Health Care Reform: Health Care Reform: Access, Cost and Access, Cost and QualityQuality

William P. Moran MD MSWilliam P. Moran MD MS

Director, General Internal Director, General Internal Medicine and GeriatricsMedicine and Geriatrics

Chair, SGIM Health Policy Chair, SGIM Health Policy CommitteeCommittee

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AgendaAgenda

Cost, access and quality of careCost, access and quality of care Battle lines are drawnBattle lines are drawn Proposals move through in Proposals move through in

Congress and a surprise for the Congress and a surprise for the SenateSenate

The Bill and the Second BillThe Bill and the Second Bill What’s in OUR future?What’s in OUR future?

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We spend twice as much as We spend twice as much as

other industrialized nations...other industrialized nations...

Per capita health care Per capita health care spending of select OECD spending of select OECD nations, 2003nations, 2003Source: The Commonwealth FundSource: The Commonwealth Fund

US Health care expenditures as percentage of GDP: Unsustainable cost growth

                                                                                                               

Source: CMS. Office of the Actuary, National Health Statistics Group.

2009

18%

If US health care was a country, it would be the 12th largest economy in the world…

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Insurance premiums are too Insurance premiums are too highhigh

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Then there is the Then there is the uninsured…uninsured… ~ 47 million uninsured~ 47 million uninsured >80 million under-insured>80 million under-insured 44,800 excess deaths annually44,800 excess deaths annually

due to lack of insurancedue to lack of insurance 8,000 Americans loose their 8,000 Americans loose their

health insurance every dayhealth insurance every day

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The Young Invincibles The Young Invincibles They’re young and healthy, and insurance is expensive. As They’re young and healthy, and insurance is expensive. As long as they don’t catch the flu, slip on the ice, crash a bike, long as they don’t catch the flu, slip on the ice, crash a bike, snowboard into a tree, rupture an appendix, or get hit by a snowboard into a tree, rupture an appendix, or get hit by a bus, everything will be fine. Right?bus, everything will be fine. Right?

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The challenge of The challenge of quality….quality…. SafeSafe Patient centeredPatient centered TimelyTimely EffectiveEffective EfficientEfficient EquitableEquitable

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Although US costs are highest Although US costs are highest …the quality of care is far from …the quality of care is far from optimaloptimal

RAND: Americans get RAND: Americans get evidence-based care evidence-based care only 55% of the timeonly 55% of the time

IOM: Up to 98,000 Americans IOM: Up to 98,000 Americans die each year due to die each year due to avoidable medical errorsavoidable medical errors

CDC: 2 million acquire CDC: 2 million acquire nosocomial infections nosocomial infections annually; 90,000 dieannually; 90,000 die

WHO: US is 32WHO: US is 32ndnd in the world in the world

Remember this couple?

Battle lines are drawn….

Early Skirmish The American Recovery and Reinvestment ActAKA the Stimulus Bill

Ruin Your Health With the Obama Stimulus Plan:

Commentary by Betsy McCaughey

Elderly Hardest Hit Daschle says health-care reform “will not be pain free.” Seniors should be more accepting of the conditions that come with age instead of treating them. That means the elderly will bear the brunt.

Medicare now pays for treatments deemed safe and effective. The stimulus bill would change that and apply a cost- effectiveness standard set by the Federal Council (464).

Threat to Privacy

Socialized Medicine

Government bureaucracy

Rationing

Elderly need to accept their fa

te

First, insurers must thoroughly cover everyone who wants, and will pay for, insurance, regardless of health, age or pre-existing conditions (this is known as “guarantee issue”). Second, insurers would be required to charge customers the same regardless of health (called “community rating”).For their part, insurance companies want a third mandate, called the individual mandate, under which the federal government forces people to buy and maintain health insurance...so that risk is spread.

Health Care Reform Effort Draws Opposition AP Saturday, March 07, 2009

The flashpoint is a proposal that would give Americans the option of buying medical coverage through a government plan. President Obama and many Democrats have endorsed it, as one part of a broader health overhaul. On Saturday, Republicans laid down a challenge.

"I'm concerned that if the government steps in, it will eventually push out the private health care plans millions of Americans enjoy today," Republican Rep. Roy Blunt (MO) said in the Republican weekly radio address.

Blunt, who will play a leading role in the debate, warned: "This could cause your employer to simply stop offering coverage, hoping the government will pick up the slack."

Mark E. Miller, Ph.D., executive director of the Medicare Payment Advisory Commission, suggested that changes in the Medicare payment system were essential to both increasing the nation's physician supply and streamlining health care delivery.

Drugmakers Boost Lobbying to Police Drug Comparisons

Jonathan D. Salant And Aliza Marcus – Fri Apr 17, 4:49 pm ET

April 17 (Bloomberg) -- U.S. drugmakers are working to ensure that President Barack Obama’s move to encourage cheaper medical care doesn’t end up dictating treatments to doctors and insurers. Already the biggest spender on influencing policy, the drug industry, including Merck & Co. and Eisai Co., is relying on well-known individuals, some with stories of personal battles against disease, to promote its views. They include Tony Coelho, a former U.S. House Democratic leader who has epilepsy; Andrea LaRue, counsel to Tom Daschle when he was Senate Democratic leader; and the firm of Democratic fundraiser Tony Podesta, brother of Obama adviser John Podesta.

Drugmakers Boost Lobbying to Police Drug Comparisons (cont’d)

Makers of drugs and other health-care products say they support side-by-side studies of medical products as a tool for doctors and patients, not as a way to stop medical professionals from prescribing a more expensive drug if they’re convinced it will work better.

The industry has already recorded one victory, supporting the removal of language concerning costs from a $1.1 billion funding provision for such studies included in the ARRA passed in February.

Party Politics

THE LANGUAGE OF HEALTHCARE 2009 (April 2009)

THE 10 RULES FOR STOPPING THE “WASHINGTON TAKEOVER” OF HEALTHCARE

Frank Luntz

Luntz - Language

(1) Humanize your approach. “Individualize. Personalize. Humanize.”

(2) Acknowledge the “crisis” or suffer the consequences. “If you have to wait weeks for tests and months for treatment, that’s a healthcare crisis.”

(3) “Time” is the government healthcare killer. “Waiting to buy a car or even a house won’t kill you. But waiting for the healthcare you need – could. Delayed care is denied care.”

Luntz - Language

(4) The arguments against the Democrats’ healthcare plan must center around “politicians,” “bureaucrats,” and “Washington” … not the free market, tax incentives, or competition.

(5) The healthcare denial horror stories from Canada & Co. do resonate, but you have to humanize them. “government takeover”

(6) Healthcare quality = “getting the treatment you need, when you need it.” “The plan put forward by the Democrats will deny people treatments they need and make them wait to get the treatments they are allowed to receive.”

(7) “One-size-does-NOT-fit-all.” “committee of Washington bureaucrats” “protection of the personalized doctor-patient relationship.”

Luntz - Language

(8) WASTE, FRAUD, and ABUSE are your best targets for how to bring down costs.

(9) Americans will expect the government to look out for those who truly can’t afford healthcare. “A balanced, common sense approach that provides assistance to those who truly need it and keeps healthcare patient-centered rather than government-centered for everyone.”

(10) It’s not enough to just say what you’re against. You have to tell them what you’re for “more access to more treatments and more doctors…with less interference from insurance companies and Washington politicians and special interests.”

Politicizing Health Politicizing Health Care ReformCare Reform

"If we're able to stop "If we're able to stop Obama on [health care Obama on [health care reform], it will be his reform], it will be his Waterloo. It will break him Waterloo. It will break him and we will show that we and we will show that we can, along with the can, along with the American people, begin to American people, begin to push those freedom push those freedom solutions...”solutions...”

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Mandatory enrollment (penalties)

Expansion of Medicaid

State Insurance Exchange

Basic benefits (including medications)

Subsidized premiums

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Transformative ChangeTransformative ChangeEquitable Access to CareEquitable Access to CareInsurance ReformInsurance ReformComparative effectiveness researchComparative effectiveness researchWorkforce changesWorkforce changesPhysician payment reform and Physician payment reform and delivery system redesigndelivery system redesign

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Transformative ChangeTransformative ChangeEquitable Access to CareEquitable Access to CareInsurance ReformInsurance ReformComparative effectiveness researchComparative effectiveness researchWorkforce changesWorkforce changesPhysician payment reform and Physician payment reform and delivery system redesigndelivery system redesign

“Larg

e-scale in

crementa

l change”

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Health Care Health Care Committees of Committees of JurisdictionJurisdiction SenateSenate

– Health, Education, Labor & Pensions Health, Education, Labor & Pensions (HELP)(HELP) – Sen. Harkin (IA) (Kennedy) – Sen. Harkin (IA) (Kennedy)

– Finance Finance – Sen. Baucus (MT)– Sen. Baucus (MT) House House

– Energy & Commerce –Energy & Commerce – Rep. Waxman Rep. Waxman (CA)(CA)

– Ways & MeansWays & Means – Rep. Levin (MI) – Rep. Levin (MI) (Rangel)(Rangel)

– Education & LaborEducation & Labor – Rep. Miller (CA) – Rep. Miller (CA)

““Laws are like Laws are like sausages. It's better sausages. It's better not to see them being not to see them being made.”made.”

Otto von BismarckGerman Prussian German Prussian politician (1815 - 1898)politician (1815 - 1898)

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Understanding the game: Understanding the game: This is how our laws are This is how our laws are mademade

And this is how And this is how sausage is made…sausage is made…

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

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“Patient-centered Outcomes Research Act of 2009”(Comparative Effectiveness Research):House Ways and Means and Senate Finance

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““Preserving Patient Preserving Patient Access to Primary Care Access to Primary Care Act”Act”

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HELP “Affordable Health Choices HELP “Affordable Health Choices Act”Act”

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HELP “Affordable Health Choices HELP “Affordable Health Choices Act”Act”

CBO: $2.6 trillion over 10 years and

covers only 16 million uninsured

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House Tri-Committee House Tri-Committee billbill

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House Tri-Committee House Tri-Committee billbill

Access to Coverage and Choice Affordability Shared ResponsibilityControlling CostsPrevention and WellnessWorkforce Investments

Reforming SGR and the Physician Payment System: Rewarding Primary Care, Coordination, and Efficiency

“Affordable Health Care

for America Act”

Passed the House 220-215

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

HR 3962HR 3962

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Christmas Eve passed the

Senate 60-40 on a

party line vote

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

But then…

HR 3962HR 3962

HR 3590HR 3590

Senator Kennedy’s death precipitated a special senate election in MA

Scott Brown (R) v Martha Coakley (D)

Republican Scott Brown elected to senate from MA

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Understanding The Game: Understanding The Game: How Our Laws Are MadeHow Our Laws Are Made

HR 3962HR 3962

HR 3590HR 3590

Senate 59-41

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HR 3962HR 3962

HR 3590HR 3590

Senate 59-41

The NEW Game: Senate Rs can The NEW Game: Senate Rs can now filibuster! Reconciliation? now filibuster! Reconciliation?

X

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A new path for HR 3590: A new path for HR 3590: Trust the Senate?Trust the Senate?

HR 3590HR 3590

““The Republicans are The Republicans are the opposition – the the opposition – the Senate is the Senate is the enemy.” enemy.”

The Honorable Thomas The Honorable Thomas P. ‘Tip’ O’Neil Jr. D-MAP. ‘Tip’ O’Neil Jr. D-MASpeaker of the House from 1977-1987

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CBO revised estimates that the bill would reduce projected federal budget deficits by $138 billion over the next decade, and more than $1 trillion over the subsequent decade

H.R. 3590

H.R. 3590

Passed the House 219-212

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The House strikes back: The House strikes back: Reconciliation H.R. 4872Reconciliation H.R. 4872

Senate Rules for Reconciliation

Must be limited to budget changes Requires a simple majority 51-49 Cannot change substantive non-

budget items Issues off the table

– Government option– Abortion restrictions or language

change

Reconciliation passed

the House 220-211

Reconciliation: Will th

e

Senate pass it?

WASHINGTON, March 23 (UPI) -- U.S. President Barack Obama will sign the sweeping healthcare reform bill into law Tuesday in the East Room, the White HOUSE said.

So what is in H.R. 3590 signed today by the President?

Market Reform Insurance Reform State insurance exchanges Coverage choices Changes to improve the quality Changes to improve the quality

and efficiency of health careand efficiency of health care

MARKET REFORM

PART A—INDIVIDUAL AND GROUP MARKET REFORMSSUBPART II—IMPROVING COVERAGESec. 2711. No lifetime or annual limits.Sec. 2712. Prohibition on rescissions.Sec. 2713. Coverage of preventive health services.Sec. 2714. Extension of dependent coverage.Sec. 2715. Development and utilization of uniform

explanation of coverage documents and standardized definitions.

Sec. 2716. Prohibition of discrimination based on salary.

Sec. 2717. Ensuring the quality of care.Sec. 2718. Bringing down the cost of health care

coverage.Sec. 2719. Appeals process.

INSURANCE REFORM

Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status.

Sec. 2701. Fair health insurance premiums.Sec. 2702. Guaranteed availability of coverage.Sec. 2703. Guaranteed renewability of coverage.Sec. 2705. Prohibiting discrimination against

individual participants and beneficiaries based on health status.

Sec. 2706. Non-discrimination in health care.Sec. 2707. Comprehensive health insurance

coverage.Sec. 2708. Prohibition on excessive waiting periods.

STATE INSURANCE EXCHANGES

Sec. 1321. State flexibility in operation and enforcement of Exchanges and related requirements.

Sec. 1322. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers.

Sec. 1323. Community health insurance option.Sec. 1324. Level playing field.

PART IV—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS

Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.

Sec. 1332. Waiver for State innovation.

E—Affordable Coverage Choices for All AmericansPART I—PREMIUM TAX CREDITS AND COST-

SHARING REDUCTIONS

Sec. 1401. Refundable tax credit providing premium assistance for coverage under a qualified health plan.

Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans.

Small business and employeesPART II—SMALL BUSINESS TAX CREDITSec. 1421. Credit for employee health insurance

expenses of small businesses.

PART I—INDIVIDUAL RESPONSIBILITYSec. 1501. Requirement to maintain minimum

essential coverage.

PART II—EMPLOYER RESPONSIBILITIESSec. 1511. Automatic enrollment for employees of

large employers.Sec. 1512. Employer requirement to inform

employees of coverage options.Sec. 1513. Shared responsibility for employers.

TITLE II—ROLE OF PUBLIC PROGRAMSImproved Access to MedicaidSec. 2001. Medicaid coverage for the lowest

income populations.

Subtitle B—Enhanced Support for the Children’s Health Insurance Program

Sec. 2101. Additional federal financial participation for CHIP.

Subtitle C—Medicaid and CHIP Enrollment Simplification

Sec. 2201. Enrollment Simplification and coordination with State Health Insurance Exchanges.

TITLE II—ROLE OF PUBLIC PROGRAMSImproved Access to Medicaid

Subtitle E—New Options for States to Provide Long-Term Services and Supports

Sec. 2401. Community First Choice Option.Sec. 2402. Removal of barriers to providing

home and community-based services.Sec. 2403. Money Follows the Person

Rebalancing Demonstration.Sec. 2404. Protection for recipients of home

and community-based services against spousal impoverishment.

Sec. 2405. Funding to expand State Aging and Disability Resource Centers.

Improved Access to Medicaid

Subtitle F—Medicaid Prescription Drug Coverage

Sec. 2501. Prescription drug rebates. Sec. 2502. Elimination of exclusion of

coverage of certain drugs. Sec. 2503. Providing adequate pharmacy

reimbursement.

Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments

Sec. 2551. Disproportionate share hospital payments.

IMPROVING THE QUALITY AND IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CAREEFFICIENCY OF HEALTH CARE

Subtitle A—Transforming the Subtitle A—Transforming the Health Care Delivery SystemHealth Care Delivery System

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• Extends through 2014 payments under the PQRI program, which provide incentives to physicians who report quality data to Medicare. • Creates appeals and feedback processes for participating in PQRI. • Establishes a participation pathway for physicians completing Maintenance of Certification program • In 2014, physicians who do not submit to PQRI will have their Medicare payments reduced.

Part I – LINKING PAYMENT TO QUALITY OUTCOMES IN MEDICARE

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• Expands Medicare’s physician resource use feedback program to develop of individualized reports by 2012.• Reports will compare the per capita utilization of physicians to other physicians who see similar patients.• Reports will be risk-adjusted and standardized

Sec. 3003. Improvements to the Sec. 3003. Improvements to the physician feedback program. physician feedback program.

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Sec. 3007. Value-based payment Sec. 3007. Value-based payment modifier under the physician fee modifier under the physician fee schedule.schedule.

• Directs the Secretary of HHS to develop and implement a budget-neutral payment system that will adjust Medicare physician payments based on the quality and cost of the care they deliver.

• Quality and cost measures will be risk-adjusted and geographically standardized.

•The Secretary will phase-in the new payment system over a 2-year period beginning in 2015.

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Sec. 3008. Payment adjustment for Sec. 3008. Payment adjustment for conditions acquired in hospitalsconditions acquired in hospitals

• Starting in FY2015, hospitals in the top 25th percentile of rates of hospital acquired conditions for certain high-cost and common conditions would be subject to a payment penalty under Medicare.

• Report to Congress by January 1, 2012 on the appropriateness of establishing a healthcare acquired condition policy related to other providers participating in Medicare, including nursing homes, inpatient rehabilitation facilities, long-term care hospitals, outpatient hospital departments, ambulatory surgical centers, and health clinics.

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PART II--NATIONAL STRATEGY TO PART II--NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITYIMPROVE HEALTH CARE QUALITY

SEC. 3011. NATIONAL STRATEGYSEC. 3011. NATIONAL STRATEGY SEC. 3012. INTERAGENCY WORKING GROUP SEC. 3012. INTERAGENCY WORKING GROUP

ON HEALTH CARE QUALITYON HEALTH CARE QUALITY SEC. 3013. QUALITY MEASURE DEVELOPMENTSEC. 3013. QUALITY MEASURE DEVELOPMENT SEC. 3014. QUALITY MEASUREMENTSEC. 3014. QUALITY MEASUREMENT SEC. 3015. DATA COLLECTION; PUBLIC SEC. 3015. DATA COLLECTION; PUBLIC

REPORTINGREPORTING

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Part III – Encouraging Development of Part III – Encouraging Development of New Patient Care ModelsNew Patient Care Models Sec. 3021. Establishment of Center for Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within Medicare and Medicaid Innovation within CMS. CMS.

Establishes within the Centers for Medicare Establishes within the Centers for Medicare and Medicaid Services (CMS) a Center for and Medicaid Services (CMS) a Center for Medicare & Medicaid Innovation. Medicare & Medicaid Innovation. – research, develop, test, and expand innovative research, develop, test, and expand innovative

payment and delivery arrangements to improve payment and delivery arrangements to improve the quality and reduce the cost of care provided to the quality and reduce the cost of care provided to patients in each program. patients in each program.

– Dedicated funding is provided to allow for testing Dedicated funding is provided to allow for testing of models that require benefits not currently of models that require benefits not currently covered by Medicare. covered by Medicare.

– Successful models can be expanded nationally.Successful models can be expanded nationally.

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Sec. 3022. Medicare shared savings Sec. 3022. Medicare shared savings program.program.

Rewards Rewards Accountable Care Organizations Accountable Care Organizations (ACOs) (ACOs) that take responsibility for the that take responsibility for the costs and quality of care received by costs and quality of care received by their patient panel over time. their patient panel over time.

ACOs can include groups of health care ACOs can include groups of health care providers (including physician groups, providers (including physician groups, hospitals, nurse practitioners and hospitals, nurse practitioners and physician assistants, and others). physician assistants, and others).

ACOs that meet quality-of-care targets ACOs that meet quality-of-care targets and reduce the costs of their patients and reduce the costs of their patients relative to a spending benchmark relative to a spending benchmark are are rewarded with a share of the savings rewarded with a share of the savings they achieve for the Medicare programthey achieve for the Medicare program..

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Part III – Encouraging Development of Part III – Encouraging Development of New Patient Care ModelsNew Patient Care ModelsSec. 3023. National pilot program on Sec. 3023. National pilot program on payment bundling. payment bundling. Direct the Secretary to develop a Direct the Secretary to develop a

national, voluntary pilot program national, voluntary pilot program encouraging hospitals, doctors, and encouraging hospitals, doctors, and post-acute care providers to improve post-acute care providers to improve patient care and achieve savings for the patient care and achieve savings for the Medicare Medicare

Requires the Secretary to establish this Requires the Secretary to establish this program by January 1, 2013 for a period program by January 1, 2013 for a period of five years. of five years.

Before January 1, 2016, required to Before January 1, 2016, required to submit a plan to Congress to expand the submit a plan to Congress to expand the pilot program if doing so will improve pilot program if doing so will improve patient care and reduce spending.patient care and reduce spending.

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Sec. 3025. Hospital Sec. 3025. Hospital readmissions reduction readmissions reduction program.program.

Beginning in FY2012, adjusts payments for Beginning in FY2012, adjusts payments for hospitals paid under DRG payment system hospitals paid under DRG payment system based on the dollar value of each hospital’s based on the dollar value of each hospital’s percentage of potentially preventable percentage of potentially preventable Medicare readmissionsMedicare readmissions– three conditions and risk adjusted readmission three conditions and risk adjusted readmission

measures that are currently endorsed by the measures that are currently endorsed by the National Quality Forum. National Quality Forum.

Secretary has authority to expand the policy Secretary has authority to expand the policy to additional conditions in future years to additional conditions in future years

Directs the Secretary to calculate and make Directs the Secretary to calculate and make publicly available information on all patient publicly available information on all patient hospital readmission rates for certain hospital readmission rates for certain conditions.conditions.

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Subtitle B – Improving Medicare for Subtitle B – Improving Medicare for Patients and ProvidersPatients and ProvidersPart I – Ensuring Beneficiary Access to Part I – Ensuring Beneficiary Access to Physician Care and Other ServicesPhysician Care and Other ServicesSec. 3101. Increase in the physician payment Sec. 3101. Increase in the physician payment update. update.

Replaces the scheduled 21 percent Replaces the scheduled 21 percent payment reduction to the Medicare payment reduction to the Medicare physician fee schedule for 2010 with a physician fee schedule for 2010 with a 0.5 percent positive update. 0.5 percent positive update.

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What happens to the RUC??

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Part III – Improving Payment Accuracy Part III – Improving Payment Accuracy Sec. 3134. Misvalued codes under the Sec. 3134. Misvalued codes under the physician fee schedule. physician fee schedule.

Directs the Secretary to regularly Directs the Secretary to regularly review fee schedule rates for physician review fee schedule rates for physician services paid for by Medicare, services paid for by Medicare, including services that have including services that have experienced high growth rates. experienced high growth rates.

Strengthens the Secretary’s authority Strengthens the Secretary’s authority to adjust fees schedule rates that are to adjust fees schedule rates that are found to be misvalued or inaccurate. found to be misvalued or inaccurate.

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Subtitle E – Ensuring Medicare Subtitle E – Ensuring Medicare Sustainability Sustainability Sec. 3403. Independent Medicare Sec. 3403. Independent Medicare Advisory Board. Advisory Board.

Creates an independent, 15-member Creates an independent, 15-member Medicare Advisory Board tasked with Medicare Advisory Board tasked with presenting Congress with comprehensive presenting Congress with comprehensive proposals to reduce excess cost growth and proposals to reduce excess cost growth and improve quality of care. improve quality of care.

When Medicare costs are projected to be When Medicare costs are projected to be unsustainable, the Board’s proposals will take unsustainable, the Board’s proposals will take effect unless Congress passes an alternative effect unless Congress passes an alternative measure that achieves the same savings. measure that achieves the same savings.

The Board would be prohibited from making The Board would be prohibited from making proposals that ration care, raise taxes or Part proposals that ration care, raise taxes or Part B premiums, or change Medicare benefit, B premiums, or change Medicare benefit, eligibility, or cost-sharing standards. eligibility, or cost-sharing standards.

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MedPAC March 2008MedPAC March 2008

“ ‘“ ‘medical home’ programs… if medical home’ programs… if designed carefully, may be a way designed carefully, may be a way to improve the value of physician to improve the value of physician and other health care services.”and other health care services.”

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Subtitle F—Health Care Quality Improvements Sec. 3502. Grants or contracts to establish community health teams to support the patient-centered medical home. Creates a program to establish and fund the

development of community health teams to support the development of medical homes by increasing access to comprehensive, community based, coordinated care.

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TITLE V—HEALTH CARE WORKFORCETITLE V—HEALTH CARE WORKFORCE Subtitle B—Innovations in the Health Care Workforce

Sec. 5101. National health care workforce commission.

Sec. 5102. State health care workforce development grants.

Sec. 5103. Health care workforce assessment.

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Subtitle C—Increasing the Supply of the Health Care Workforce (inducements)

Sec. 5201. Federally supported student loan funds.Sec. 5202. Nursing student loan program.Sec. 5203. Health care workforce loan repayment

programs.Sec. 5204. Public health workforce recruitment

and retention programs.Sec. 5205. Allied health workforce recruitment and

retention programs.Sec. 5206. Grants for State and local programs.Sec. 5207. Funding for National Health Service

Corps.Sec. 5208. Nurse-managed health clinics.Sec. 5209. Elimination of cap on commissioned

corps.Sec. 5210. Establishing a Ready Reserve Corps.

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Subtitle D—Enhancing Health Care Workforce Education and Training

Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.

Sec. 5302. Training opportunities for direct care workers.

Sec. 5303. Training in general, pediatric, and public health dentistry.

Sec. 5304. Alternative dental health care providers demonstration project.

Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education.

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Subtitle F – Strengthening Primary Care and Other Subtitle F – Strengthening Primary Care and Other Workforce Improvements Workforce Improvements Sec. 5501. Expanding access to primary Sec. 5501. Expanding access to primary care services and general surgery care services and general surgery services. services.

Beginning in 2011, provides primary Beginning in 2011, provides primary care practitioners, as well as general care practitioners, as well as general surgeons practicing in health surgeons practicing in health professional shortage areas, with a professional shortage areas, with a 10 10 percent Medicare payment bonus for percent Medicare payment bonus for five years.five years.

Half of the cost of the bonuses would Half of the cost of the bonuses would be offset through an across-the-board be offset through an across-the-board reduction in all other services. reduction in all other services.

Coverage and individual mandates Senate Bill Makes insurance

available to an estimated 94% of non-elderly citizens by dramatically expanding Medicaid and offering tax credits to Americans who would otherwise find it difficult to afford coverage.

Individuals must purchase insurance or pay a penalty that would be the greater of $750 or 2% of income by 2016.

Reconciliation Makes insurance available

to an estimated 95% of non-elderly citizens.

Adopts the Senate approach but lowers the assessment and raises the percent of income that individuals would pay if they chose not to become insured. Individuals must purchase insurance or pay a penalty that would be the greater of $695 or 2.5% of income.

Employer Mandate

Senate Bill The Senate bill does

not include an employer mandate, but requires companies with 50 or more employees to help defray the cost if taxpayers are footing the bill for their workers.

Reconciliation Also penalizes

companies with 50 or more employees, but helps mid-size businesses by exempting the first 30 workers when calculating the tax ($2000 annually per non-exempted employee).

How it’s is paid for

Senate Bill Would be financed

through billions in Medicare cuts and new taxes, including a tax on insurance plans that are worth more than $23,000 for a family of four. Couples making more than $250,000 would pay additional Medicare payroll taxes.

Reconciliation Scales back the tax on

high-end Cadillac plans and delays its imposition to 2018, but increases the tax's impact in the years following. The 2.9 percent Medicare payroll tax would extend to unearned income for couples making more than $250,000 a year.

Abortion Coverage

Senate The new insurance

exchanges can offer plans that cover abortion, but people who choose those plans must pay for their coverage with separate checks — one for abortion coverage, one for the rest of their health care services.

Reconciliation No change

Exchanges/Subsidies

Senate Sets up 50 different

exchanges, administered by the states, where people without employer-based coverage will buy insurance.

Reconciliation The subsidies to help

low and middle-income families buy coverage are larger than in the Senate bill, but the rate at which they will increase over time is lower, meaning that coverage may become somewhat less affordable.

Medicare Drug Coverage Senate The Medicare drug

benefit would expand to include coverage for retirees.

Reconciliation Closes the hole in

drug coverage over a decade, starting with a $250 rebate this year, half what was in the Senate bill. After that, the gap would gradually shrink, with drug companies giving 50 percent discounts on brand name drugs and the government increasingly paying the rest until patients, by 2020, have to pay just 25 percent of the costs.

Medicaid Expansion

Senate Medicaid would be

expanded to cover everyone earning under 133% of Federal Poverty Level ($29,327 for a family of four).

Reconciliation Seeks to address

states' concerns about the cost of expanding Medicaid by increasing the Federal share of covering newly eligible people. It also jettisons the speacial deal that Sen. Ben Nelson (D-Neb.) secured for his home state.

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Timing of provisions: Timing of provisions: First yearFirst year Donut hole rebates of $250Donut hole rebates of $250 Small business tax creditsSmall business tax credits Establish high-risk pool for people with Establish high-risk pool for people with

pre-existing conditionspre-existing conditions Ban excluding children with pre-Ban excluding children with pre-

existing conditions, recision and existing conditions, recision and lifetime capslifetime caps

Dependants can stay on parents Dependants can stay on parents insurance until age 26insurance until age 26

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TimingTiming 2011 2011

– requires Insurance companies to spend 80-85% requires Insurance companies to spend 80-85% of premiums on careof premiums on care

2013 2013 – increase Medicare payroll taxes for increase Medicare payroll taxes for

individuals>$200k investment income, $250k individuals>$200k investment income, $250k couples incomecouples income

2014 2014 – Subsidies for families at <400% FPLSubsidies for families at <400% FPL– Most employers and people must offer/be insuredMost employers and people must offer/be insured

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TimingTiming

2015 – Part of expanded Medicaid 2015 – Part of expanded Medicaid costs shift to statecosts shift to state

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Historic Health Care Reform: What now? Senate will pass reconciliation bill? Efforts at repeal? Agencies will write rules for

implementation Challenge of some provisions in

court including insurance mandates and Medicaid cost transfers to states

Insurers and health care organizations will reposition themselves

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Health Care Reform: Health Care Reform: Access, Cost and Access, Cost and QualityQuality

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