1. Great Plains Regional Medical Center Logo Refresh Exploration February 8, 2013 2013 NEBRASKA POLICY & ISSUES SUMMIT New Norms and Innovation in Health Care Delivery November 18, 2013 Greg Nielsen, FACHE

2. Affordable Care Act Delivery System Changes – Insurance exchanges – Value-based purchasing programs – Bundled payments – Accountable care organizations – Geographic variation adjustments – Medicare and Medicaid quality reporting – Meaningful use (product of ARRA)

3. Reimbursement Cuts Medicare reductions since ACA enacted – ACA, sequestration, bad debt and coding adjustment cuts $1.3 B over ten years -8.0% reduction – Cuts under consideration Outpatient E/M, Indirect Medical Education, Direct Medical Education, Bad Debt, SCH program and CAH payments $608 M over ten years

4. Nebraskans by FPLs Source: Kaiser Family Foundation. Note: Nebraska Total Population 1,809,700

5. Transitions of Coverage Source: Kaiser Family Foundation. Note: Nebraska Total Population 1,809,700 20102014

6. Reform Effects Living it since 2010 – Reimbursement cuts – Value-based purchasing – Reimbursement penalties – Transparency – New IT requirements – FTE reductions – Supply negotiations – Benefit plan changes

7. Status of Hospitals? “Not-for-Profit hospitals saw declines in volumes, revenue growth” – Moody’s Investor Service “2012 may have been the ‘high water mark’ year for hospitals” – Fitch “Moody’s predicts slow revenue growth, confirms negative outlook’ – Advisory Board Daily Briefing “In states that say no to Medicaid, hospitals worry about ‘death by 1,000 cuts’” – Advisory Board

8. Status of Hospitals? “In exchanges, many plans will limit hospital choices.” “Many young Americans have not heard of the exchanges.” “Hospitals want an ACA delay too.” “Doctors may see pay delays in ACA exchanges.” Source: Advisory Board Daily Briefing

9. Status of Hospitals? Strong, vulnerable, fragile and scared Declining volumes and reimbursements No clear business model Inconsistent quality results being published Run to safety through mergers and alliances

10. Great Plains Regional Medical Center Logo Refresh Exploration February 8, 2013 Q&A