Presentation on theme: "Nurse Navigators and the Changing Healthcare Landscape"— Presentation transcript:
1Nurse Navigators and the Changing Healthcare Landscape Carol Bush, BS RNCoordinator, ONS Nurse Navigator SIGNurse Consultant, Remedy Healthcare
2Presentation Objectives Describe the key provisions of the 2010 Affordable Care Act (ACA)Identify major issues, challenges and opportunities that healthcare reform presents for cancer patientsAs oncology nurse navigators practicing in the era of the ACA, identify core clinical competencies, patient care coordination strategies and opportunities for professional collaboration
4“The legislation provides a road map for healthcare reform, the only problem is that there is no road.” unknownThe legislation provides a road map for healthcare reform, the challenge is….there is no road.
6Extends Coverage - 3 Major Ways: AccessExtends Coverage - 3 Major Ways:Requires Employers to provide coverageExpands Medicaid → $24, 350 per familyContinues Children’s Health Insurance Program (CHIP) funding30 million more Americans will be insuredKaiser Family Foundation.
7Cost Taxes Fees Cuts Medical Devices : 2.3% Indoor Tanning : 10% Individuals; Earn > $200K: 0.9%FeesInsurance Companies: $8 BillionPharmaceuticals : $3 BillionCutsMedicare & MedicaidWhat is it going to cost us and where is the money coming from? 3 Financing Strategies…Taxes, Fees and CutsKaiser Family Foundation.
8Healthcare Quality is a Legislative Priority Patient Centered Outcomes Research InstituteWhat works in EBP?Pay for performance of Quality MeasuresMedicare VBP; hospitals, SNFs, ASC’s, othersHealthcare Quality is a Legislative PriorityHow do I get the best care?Kaiser Family Foundation.
9Healthcare Quality is a Legislative Priority CMS Innovation CenterImprove quality, reduce cost via pilot projectsACOsProviders organize; meet quality thresholds; realize Medicare cost savingsHealthcare Quality is a Legislative Priority
102010201120122013201420152016201720182019Coverage: Medicaid expansion, major insurance reforms (eg, guaranteed issue, rating rules, no pre-ex for adults) insurance exchanges, premium / cost sharing subsidies, individual / employer responsibility requirementsImmediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate reviewCoverage: Small business premium tax creditMedicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebatesMedicare Savings: MA payment reductions, productivity offset to FFS updatesMedicare/Medicaid Savings: DSH reductions, IPAB Medicare proposalDelivery System Reform: Center for Medicare and Medicaid InnovationDelivery System Reform: ACOs, hospital value-based purchasingTimeline of Key Health Reform ProvisionsDelivery System Reform: Hospital readmissions, payment bundlingDelivery System Reform: Physician quality reporting penaltiesNew Revenue: Tax on prescription drug manufacturersNew Revenue: Excise tax on medical device makers, Medicare tax on high earnersNew Revenue: Tax on health insurersNew Revenue: Tax onhigh-cost health plansCancer Action Network Website. (2013) acscan.org/healthcare
11What does this mean for Cancer Care Close to Home?
12Goodbye Donut Hole! 2010 = $250 rebate 2011 = Discounts while in donut hole50% name brand & 7% generic Gap to close by 2020.cancercare.org 2013
13Let’s hear it for the Kids! Coverage for YA’s up to 26 years old Health plansprohibited 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
14The 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
15Raise your Right Hand & Repeat Health plans take a vowInsurers are barred from dropping people from coverage when they get sick. In other words, you can’t lose your insurance if diagnosed with canceracscan.org (2013)
16Prevention, Prevention, Prevention Coverage is guaranteed; out-of-pocket costs will be eliminatedThere are over 30 such services, ie Mammography immunizations, colon cancer screeningIncentives for smoking cessation & weight reductionacscan.org (2013)
17Clinical Trials Coverage All group or individual commercial plans must cover routine patient care costs for trials participationIncludes FEHBP plans, but not self-insured plans (ERISA plans)Preemption provision protects existing state laws & voluntary agreementsDespite increasing expansion of coverage for routine care costs in clinical trials across the US (more than half the states and DC provide such coverage), the scope of this coverage varies considerably.The health care reform package includes provisions pulled directly from the Access to Cancer Clinical Trials Act of legislation. Effective immediately upon enactment, it:1. Requires all commercial health insurance plans offering group or individual coverage to pay for the routine patient care costs associated with participation in high-quality clinical trials (phases I to IV) for cancer or other life-threatening disease or condition.2. Specifically includes health plans offered through the Federal Employee Health Benefit Program (FEHBP). But it does not include coverage for the millions of people enrolled in employer-sponsored plans that self insure and operate under ERISA or who are state employees enrolled in state self-insured plans.3. Coverage does extend to clinical trials conducted outside the state in which the patient resides. It does not, however, require coverage for out of network services unless those benefits are otherwise provided under the plan.4. Includes preemption provision protecting validity of State clinical trials policy for State regulated health insurance plans that is in addition to this new federal coverage.acscan.org (2013)
18Businesses < 25 employees: > 50 employees: > 200 employees: Not required to provide coverage; tax credits availableBy 2017, Small Biz Exchange> 50 employees:Provide coverage or face a fine> 200 employees:Automatic enroll employees in planOpt out availableacscan.org (2013)
19Providers Millions added to insurance pool Bonuses for quality available10% to PCPs and Gen Surgeons in certain areasEnhanced trainingScholarships & loansInnovation ModelsMedical Home & Medical NeighborhoodMoy, B. et al
20Exchanges Explained People w/o employer-sponsored plans New MarketplacesPeople w/o employer-sponsored plansSmall Businesses (through separate exchanges)One in Every StateFederally run, if not State-runReady for sign up October 2013Plan year begins Jan 1, 2014Effective Practice--Massachusetts—Health ConnectorHealthCareandYou.org 2013
21Exchanges Explained 133 to 400% FPL = up to $88K for family of 4 Subsidies via sliding scale133 to 400% FPL = up to $88K for family of 4The HopeConsumer friendly comparisonsInternet portal; assistance in real-timeProvide choice, flexibility and drive down costHealthCareandYou.org 2013
23Cancer Incidence Trends: State vs US Percentage of change over 5 years* Breast Colon Kidney Lung Melanoma Non-Hodgkin PancreasLymphomaThis chart shows the percentage of increase or decrease in the incidence for 7 types of cancer over a period of 5 years for both Florida and the United States. Florida did better than the United States in reducing lung cancer, while there was a rise in the breast cancer and melanoma rates during this period of time. Both Florida and the United States experienced a substantial drop in the rate of colon cancer.Note: This is the most up-to-date data available for this slide’s topic.Source: National Cancer Institute and the Centers for Disease Control and Prevention. State cancer profiles: Florida and US. Accessed December 1, 2011.*Data are forSource: National Cancer Institute and the Centers for Disease Control and Prevention.
24Payer Mix: State vs US1 * † The payer mix shows where people get their health benefits. Higher or lower rates of Medicare or Medicaid, compared to the national average, can reflect differences in state population demographics. For example, a smaller number of people with Medicaid and a higher percentage without insurance suggest the local population might have a high number of the “working poor”—individuals not receiving insurance through their employers and making too much to qualify for public assistance but not enough to be able to afford insurance on their own.TRICARE serves:Active duty service membersNational Guard and Reserve membersRetirees, their families, survivors and certain former spouses worldwideTRICARE brings together:Military health careCivilian health care professionals, institutions, pharmacies and suppliersNotes:Kaiser Family Foundation is the only source available for comparing all categories during the same year, with being the most recentThis is the most up-to-date data available for this slide’s topicSources:Kaiser Family Foundation. Health coverage & uninsured: Florida ( ) and US (2009). StateHealthFacts.org website. Accessed December 1, 2011.Kaiser Family Foundation. Medicare facts at-a-glance: Florida ( ) and US (2009). StateHealthFacts.org website. Accessed December 1, 2011.32% % % of Medicare beneficiaries enrolled in Medicare Advantage plans2950, ,771, LivesNotes: 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.Kaiser Family Foundation.Kaiser Family Foundation.
25Payer Mix: State vs US1 * † The payer mix shows where people get their health benefits. Higher or lower rates of Medicare or Medicaid, compared to the national average, can reflect differences in state population demographics. For example, a smaller number of people with Medicaid and a higher percentage without insurance suggest the local population might have a high number of the “working poor”—individuals not receiving insurance through their employers and making too much to qualify for public assistance but not enough to be able to afford insurance on their own.TRICARE serves:Active duty service membersNational Guard and Reserve membersRetirees, their families, survivors and certain former spouses worldwideTRICARE brings together:Military health careCivilian health care professionals, institutions, pharmacies and suppliersNotes:Kaiser Family Foundation is the only source available for comparing all categories during the same year, with being the most recentThis is the most up-to-date data available for this slide’s topicSources:Kaiser Family Foundation. Health coverage & uninsured: Florida ( ) and US (2009). StateHealthFacts.org website. Accessed December 1, 2011.Kaiser Family Foundation. Medicare facts at-a-glance: Florida ( ) and US (2009). StateHealthFacts.org website. Accessed December 1, 2011.32% % % of Medicare beneficiaries enrolled in Medicare Advantage plans2950, ,771, LivesNotes: 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.Kaiser Family Foundation.Kaiser Family Foundation.
26Employment and Health Coverage: State vs US Higher rates of people without insurance might reflect the number/percentage of employers offering insurance to their employees. During the past year, the unemployed rate has dropped, while the uninsured rate has remained steady. The uninsured have poorer access to needed therapies. In light of health care reform, the uninsured rates should drop even more once the new Health Insurance Exchanges (HIXs) are put in place in Although Florida’s governor and legislature have refused to establish an HIX, the federal government would assume responsibility for running one in the state after January 1,Note: This is the most up-to-date data available for this slide’s topic.Sources:Kaiser Family Foundation. Unemployment rate (seasonally adjusted): October StateHealthFacts.org website. Accessed December 13, 2011.HealthLeaders-InterStudy. Florida health plan data. Waltham, MA: HealthLeaders-InterStudy; January 2011.Kaiser Family Foundation. State exchange profiles: Florida. State-Exchange-Profiles/florida. Revised October 15, Accessed December 13, 2011.(October)(October)(January)(January)Unemployed1 (2011)Uninsured2 (2011)1. Kaiser Family Foundation.2. HealthLeaders-InterStudy. Florida health plan data. January 2011.
27Medicare and Medicaid: State vs US Percentage of the total population 1Medicare is the federally funded program providing health benefits to those over the age of 65 (and the disabled). Medicaid is a state-administered program receiving federal matching funds to provide coverage for the indigent. Dual eligibles are individuals who qualify for both programs. Medicaid covers services and therapies Medicare does not. The number of dual eligibles is often reported as a percentage of the Medicare population.As explained earlier in this presentation, health care reform is expected to expand Medicaid enrollment by 25.8% in Illinois and 27.4% in the United States between 2013 and 2019.Medicare has some cost-sharing requirements—20% for physician services and therapies administered in the physician office. For dual eligibles, Medicaid picks up these costs.Notes:Medicare drug coverage here indicates coverage for self-administered or oral therapies. These numbers do not reflect coverage for Genentech’s office-administered products but it’s some indication of access for beneficiariesThis is the most up-to-date data available for this slide’s topicSources:Kaiser Family Foundation. Health coverage & uninsured: Florida ( ) and US (2009). StateHealthFacts.org website. Accessed December 2, 2011.Kaiser Family Foundation. Medicare facts-at-a-glance: Florida ( ) and US (2009). StateHealthFacts.org website.http://www.statehealthfacts.kff.org/comparecat.jsp?cat=6&rgn=11&rgn=1. Accessed December 2, 2011.Kaiser Family Foundation. Medicare drug benefit: distribution of Medicare beneficiaries with creditable prescription drug coverage by type, Florida and US, as of February StateHealthFacts.org website. Accessed December 2, 2011.18% % Dual eligibles as a % of Medicare enrollees287% % Medicare population with prescription drug coverage (2010)3Note: Medicaid, Medicare and dual eligibles data are for1. Kaiser Family Foundation.2. Kaiser Family Foundation.3. Kaiser Family Foundation.
28Medicaid: State vs US Percentage of the total population* This chart takes a closer look at the ages of people making up the Medicaid population in Florida and the United States. A slightly higher percentage of children are covered by Medicaid than adults in both Florida and the United States.Note: This is the most up-to-date data available for this slide’s topic.Source: Kaiser Family Foundation. State Medicaid fact sheet: Florida and US ( ). StateHealthFacts.org website. 1&x=13&y=18. Accessed December 5, 2011.*Data are for28Source: Kaiser Family Foundation.28
29Medicaid in Florida Florida’s Medicaid program includes: HMOs and provider service networks (PSNs)MediPass, a primary-care case management programFlorida 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 needsFlorida’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 useThe 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 reformMedicaid rates are different for each county and are based on FFS and financial data. A 5% reimbursement cut for providers has been proposedSource: HealthLeaders-InterStudy. Miami Market Overview. Nashville, TN: HealthLeaders-InterStudy; March 2011.Source: HealthLeaders-InterStudy. Miami Market Overview. March 2011.
30Medicaid Expansion State – US Comparison LocationCurrent Status of Medicaid Expansion DecisionGovernor's Position2013 Legislative Session StatusKey Legislative ActivityUnited States25 Moving Forward at this Time;22 Not Moving Forward at this Time;4 Debate Ongoing30 Supports;16 Opposes;5 Weighing Options42 Out of Session;8 In Session Year Round;1 In RegularSession and Special SessionKansasNot Moving Forward at this TimeWeighing OptionsOut of SessionFlorida2SupportsLegislative session ended with no legislation authorizing the Medicaid expansion.
31Nurse Navigator Focus in Healthcare Transformation
32Go. Make something happen. Linchpin ManifestoI 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:Book: Linchpin: Are You Indespensible?
33Nurse Navigator Focus in Healthcare Transformation Models of Care Process Improvement Establish and Maintain Relationships Community Outreach
34Oncology Nurse Navigator Impact Models of CareCoordinate Care TransitionsIdentify & Share EBPEmploy mobile technologyAmerican Nurses Association 2012
35Oncology Nurse Navigator Impact Team LeadershipRelationship BuildingStrengthen Multi-Disc Team CommunicationChange ManagementAmerican Nurses Association 2012
36Oncology Nurse Navigator Impact Cost ContainmentMetricsNurse Navigator as best in class partner for ITClinical Care outcomesReturn On InvestmentAmerican Nurses Association 2012
37Oncology Nurse Navigator Impact Community OutreachBroaden Innovation Skill SetEngage new community partnersCoach cross-community team members
38Need More Info?Most comprehensive White House version User friendly
39Special Thanks to….ONS Nurse Navigator SIG Mario Quitoriano, MSN, RN (video editor, extraordinaire)
40Time for Q&A: Exchange ideas and experiences email@example.com