1. Health Care Reform: How Will it Change the Delivery System? SOUTH CAROLINA HOSPITAL ASSOCIATION 4/1/2010

2. Who wants the federal government to get the deficit under control? Who wants the federal government to protect Medicare and Medicaid payments to hospitals and physicians? You should all vote Republican! You should all vote Democrat! Simplifying this year’s election

3. Evolution of U.S. Health Care Policy Our system is the result of several major policy decisions rather than one, unified health care policy. – Employer-based coverage – Government-sponsored coverage – EMTALA

4. The Emergence of Employer- Sponsored Coverage During World War II, wage controls administered by the federal government’s Office of Price Administration led employers to offer health insurance as a benefit in lieu of wage increases. 1940s1940s

5. Enactment of Medicare & Medicaid To provide coverage for the elderly as well as poor women and children, Congress enacted Medicare & Medicaid in the mid- 1960s. 1960s1960s

6. “In my State of the Union message, I pledged to present a program to assure that no American family will be prevented from obtaining basic medical care by inability to pay. I am announcing that program today.” “What I am proposing will require employers to provide basic health insurance for their employees. In the past, we have taken similar action to assure workers a minimum wage, to provide disability and retirement benefits. We should go one step further and guarantee that all workers will receive adequate health insurance protection.” President Richard Nixon February 18, 1971 1970s1970s

7. The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 is arguably the largest unfunded mandate ever imposed on private business. The law requires hospitals to screen and stabilize (treat) each and every patient who comes to the hospital ED seeking care, regardless of the patient’s ability to pay and regardless of what it costs the hospital to provide the care. 1980s1980s

8. In the early 1990s, the Clintons pressed for government-led health care reform… 1990s1990s

9. …but Republicans, led by Senator Bob Dole, strenuously opposed the Clinton plan. Dole and his fellow Republicans argued for a market-based system designed around an individual mandate and the creation of state insurance exchanges. 1990s1990s

10. Patient Protection and Affordable Care Act On March 23 rd, the Patient Protection and Affordable Care Act was signed into law. 20102010

13. Bipartisanship 1935 House: 372-33 Senate: 77-6 1965 House: 307-116 Senate: 70-24

14. 1964 House: 290-30 Senate: 73-27 1965 House: 328-74 Senate: 79-18 Bipartisanship

15. Democrats own it

16. “The Democrats are stuck with this bill…they’re going to have to live with it for the rest of their lives. Every problem that comes up is going to be blamed on them.” Senator Orrin Hatch (R-UT) March 24, 2010

17. The new law will bring a number of significant changes to the US healthcare system over the course of the next decade.

18. Strategic directions Coverage Delivery system reforms Payment reforms Transparency IT What is NOT in the law Movement away from fee-for- service…toward ‘integration” Emphasis on value vs. volume Emphasis on quality vs. quantity

19. What is NOT in the law No new public program No requirement that private insurance plans in state insurance exchanges pay Medicare or Medicaid rates No expansion of Medicare to age 55 to 65 No problematic provisions on spending variation No charity care requirement/formula to qualify for tax-exempt status No cuts in the indirect medical education adjustment No cuts for CAHs and exemptions No jurisdiction of Independent Board over (PPS) hospitals

21. Concerns Coverage targets being met Lack of meaningful liability reform Limited expansion of Medicare GME slots Failure to address end-of-life issues… “death panels” Changing the focus toward prevention Partisan politics

22. Strategic directions Delivery System Reforms Demonstration and Pilot Programs Accountable care organizations Bundling Medical homes Gain-sharing CMS Center for Innovation Physician self-referral Administrative simplification HHS Secretary can waive regulatory barriers to clinical integration

23. 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 Post Acute Care Episode Bundling Models of Service Delivery Accountable Care Organizations

24. Value based purchasing (2013) Quality −Readmissions (2013) −HAC penalties (2015) Medicaid physician payment 340B program expansions Payment Reforms Strategic directions

25. Quality Tax-exempt status Pricing Research protocols Comparative effectiveness research Transparency Strategic directions

26. Achieve solid hospital-physician (clinical) alignment Measure, report and deliver superior outcomes Attain a favorable cost position Strategic alliances For Hospitals

27. CORE PERFORMANCE! (Quality/Safety/Efficiency/Etc) ADDED VALUE? (Geography/Population/Physicians/Continuum/Public Health/Etc) INFO EXCHANGE CAPABILITY? (Interoperable/Regional Exchange/Etc) INSURANCE RISK CAPABILITY? (Stratification/Allocation/Real Time Info/Etc) MAKE?BUY? MOST FEWESTINTEGRATED NOT COLLABORATE? SPECIALIZE/RE-PURPOSE STRATEGIC QUESTIONS

28. For Physicians ThemeImplication Quality/TransparencyApply evidence-based practices to achieve best clinical results Value, not VolumeHow do we deliver the right care at the least cost? Payment reformsCoordinate your patients’ care (readmissions, bundling) with other providers ACOsLearn to manage risk in partnership with hospital and physician colleagues

29. More people with insurance means capacity challenges Payment reductions mean constrained resources at the bedside Enhanced focus on quality and transparency IOM Report: A Clear Message for Nursing Leaders For Nurses

30. In 2008, the RWJF approached the IOM to propose a partnership to assess and respond to the need to transform the nursing profession. Why? The nursing profession faces several challenges in fulfilling the promise of a reformed health care system and meeting the nation’s health needs. This partnership established a 2-year study on the future of nursing. The report was released this month, October 2010. The IOM Report

31. 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system. 3. Nurses should be full partners with Physicians and other health professional in redesigning healthcare in the U.S. 4.Effective workforce planning and policy making require better data collection and an improved information infrastructure. IOM’s 4 Key Messages

32. Health Care Reform: How Will it Change the Delivery System? SOUTH CAROLINA HOSPITAL ASSOCIATION 4/1/2010