Presentation on theme: "Carol Bush, BS RN Coordinator, ONS Nurse Navigator SIG Nurse Consultant, Remedy Healthcare."— Presentation transcript:
Carol Bush, BS RN Coordinator, ONS Nurse Navigator SIG Nurse Consultant, Remedy Healthcare
Presentation Objectives Describe the key provisions of the 2010 Affordable Care Act (ACA) Identify major issues, challenges and opportunities that healthcare reform presents for cancer patients As oncology nurse navigators practicing in the era of the ACA, identify core clinical competencies, patient care coordination strategies and opportunities for professional collaboration
Health Reform & the ACA What Is It?
“The legislation provides a road map for healthcare reform, the only problem is that there is no road.” unknown
Health Coverage in America Cost Quality Access
Extends Coverage - 3 Major Ways: Requires Employers to provide coverage Expands Medicaid → $24, 350 per family Continues Children’s Health Insurance Program (CHIP) funding 30 million more Americans will be insured Kaiser Family Foundation.
Quality Patient Centered Outcomes Research Institute What works in EBP? Pay for performance of Quality Measures Medicare VBP; hospitals, SNFs, ASC’s, others Healthcare Quality is a Legislative Priority Kaiser Family Foundation.
Quality CMS Innovation Center Improve quality, reduce cost via pilot projects ACOs Providers organize; meet quality thresholds; realize Medicare cost savings Healthcare Quality is a Legislative Priority
Medicare Savings: MA payment reductions, productivity offset to FFS updates Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal Coverage: Small business premium tax credit Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review Delivery System Reform: Center for Medicare and Medicaid Innovation Delivery System Reform: ACOs, hospital value-based purchasing Delivery System Reform: Hospital readmissions, payment bundling Delivery System Reform: Physician quality reporting penalties New Revenue: Tax on prescription drug manufacturers New Revenue: Excise tax on medical device makers, Medicare tax on high earners New Revenue: Tax on health insurers New Revenue: Tax on high-cost health plans Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates Coverage: Medicaid expansion, major insurance reforms (eg, guaranteed issue, rating rules, no pre-ex for adults) insurance exchanges, premium / cost sharing subsidies, individual / employer responsibility requirements Cancer Action Network Website. (2013) acscan.org/healthcare
What does this mean for Cancer Care Close to Home?
Goodbye Donut Hole! 2010 = $250 rebate 2011 = Discounts while in donut hole 50% name brand & 7% generic Gap to close by cancercare.org 2013
Let’s hear it for the Kids! Coverage for YA’s up to 26 years old Health plans prohibited from denying coverage to children up to age 19 years with pre-existing conditions (such as cancer) Have a child who is a survivor? no longer need to worry about insurance continuing if you change jobs cancercare.org 2013
The Well is Deeper Bans on setting lifetime dollar limits Annual dollar limits on coverage will be tightly restricted for most plans and will be eliminated altogether in Patients will no longer have to put off treatment, waiting for the new plan year to start. cancercare.org 2013
Raise your Right Hand & Repeat Health plans take a vow Insurers are barred from dropping people from coverage when they get sick. In other words, you can’t lose your insurance if diagnosed with cancer acscan.org (2013)
Prevention, Prevention, Prevention Coverage is guaranteed; out-of-pocket costs will be eliminated There are over 30 such services, ie Mammography immunizations, colon cancer screening Incentives for smoking cessation & weight reduction acscan.org (2013)
Clinical Trials Coverage All group or individual commercial plans must cover routine patient care costs for trials participation Includes FEHBP plans, but not self- insured plans (ERISA plans) Preemption provision protects existing state laws & voluntary agreements acscan.org (2013)
Businesses < 25 employees: Not required to provide coverage; tax credits available By 2017, Small Biz Exchange > 50 employees: Provide coverage or face a fine > 200 employees: Automatic enroll employees in plan Opt out available acscan.org (2013)
Providers Millions added to insurance pool Bonuses for quality available 10% to PCPs and Gen Surgeons in certain areas Enhanced training Scholarships & loans Innovation Models Medical Home & Medical Neighborhood Moy, B. et al
Exchanges Explained New Marketplaces People w/o employer-sponsored plans Small Businesses (through separate exchanges) One in Every State Federally run, if not State-run Ready for sign up October 2013 Plan year begins Jan 1, 2014 Effective Practice--Massachusetts—Health Connector HealthCareandYou.org 2013
Exchanges Explained Subsidies via sliding scale 133 to 400% FPL = up to $88K for family of 4 The Hope Consumer friendly comparisons Internet portal; assistance in real-time Provide choice, flexibility and drive down cost HealthCareandYou.org 2013
Cancer Incidence Trends: State vs US Percentage of change over 5 years* 23 Source: National Cancer Institute and the Centers for Disease Control and Prevention. Breast Colon Kidney Lung Melanoma Non-Hodgkin Pancreas Lymphoma *Data are for
24 Payer Mix: State vs US 1 1. Kaiser Family Foundation. 2. Kaiser Family Foundation. Notes: Data are for , latest year available for all categories. Percentages may not add up to 100% due to rounding effects. *Dual eligibles are included in the Medicare population. †Medicare Advantage beneficiaries are not included in the “Private” totals. 32% 26% % of Medicare beneficiaries enrolled in Medicare Advantage plans 2 950,816 9,771,658 Lives * †
25 Payer Mix: State vs US 1 1. Kaiser Family Foundation. 2. Kaiser Family Foundation. Notes: Data are for , latest year available for all categories. Percentages may not add up to 100% due to rounding effects. *Dual eligibles are included in the Medicare population. †Medicare Advantage beneficiaries are not included in the “Private” totals. 32% 26% % of Medicare beneficiaries enrolled in Medicare Advantage plans 2 950,816 9,771,658 Lives * †
26 Employment and Health Coverage: State vs US 1. Kaiser Family Foundation. 2. HealthLeaders-InterStudy. Florida health plan data. January Unemployed 1 (2011)Uninsured 2 (2011) (October) (January)
27 Medicare and Medicaid: State vs US Percentage of the total population 1. Kaiser Family Foundation. 2. Kaiser Family Foundation. 3. Kaiser Family Foundation. 18% 21% Dual eligibles as a % of Medicare enrollees 2 87% 86% Medicare population with prescription drug coverage (2010) 3 1 Note: Medicaid, Medicare and dual eligibles data are for
Medicaid: State vs US Percentage of the total population * Source: Kaiser Family Foundation. 28 *Data are for
29 Medicaid in Florida Source: HealthLeaders-InterStudy. Miami Market Overview. March Florida’s Medicaid program includes: ̶HMOs and provider service networks (PSNs) ̶MediPass, a primary-care case management program ̶Florida KidCare, the Children’s Health Insurance Program, including MediKids for those under age 5, Florida Healthy Kids for those ages 5 to 18, and the Children’s Medical Services Network for those 18 and younger with special health care needs Florida’s Medicaid enrollment has swelled under continuing joblessness and is expected to surpass 3 million in the fiscal year. This is resulting in thousands of beneficiaries being added to the state’s fee-for-service (FFS) and Medicaid HMO programs and tighter control by the HMOs over prescription drug use The Legislature is expanding Medicaid reform by increasing the use of HMOs to deliver care to Florida’s Medicaid beneficiaries. In the 5 counties currently under a Medicaid reform pilot, enrollment in an HMO or a PSN is mandatory. Legislation requires most PSNs to apply for conversion from a FFS to a capitated payment model by September 2012, raising doubts about whether FFS can survive reform Medicaid rates are different for each county and are based on FFS and financial data. A 5% reimbursement cut for providers has been proposed
Location Current Status of Medicaid Expansion Decision Governor's Position 2013 Legislative Session Status Key Legislative Activity United States 25 Moving Forward at this Time; 22 Not Moving Forward at this Time; 4 Debate Ongoing 30 Supports; 16 Opposes; 5 Weighing Options 42 Out of Session; 8 In Session Year Round; 1 In Regular Session and Special Session Kansas Not Moving Forward at this Time Weighing OptionsOut of Session Florida 2 2 Not Moving Forward at this Time SupportsOut of Session Legislative session ended with no legislation authorizing the Medicaid expansion. Medicaid Expansion State – US Comparison
Nurse Navigator Focus in Healthcare Transformation
Linchpin Manifesto I am an artist. I take initiative I do the work, not the job. Without critics, there is no art. I am a Linchpin. I am not easily replaced. If it’s never been done before, even better. I make it happen. Every day. Every interaction is an opportunity to make a connection. Energy is contagious. The more I put in, the more the world gives back. I raise the bar. I know yesterday’s innovation is today’s standard. Rule-breaking works better and is worth the effort. I will not be brainwashed into believing in the status quo. There is no resistance if I don’t allow it to defeat me. I embrace a lack of structure to find a new path. I am surprising. (And often surprised). I donate energy and risk to the cause. I turn charisma into leadership. The work matters. Go. Make something happen. Source: BookBook: Linchpin: Are You Indespensible?Linchpin: Are You Indespensible?
Nurse Navigator Focus in Healthcare Transformation Models of Care Process Improvement Establish and Maintain Relationships Community Outreach
Oncology Nurse Navigator Impact Models of Care Coordinate Care Transitions Identify & Share EBP Employ mobile technology American Nurses Association 2012
Oncology Nurse Navigator Impact Team Leadership Relationship Building Strengthen Multi-Disc Team Communication Change Management American Nurses Association 2012
Oncology Nurse Navigator Impact Cost Containment Metrics Nurse Navigator as best in class partner for IT Clinical Care outcomes Return On Investment American Nurses Association 2012
Oncology Nurse Navigator Impact Community Outreach Broaden Innovation Skill Set Engage new community partners Coach cross-community team members
Need More Info? Most comprehensive White House version User friendly
Special Thanks to…. ONS Nurse Navigator SIG Mario Quitoriano, MSN, RN (video editor, extraordinaire)