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Nurse Navigators and the Changing Healthcare Landscape

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Presentation on theme: "Nurse Navigators and the Changing Healthcare Landscape"— Presentation transcript:

1 Nurse Navigators and the Changing Healthcare Landscape
Carol Bush, BS RN Coordinator, ONS Nurse Navigator SIG Nurse Consultant, Remedy Healthcare

2 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

3 Health Reform & the ACA What Is It?

4 “The legislation provides a road map for healthcare reform, the only problem is that there is no road.” unknown The legislation provides a road map for healthcare reform, the challenge is….there is no road.

5 Health Coverage in America
Access Cost Quality

6 Extends Coverage - 3 Major Ways:
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.

7 Cost Taxes Fees Cuts Medical Devices : 2.3% Indoor Tanning : 10%
Individuals; Earn > $200K: 0.9% Fees Insurance Companies: $8 Billion Pharmaceuticals : $3 Billion Cuts Medicare & Medicaid What is it going to cost us and where is the money coming from? 3 Financing Strategies…Taxes, Fees and Cuts Kaiser Family Foundation.

8 Healthcare Quality is a Legislative Priority
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 How do I get the best care? Kaiser Family Foundation.

9 Healthcare Quality is a Legislative Priority
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

10 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 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 Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review Coverage: Small business premium tax credit Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates Medicare Savings: MA payment reductions, productivity offset to FFS updates Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal Delivery System Reform: Center for Medicare and Medicaid Innovation Delivery System Reform: ACOs, hospital value-based purchasing Timeline of Key Health Reform Provisions 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 Cancer Action Network Website. (2013) acscan.org/healthcare

11 What does this mean for Cancer Care Close to Home?

12 Goodbye Donut Hole! 2010 = $250 rebate
2011 = Discounts while in donut hole 50% name brand & 7% generic  Gap to close by 2020. cancercare.org 2013

13 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

14 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

15 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)

16 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)

17 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 Despite 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)

18 Businesses < 25 employees: > 50 employees: > 200 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)

19 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

20 Exchanges Explained People w/o employer-sponsored plans
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

21 Exchanges Explained 133 to 400% FPL = up to $88K for family of 4
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

22 Florida at a Glance

23 Cancer Incidence Trends: State vs US Percentage of change over 5 years*
Breast Colon Kidney Lung Melanoma Non-Hodgkin Pancreas Lymphoma This 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 for Source: National Cancer Institute and the Centers for Disease Control and Prevention.

24 Payer 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 members National Guard and Reserve members Retirees, their families, survivors and certain former spouses worldwide TRICARE brings together: Military health care Civilian health care professionals, institutions, pharmacies and suppliers Notes: Kaiser Family Foundation is the only source available for comparing all categories during the same year, with being the most recent This is the most up-to-date data available for this slide’s topic Sources: 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 plans2 950, ,771, Lives 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. Kaiser Family Foundation. Kaiser Family Foundation.

25 Payer 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 members National Guard and Reserve members Retirees, their families, survivors and certain former spouses worldwide TRICARE brings together: Military health care Civilian health care professionals, institutions, pharmacies and suppliers Notes: Kaiser Family Foundation is the only source available for comparing all categories during the same year, with being the most recent This is the most up-to-date data available for this slide’s topic Sources: 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 plans2 950, ,771, Lives 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. Kaiser Family Foundation. Kaiser Family Foundation.

26 Employment 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.

27 Medicare and Medicaid: State vs US Percentage of the total population
1 Medicare 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 beneficiaries This is the most up-to-date data available for this slide’s topic Sources: 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 enrollees2 87% % Medicare population with prescription drug coverage (2010)3 Note: Medicaid, Medicare and dual eligibles data are for 1. Kaiser Family Foundation. 2. Kaiser Family Foundation. 3. Kaiser Family Foundation.

28 Medicaid: 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 for 28 Source: Kaiser Family Foundation. 28

29 Medicaid in Florida 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 Source: HealthLeaders-InterStudy. Miami Market Overview. Nashville, TN: HealthLeaders-InterStudy; March 2011. Source: HealthLeaders-InterStudy. Miami Market Overview. March 2011.

30 Medicaid Expansion State – US Comparison
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 Options Out of Session Florida2 Supports Legislative session ended with no legislation authorizing the Medicaid expansion.

31 Nurse Navigator Focus in Healthcare Transformation

32 Go. Make something happen.
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: Book: Linchpin: Are You Indespensible?

33 Nurse Navigator Focus in Healthcare Transformation
Models of Care Process Improvement Establish and Maintain Relationships Community Outreach

34 Oncology Nurse Navigator Impact
Models of Care Coordinate Care Transitions Identify & Share EBP Employ mobile technology American Nurses Association 2012

35 Oncology Nurse Navigator Impact
Team Leadership Relationship Building Strengthen Multi-Disc Team Communication Change Management American Nurses Association 2012

36 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

37 Oncology Nurse Navigator Impact
Community Outreach Broaden Innovation Skill Set Engage new community partners Coach cross-community team members

38 Need More Info? Most comprehensive White House version User friendly

39 Special Thanks to…. ONS Nurse Navigator SIG Mario Quitoriano, MSN, RN (video editor, extraordinaire)

40 Time for Q&A: Exchange ideas and experiences carol@remedyrn.com


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