1. Current Health Care Reform- Summer 2009 IHC Selective Georgetown University Keisa Bennett, MD

2. May 20092 Sources/References Dartmouth Atlas/John Wennberg –Presentation STFM Annual Mtg 2009 Hope Wittenberg and Jerry Kruse –Presentations STFM and Congressional Conference 2009 AAFP’s Congressional Handbook 2009 U.S. Constitution Online: http://www.usconstitution.net/consttop_law.html

3. May 20093 The Journey of a Bill Note: Bills create public policy Resolutions express a statement OR appropriate $$$ –Joint, concurrent, or simple

4. May 20094 The Journey of a Bill Ideas for bill generated by anyone: legislator, organization, or constituent Sponsor is found for bill and drafted by his/her staff Bill “introduced” by sponsor, assigned a number, and assigned to 1+ committees ($ appropriations must be introduced in House)

5. May 20095 The Journey of a Bill Committee(s) in one house consider bill by: –Referring to subcommittee –Public hearings –“mark up”: amendments by members –Voted on: if majority votes to send to Congress, bill is “reported out” –Process may be repeated by full committee Reported out to full House or Senate

6. May 20096 The Journey of a Bill Committee writes report on bill and debate If in House, Rules Committee can ignore bill or make rules about debate and amendments and put it on calendar If in Senate, debate is flexible and any individual may filibuster (speak forever against a bill) – overridden by “cloture” (vote of 60 Senators)

7. May 20097 The Journey of a Bill Bill voted on in house of origin If passed, moves to other house If similar bills passed in both houses at once, moves to Conference Committee In all cases, Conference Committee resolves differences and both houses re-vote If passed, sent to President

8. May 20098 The Journey of a Bill President may: –Sign –Veto +/- recommendations on changes –Take no action: bill becomes law in 10 days if Congress still in session –Take no action: bill dies if Congress no longer in session (pocket veto)

9. May 20099 The Journey of a Bill If bill vetoed, –2/3 vote in BOTH houses needed to override What happens to the thousands of bills that never make it this far?

10. May 200910 The Journey of a Bill http://www.youtube.com/watch?v=mEJL2Uuv-oQ

11. May 200911 What’s Going on Now? Universal coverage –Health insurance exchange? –Mandate? –Public plan? Medicare payment reform –Sustainable growth rate –Bonuses for primary care

12. May 200912 What’s Going on Now? Patient-centered medical home GME reform Title VII and VIII funding HIT funding and regulations Quality and Efficiency issues: variation in Medicare costs

13. May 200913 Comic deleted due to copyright

14. May 200914 Universal Coverage Committees all working on own versions –Senate HELP (Health, Ed, Labor, Pensions) –Senate Finance –House Education and Labor –House Energy & Commerce, Ways & Means

15. May 2009http://www.imakenews.com/cppa/e_a rticle000845383.cfm?x=b11,0,w 15 Elements of Universal Coverage Health Insurance Exchange –Can set up standard criteria for what counts as sufficient insurance –Insurance companies meeting standard may participate if guarantee issue –Individuals/small employers’ premiums pooled to share risk –Shop amongst plans, portable

16. May 200916 Elements of Universal Coverage Public plan –Structured on Medicare or FEBP –An option to compete with private companies themselves or the private “exchange” –Would only those not currently covered by employer have this as an option? –Would it take away all insurance co. business? –Would it prevent insurance co. monopolies?

17. May 200917 Elements of Universal Coverage Mandates –Requirement to buy health insurance –Insurance co.’s support – only way to adequately pool in order to guarantee issue –Low income premiums subsidized –How to enforce? Any exemptions? Play or pay –Employers must offer or pay fee

18. May 200918 Other Universal Coverage Ideas Convert to everyone on individual private insurance using state-based pools and coordination agencies combined with mandates Single-payer Direct-pay primary care (by individual, employer or government) combined with mandate to purchase high-deductible catastrophic coverage and maybe HSA

19. May 200919 Medicare Payment Reform Sustainable Growth Rate –Formula established in 1990’s –Ties Medicare payment rates with achievements of cost-containment goals –Every year target not met, so payments scheduled for reduction, but instead “patched” –Jan. 2010 scheduled reduction: 21%

20. May 200920 Medicare Payment Reform Resource-based Relative Value Scale –Assigns a value to every visit type or procedure –E&M codes undervalued; procedures pay more –Encourages less counseling, more procedures In lieu of major changes –Give primary care a coordination-of-care capitation fee –Increase RVU value for E&M codes or PC bonus

21. May 200921 Medicare Payment Reform Medicare Advantage –Govnt. pays private co’s substantially more to run Medicare benefits through their company –Flexibility/innovation supposed to increase value but instead increased cost –Should program be cancelled or just more heavily regulated and with more accountability?

22. May 200922 Patient-centered medical home Mechanism for better delivery Primary care home with team-based care and connections to dentistry, mental health, social work Access is key: open scheduling Use of HIT for QI, communication Not tied to specific financing mechanism

23. May 200923 Patient-centered medical home Patient Centered Primary Care Collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians and many others who have joined together to develop and advance the patient centered medical home. The Collaborative has well over 500 members. http://www.pcpcc.net/content/about-collaborative

24. May 200924 Characteristics of Practices of Personal Physicians Associated with Improved Health Outcomes and Equity, and with Lower Costs FFirst Contact Care The degree to which patients seek advice and care first at the practice of the personal physician, except for medical catastrophes Patient-focused Care Over Time The degree to which the practice emphasizes patient-focused care, rather than disease-focused care; and longitudinal care, rather than episodic care Comprehensive Care The degree to which the personal physician provides a broad range of health services Coordinated (Integrated) Care The degree of integration of care among health professionals and staff, both within the Patient-Centered Medical Home and with outside organizations and consultants, and the degree to which talents of all members of the team are used optimally. FFamily Orientation The degree to which medical services are provided to family members by the same personal physician Community Orientation The degree to which the practice assesses the needs of the community, designs interventions, and measures outcomes Cultural Competence The degree to which the biopsychosocial model is employed and health beliefs are addressed The Patient-Centered Medical Home Starfield, et al: The Milbank Quarterly 83(3), 2005; 457-502 Starfield & Shi: Pediatrics, 2004;113:1493-99 AOA, AAFP, AAP and ACP Legislative Definition of the PCMH and Vision for the Office of the Future (Joint Principles) Personal Physician PPhysician Directed Medical Practice WWhole Person Orientation CCoordinated and Integrated Care QQuality and Safety Measures Evident EBM and Clinical Decision Support Voluntary CQI Processes Patient’s Expectation Met HIT used appropriately EEnhanced Access & Appropriate Payment http://www.medicalhomeinfo.org/Joint%20Statement.pdf A critical evaluation of the scientific evidence for each of these characteristics: Rosenthal T: J Am Board Fam Med 2008;21:427-440

25. May 200925 GME Reform Graduate Medical Education –Largely paid by Medicare –Total amt frozen by BBA 1997 –Hospitals still add fellowships in lucrative specialties, but pay for it themselves or cut less popular programs –All $$ go through hospital; no support to train in community

26. May 200926 GME Reform Proposals include residency slot expansion +/- preferences for primary care –High probability of increasing IMG entry –Mod probability of increasing subspecialty slots Allow GME $ to “follow the resident” –Pay program, not hospital, then disburse per training distribution

27. May 200927 GME Reform Medicare Part A Trust Fund GME Funding Primary Care GME Funding $ Funds from other Payers $ Hospital $$ $ Accrediting Bodies Program is accountable to $ Chas Physician’s Offices Rural Locations Nursing Homes Other community ambulatory sites Accredited Primary Care Residency Training program

28. May 200928 Title VII and VIII Granting programs that support primary care in medicine, dentistry (VII) and nursing (VIII) Advisory Committee of Primary Care Medicine and Dentistry recommends $215 million –Obama’s budget calls for $54m, up from $0 designated and $48m given in last few years

29. May 200929 HIT Health Information Technology –Most reform plans include $ to help fund EMRs, data-sharing networks (RHIOs), e- prescribing and order entry, etc. –Most eventually with mandates for EMR, quality measures reporting –Will it really improve efficiency? Decrease costs? Improve patient care?

30. May 200930 Quality/Cost - Variation Costs to Medicare system vary widely across U.S. High-cost areas, adjusted for case mix of patients, do not have better outcomes or satisfaction Work of Dartmouth Atlas team, John Wennberg

31. May 200931 Quality/Cost - Variation Preference Sensitive Care (25%) Effective Care (12%) Supply Sensitive Care (63%) Proportion of Medicare Spending Attributed to Each Category of Unwarranted Variation

32. May 200932 Knee Replacement: An Example of Preference-sensitive Care Ratio of knee replacement rates to the U.S. average (2002-03) 1.30 to to1.78 (40) (40)1.10 to < to <1.30 (75) (75) 0.90 to < to <1.10 (120) (120) 0.75 to < to <0.90 (46) (46) 0.36 to < to <0.75 (25) (25) Not Populated

33. May 200933 Supply-Sensitive Care Physician Visits per Decedent during Last Six Months of Life Among Patients assigned to Academic Medical Centers 10.0 20.0 30.0 40.0 50.0 60.0 70.080.0 NYU Medical Center76.2 UCLA Medical Center43.9 NY Presbyterian Hospital40.3 Mass. General Hospital38.8 Cedars-Sinai Medical Center66.2 Mount Sinai Hospital53.9 Brigham & Women's Hospital31.9 Boston Medical Center31.5 Beth Israel Deaconess29.2 UCSF Medical Center27.2 Stanford University Hospital22.6

34. May 200934 Quality-Cost/Variation Legislators are talking about this information and potential to cut costs by standardizing care, but how? Message is to increase or hold steady primary care, reduce acute-care hospital beds and certain specialty services Lots of special-interest influence

35. May 200935 Comic deleted due to copyright

36. May 200936 Quality-Cost/Variation Another message is determining what is needed vs. preference vs. supply-driven Comparative Effectiveness Research –Heavy funding through AHRQ/HRSA/NIH –Controversial: consumer groups don’t want preference or supply services taken away See www.dartmouthatlas.org & http://www.ahrq.gov/consumer/cc/cc040709.htm www.dartmouthatlas.org

37. May 200937 President’s Budget increased funding for the President's health priorities for NIH, HRSA, CDC, IHS, and FDA HRSA -- significant increases for CHCs, health professions, and NHSC public health -- addressing health promotion and disease prevention. Senate and House reserve funds –comprehensive health reform legislation –including legislation for improvements in Medicare's system for paying physicians.

38. May 200938 Stimulus Bill (American Recovery and Reinvestment Act (H.R. 1) $10 billion NIH $1.1 billion comparative effectiveness at AHRQ (some of the money will go to NIH) The word clinical dropped – without prejudice. $3 billion for adoption of Health IT programs (appropriations) $16.38 billion for IT (Ways and Means) $2 billion Community Health Centers $1 billion prevention/wellness trust (including vaccines) $500 million Indian Health Service $500 million – Health Workforce Investment (Title VII and VIII)

39. May 200939 New HRSA Personnel  Assistant Secretary for Health Named Howard Koh, MD, Harvard School of Public Health  New HRSA Administrator Mary Wakefield, PhD, RN, FAAN  Acting HRSA Deputy Administrator Marcia Brand  New Director, Division of Medicine and Dentistry Daniel Mareck, MD – family physician  New Deputy Director, DoM, Lieutenant Commander Shari Campbell -- podiatrist

40. May 200940 Principles of Healthcare Reform - Obama PPhilosophy IInsurance MMedicaid and Mandated Insurance CClinical Emphasis Quality Measures CCollective Responsibility PPublic Accountability for Ins. Cos. Insurance premium not based on health Public / Private health plan competition MMandated for all children (up to age 25) National Health Insurance Exchange to move toward universal coverage IIncrease funding for Public Health $50 billion for CER emphasis on primary care and prevention National Institute for Health Reporting and Quality Analysis

41. May 200941 What’s Going On Now? Senate Finance Committee Options Paper Rep. Allyson Schwartz (D-PA)’s bill, HR 2350, Preserving Patient Access to Primary Care Act of 2009 Senator Bill Nelson (D-FL)’s bill, S. 973, Resident Physician Shortage Act of 2009 Sen. Jeff Bingaman (D-NM)’s Health Access and Health Professions Supply Act of 2009

42. May 200942 Remember This? The decisions, rules, regulations and societal norms that constitute a health care system, and the field of study and action involved in influencing that system Is this health policy? Does it matter?

43. May 200943 Comic deleted due to copyright

44. May 200944 What Can You Do? Join specialty organizations Establish relationships with legislators so that they come to you with questions Talk to peers, friends, and family VOTE LISTEN