Care Today Curve: Volume Procedures Specialty Care Hospital Care Cost based payment Revenue 2010201220142016 Tomorrow Curve: Quality Efficiency Performance Bundling Reduce expenses

49. “By 2014, you must learn how to make money at Medicare payment levels…” Revenue per patient Cost per patient CommercialMedicaidMedicareUninsured 2010 2010Dollars Payor Source Medicare 100%

50. 10. Why do people hate the health reform legislation?

51. Why hate the health reform legislation ? 1.Higher taxes 2.Lower reimbursement for some clinical services 3.Forced insurance coverage 4.Forced mandates on States 5.Big change in how we do things……

52. 11. Is there a way to organize all of this in your head so that the “emerging future” makes some sense ? a.No b.Yes c.Maybe d. all Does not matter, it is all going to be repealed starting in November.

53. 2009 – 2018 A time of great change ….. Pre-health reform  Implement health reform Uninsured  Many newly insured Physician centered care  Patient centered medical home Individual practitioners  Team care Paper  EMR  Health information exchange Volume based care  Performance, quality, efficiency focus Fee for service  Bundled payment Primary care focused GME  add specialty GME Distant relationship with payors  “All In” partnerships

54. “All In” All In – In poker, the “all in” strategy involves betting all of your chips on a single hand and declaring “I am going all in.” Other players must respond by also going “all in”, or folding. It is a risky move but often used when a player is losing ground and must catch up to stay in the game. A similar analogy is playing out in communities across the US. Health disparities are so severe in some of these regions, that these at-risk communities cannot economically compete.

55. Workforce Expanded, dedicated, diverse, culturally Expanded, dedicated, diverse, culturally competent, team-oriented skills to promote quality, competent, team-oriented skills to promote quality, efficiency and equity efficiency and equity Facile with health Information technologies Facile with health Information technologies Access to Care Right clinician at right Right clinician at right location at right time location at right time Community Community embedded embedded Safety, Quality and Efficiency New system promotes New system promotes high quality - efficient care high quality - efficient care with no errors, team care with no errors, team care Leverages health information Leverages health information technology technology Linked to Broader Determinants of Health Education, urban design, Education, urban design, economic development, safety economic development, safety Health literacy, early childhood Health literacy, early childhood Payment Models Promote safety, quality, efficiency, Promote safety, quality, efficiency, access for all, physician retention for access for all, physician retention for care of the underserved care of the underserved “All In” Integrated Model for High Performance Health Systems for the Underserved Community Medicine is far more than the medical school……..

56. Workforce Partnership with TU SCM Track and Recruitment Summer Institute PA program initiated Bedlam L team-care EMR sophistication Public Health certificates / MPH Preventive Medicine fellowships Access to Care Bedlam E / L FQHC expansion School-based Clinics Tulsa Housing Auth. Clinics North Tulsa Regional Ctr Tisdale Specialty Clinic Safety, Quality and Efficiency LEAN Patient Centered Medical Home and IMPACT Outreach Teams Doc 2 Doc Health Access Network Greater THAN Health Information Linked to Broader Determinants of Health Educare and Promise Neighborhoods OU Urban Design - CHED OU Pharmacy - health literacy OU Social Work – Turley YMCA Wellness and LIVESTRONG OU Community Engagement Center and Public Schools Payment Models Loan payback programs PMPM and case rates for team care Bumps for EMR and e-prescribing Preparing for quality reporting Direct to employer contracts Summit on Urban Health Center for Medicare and Medicaid Innovation, HRSA Tulsa “All In” Integrated Model for High Performance Health Systems for the Underserved

57. LEAN Initiative Savings (July-06 to June-09)

58. Wellness for those with major medical illness and chronic disease

59. Clinical Services Network Supported by Medical Education 346 clinicians, 98 specialized programs at 52 sites of practice Traditional Hospital-Based Services (5 hospitals, 18 programs) St. John – St. John – 24 / 7/ 365 Internal Medicine hospitalist teams, ICU team, geriatrics team*, general surgery teams, orthopedics trauma fellowship, dialysis team, procedures team, palliative care, vascular team. Hillcrest Medical Center – Hillcrest Medical Center – 24 / 7/ 365 Family Medicine hospitalists, in- house OB Gyn 24 / 7 / 365 services, Maternal Fetal Medicine program. Saint Francis Hospital – Saint Francis Hospital – Emergency Medicine faculty and residents, 24 / 7/ 365 OU Peds hospitalist teams, Psychiatry consultation team. Laureate Psychiatric Hospital – 24 / 7/ 365 Laureate Psychiatric Hospital – 24 / 7/ 365 Inpatient psychiatry care Jane Phillips Hospital – Jane Phillips Hospital – inpatient Family Medicine hospitalist and ob care. Resident Moonlighting – St. John, Saint Francis, Hillcrest. General medicine, OB. Traditional OU Clinics (5 OU Clinics, 37 specialized programs) Schusterman Center – Schusterman Center – “green card” ER referral from hospitals, general medicine clinic, geriatrics, HIV / Hepatitis, dermatology, geriatric psychiatry, psychiatry, adult diabetes, pediatric diabetes, gestational diabetes, general pediatrics, pediatric pulmonology, pediatric urology, OB, gynecology, perinatology, hypertension, headache, nephrology, Flu Clinics, student and employee health, OU Pharmacy, pain management, patient centered medical home teams. OU Family Medicine Center – OU Family Medicine Center – green card ER referrals from hospitals, family medicine, sports medicine, physical therapy, STEP Pharmacy, patient centered medical home teams. Warren Clinic – Warren Clinic – peds behavioral health, peds GI St. John Bernsen Center – St. John Bernsen Center – green card ER referrals from hospitals, OU Surgery Clinic, OU Vascular Clinic, OU Neurology Clinic. Ramona Clinic – Ramona Clinic – Family medicine and obstetrics Community Health Clinics (27 clinic sites and programs) Primary Care - Primary Care - 2 Bedlam Evening Clinics / week, 6 Bedlam Chronic Care / Longitudinal Clinics / week – patient centered medical home teams, Family and Children’s Services Primary Care Clinic in a mental health center, 2 Tulsa Housing Authority Apartment Clinics, 19 School-Based Clinics, Mobile Sooner Schooner II Clinics, Neighbors Along the Line Clinic, Day Center for the Homeless PA Clinic 5 days per week. Specialty Care - Bedlam Surgery Clinic, Bedlam Women’s Clinic, Bedlam Dermatology Clinic, Shriner’s Telemedicine Clinics, Bedlam Pharmacy Network, Bedlam Case Management, Bedlam Pharmacy Consultation, Web-based Visits, Web-based Consultations, Bedlam Specialist Referral Network, Xavier Breast Clinics, Optometry / Wound Care, Bedlam HIV and Hepatitis Clinic, Specialized Community Health Teams (20 programs) IMPACT Mobile Psychiatric Team, Community Health Connections and Morton Obstetrics Clinics, Porter and Hominy Obstetrics Outreach, Margaret Hudson High School Clinic, Neighbor for Neighbor and Morton Heart Intervention Program, Child Abuse Network – severe child abuse intervention team, Oklahoma Bio-ethics Center, Oklahoma Institute for Disaster and Emergency Medicine, Greater Tulsa Health Access Network (Greater THAN), Indian Health Resource Center Psychiatry - OB Programs, Youth Services of Tulsa Clinic team, Youth Services of Tulsa outreach clinic, Laura Dester – child abuse shelter, OU Nursing Prenatal Outreach – Inter-conception Care. Harvard Center for Child Development partnership. Tulsa Health Department Dysplasia Clinic, US Probation Office Clinic. Coming Soon – Coming Soon – ER frequent flyer case management team, pediatric bone cancer, Wayman Tisdale Specialty Health Center

60. OU Wayman Tisdale Specialty Health Center: OU Cancer Center, OU Diabetes Center, diagnostic testing, urgent / cardiac care in the heart of an underserved area

61. We Can Fight Everything or We Can Build Something Great….