HEALTHCARE REFORM IS NOT NEW. ROLE CALL cont. 9/15/2012. What is HEALTH CARE EFORM?

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1 Wanda Ali-Matlock, R.N., BS, MA, FAACM OBJECTIVES Understand the general government plan to assure every U.S. citizen has access to healthcare. Understand the changes implemented to healthcare as a result of the healthcare reform law. Understand the role of case management during a time of healthcare reform. 1 2 HEALTHCARE REFORM IS NOT NEW President Theodore Roosevelt was the first president to express the concept of health insurance for every American. President Barrack Obama was the first president who successfully enacted a law to provide health insurance for every American. The Patient Protection and Affordable Care Act became law on March 23, Succeed in 1964 with the Medicare bill which created Medicare and Medicaid in ROLE CALL cont. His plan laid the foundation for President Obama s plan. Proposed Medicare expansion but repealed due to concerns of new taxes What is HEALTH CARE EFORM? Health care reform is about introducing changes to our healthcare delivery system which will promote quality, greater access and increased coverage for optimal utilization of resources to yield a more efficient process and accountability. Signed the Medicare prescription drug benefit expansion Developed a plan while he was in office

2 Children under 19 with pre-existing condition can t be denied coverage. Well-baby and well-child care from birth to age 21 are covered. Adults up to age 26 can remain on their family's health insurance plan. No deductibles and other out-of-pocket expense for preventive care on new individual or group private insurance plans. Insurance companies can't drop your coverage if you become sick. Insurance companies can't place lifetime limits on health coverage. Uninsured adults with pre-existing condition can get health insurance as part of a high risk pool. Medicare beneficiaries who fell in the part D donut hole gap got a $ rebate for their prescription. 7 8 Medicare beneficiaries in the part D doughnut hole receive a 50 % discount on brand-name prescriptions and 7% discount on generic. Medicare expands coverage to include wellness and preventive care. Payments to Medicare advantage plans were frozen at the 2010 dollar amount then it starts to decrease. States can offer home and community based care for the disable under Medicaid. Value of your insurance benefits must be disclosed on your W-2. Medicare and Medicaid began tracking hospital readmission rates and put financial incentives to reduce preventable readmissions. Hospitals that improve the quality of care for patients with Medicare can qualify for the new payments. Medicare beneficiaries in the part D doughnut hole receives a 50% discount on brand-name prescriptions and a 14% discount on generic. Rates for Medicare Advantage plans are reduced further Medicare beneficiaries who reach the part D doughnut hole receive a 52.5% discount on brand-name prescription and a 21% generic prescription drugs. Individual mandate for health insurance. People will be charged a tax of $95.00 or 1% of their income whichever is higher if they do not buy insurance. This tax will increase yearly up to $ or 2.5% of a person s income in

3 All American citizens or legal immigrant. The cheapest insurance available to you costs more than 8 percent of your income. You will be uninsured for three months or less. Certain religious objections. You are a member of an American Indian tribe. You are a prisoner HEALTH CARE EXCHANGES- are on-line insurance marketplaces offering health insurance coverage with comprehensive benefits. Essential health benefits like doctor s office and clinic visits, tests, emergency services, prescription drugs, and maternity care. Pay 100% of the cost of preventive services such as immunizations and certain health screenings. Exchanges will offer at least two coverage levels however some exchanges may offer all 5 of the coverage levels Bronze: pays for 60% of all covered medical Silver: pays for 70% of all covered medical Gold: pays for 80% of all covered medical Platinum: pays for 90% of all covered medical Catastrophic: available for people under 30 which would cover: Three primary care visits a year. 100% of the cost of preventive care. Essential health benefits once you have reached a deductible (Currently: $5,950/individual)

4 Subsidies are available to purchase health insurance through an exchange for individual who make less than 400% of the poverty level which currently at $44,680 for a single person. These individuals will not pay more than 9.5% of their income for insurance premiums. Children, parents and adults without children who do not have Medicare and who have a limited income are able to apply for Medicaid. 19 Medicare beneficiaries who reach the part D doughnut hole continues to receive a discount on brand-name and generic prescription drugs annually until they receive a 70% discount on brand-name and 63% percent discount on generic in 2019 to completely close the hole in Insurance companies are banned from putting annual limits on health coverage. Insurance companies can't deny anyone health coverage because of a pre-existing condition. 20 Expands readmission policy to include more conditions. Maximum payment penalty to hospitals with higherthan-expected readmissions rate increases to 3%. Is not going away. It will affect reimbursement. Is an opportunity for case managers to be proactive in their role A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual s and family s comprehensive health needs through communication and available resources to promote quality and cost-effective outcomes. Evaluation and management of medical resources and services for necessity and appropriateness. Involves the management of care for efficient use of healthcare services, procedures, and facilities under the patient s healthcare benefits. Match the patient s needs with the necessary care interventions to reduce waste, prevent over utilization of the healthcare resources and deliver the highest quality of care in the most effective and efficient settings

5 Reducing readmissions rates. Core Measures are being tracked and reported on because they are rooted in evidence based care for quality delivery. Case managers will have to be proactive in care management as DRG payments are reduced. We will need to be more diligent in assessment, planning and coordinating our patient population s care along the continuum. We will need to establish resources of reliable entities to assist with readmission reduction, care continuum provider. ED Case manager are the first line of defense in identification of potential readmissions before they are readmitted and for assessment and planning for alternatives to admission if appropriate. May need to incorporate a complex case management model and the utilization of readmission risk assessment tools. Greater involvement of family participation and compliance Education of patients and caregivers in reference to appropriate utilization of healthcare benefits Cititations Continue to Advocate for your patients. Do not let health care reform be an obstacle to receiving and delivery quality care. Landmark. The Inside Story of America s New Health- Care Law and What It Means for Us All. The Staff of The Washington Post The Henry J Kaiser Family Foundation Instruments/HospitalQualityInits/Downloads/0210_Slides.pdf