Advancing Health Care Reform:
The ACA and Medicare
Aging Advocacy Summit
Presented by Joyce Dubow
Augusta, ME
November 14, 2012
Presentation overview
• How consumers can engage in the “3 aims”
and help to reform health care
• Approaches to quality improvement and
delivery in health reform legislation (ACA)
• ACA and Medicare
• Future of Medicare
• Implications of sequestration
The Three Aims (DHHS)
• Better healthcare:
– Improve individual patient experiences of care along the
Institute of Medicine’s six domains of quality: Safety,
Effectiveness, Patient-centeredness, Timeliness, Efficiency, and
• Better health:
– Encourage better health for entire populations by addressing
underlying causes of poor health, such as physical inactivity,
behavioral risk factors, lack of preventive care and poor
• Reduced costs:
– Lower the total cost of care resulting in reduced monthly
expenditures for each Medicare, Medicaid or CHIP beneficiary
by improving care.
Patient Engagement: 2 pathways
(1)Engagement in one’s own health and health care; and
Center for Advancing Health- “actions individuals must take to
obtain the greatest benefit from the health care services
available to them” (Jessie Gruman, et al., 2010)
Judy Hibbard- Consumers taking on new roles and behaviors,
such as choosing high performing providers; selecting evidencebased treatments; collaborating with their providers; taking
preventive actions; self-management; being vigilant to prevent
(2) Engagement in policy development and governance to
ensure patient perspectives are addressed
Why Patient Engagement Now?
Greater sense of urgency due to fiscal constraints of
federal and state budgets and the unwillingness of
purchasers to contribute to a system that doesn’t
produce good results
HIT, and the need to tie clinical and patient decisions
to evidence
A demand for greater accountability through
measurement and public reporting
How will we know success?
Health care that gives each individual and family an active
role in their care;
Care that adapts readily to individual circumstances as well as
differing cultures, languages, disabilities, health literacy levels,
and social backgrounds;
Sees a person as a multi-faceted
Requires a partnership between the provider and the patient
with shared power and responsibility
Gives the patient access to understandable information and
decision support tools
Determines whether patients achieve their desired
(AHRQ Report to Congress, 3/2011)
Problem drivers
Scientific uncertainty
Perverse economic and practice incentives
System fragmentation
Opacity to cost and quality
Changes in health status
Lack of patient involvement
We get what we pay for, but
not what we want
• Incentives for high volume and intensity
• Inadvertent reward for poor care (e.g., payment for
readmissions, correction of mistakes)
• Procedures paid more than primary care
• No incentive to integrate care
• Payment does not differentiate between good/poor
performance (no reward for high quality, no penalty for poor
Where we need to go
Current system
• (Too) often, unsafe
• Fragmented,
unnecessary care
• Provider-focused
• Timely (?), rushed
• Inefficient, wasteful
• Disparate (geography,
gender, age, race, ethnicity)
• Costly, >unaffordable
IOM Aims for improvement
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable
How we get there…
IOM, the Healthcare Imperative, 2010
• Payment redesign to focus
on results and value
• Quality and consistency in
• Timely evidence that is
independent, and
• Clinical records that are
reliable, shareable, and
• Transparency requirements
on cost, quality, including
Health Care Reform:
Infrastructure to support quality goals
Evidence base
Performance measures
Health Information Technology
Robust workforce
ACA quality provisions that relate to
delivery reform
• Infrastructure: develop evidence, measures, HIT;
test new ideas; certify shared-decision making
• New models of care: Shared Savings Program
(ACOs); medical/health homes
• Accountability: transparency/public reporting
• Financial incentives/payment reform
• Workforce reform/strengthen primary care
• Wellness and health promotion
• *(HITECH provisions in ARRA “meaningful use”
of HIT have significant implications for quality)
National Strategy for Quality Strategy
Improvement in Health Care (NQS)
• Make care safer by reducing harm caused in the delivery of care.
• Ensure that each person and family is engaged as partners in their
• Promote effective communication and coordination of care
• Promote the most effective prevention and treatment practices for
the leading causes of mortality, starting with cardiovascular disease
• Work with communities to promote wide use of best practices to
enable healthy living
• Make quality care more affordable for individuals, families,
employers, and governments by developing and spreading new
health care delivery models.
ACA: evidence for clinical and
patient decisions: PCORI
• Patient-Centered Outcomes Research
Institute, a private, not-for-profit entity to:
– identify research priorities and a research agenda
– conduct research, with priority to AHRQ, NIH
– release and disseminate findings (which many
not be used in making Medicare coverage
determinations, or for reimbursement or
incentive programs.)
Patient-Centered Outcomes Research Institute (PCORI)
•PCORI doesn’t actually define patient engagement or patientcenteredness, but rather incorporates these concepts in its approach to
•Research focuses on outcomes that people notice and care about: survival,
function, symptoms, and health-related quality of life
PCORI poses the following questions
•“Given my personal characteristics, conditions and preferences, what
should I expect will happen to me?”
•“What are my options and what are the benefits and harms of those
•“What can I do to improve the outcomes that are most important to
me?” and
•“How can the health care system improve my chances of achieving
the outcomes I prefer?”
•PCORI models another aspect of patient engagement—inclusion of
patients at the governance level
Infrastructure: measure development and reporting
ACA : quality infrastructure: capacity
to measure performance
• Performance measurement to improve quality,
safety and efficiency, promote accountability,
payment, and delivery reform
– HHS will:
develop and implement a national strategy (3-21-11)
• identify and fund gaps in measures
• oversee a process for collecting and aggregating data
• develop a framework for public reporting
engage in a consultative process with stakeholders on
selection of national priorities and quality measure (5-11)
ACA: CMMI to test new ideas
• The Center for Medicare and Medicaid Innovation to
test innovative payment and service delivery models
that enhance quality of care provided to Medicare and
Medicaid beneficiaries; implement innovations as
they are ready for prime time
• Examples of initiatives: ACOs, bundled payments,
Primary Care Initiative, FHQC Advanced Medical
Homes, Medicaid Incentives for the Prevention of
Chronic Diseases
ACA: advance accountability, reward
good quality, greater efficiency
• Physicians rewarded for P4R through 2014, then
those who fail to report lose $
• Physicians participating in MOC eligible for bonuses
• HHS to provide physicians with information on their
resource use
• In 2013, public reporting on Physician Compare
• “Value-modifier” to reward physicians who deliver
better care, lower costs
Delivery reform
ACA: new delivery models
• Medicare Shared Savings Program (ACOs)
• Medical Homes pilot (Health Homes in Medicaid)
• Medicare Community-based Care Transitions
• Independence-at-home demonstration
ACOs in the traditional Medicare
program (MSSP)
• Governance
• Process to promote patient-centeredness,
patient engagement, use of evidence
• Quality measurement and reporting
• Beneficiary notices
• Data sharing
• Risk sharing
ACO: whole-person orientation
• Seamless, coordinated, integrated care,
available 24/7
• Responsive, respectful, care that recognizes
patients as equal partners in care decisions
and delivery
• Ongoing efforts to examine care to improve
performance, eliminate disparities
Patient engagement in ACOs
ACO functions to demonstrate patient engagement:
Patient involvement in governance
Use of a patient experience survey
Process for evaluating and addressing needs of population served
Systems to identify high-risk individuals
Mechanisms in place to coordinate care via enabling technologies
Written standards for beneficiary access and communication
Process to allow for shared decision making
Communicating clinical knowledge in a way that is understandable
to patients
Financial incentives
ACA: accountability, incent better
care, lower costs
• Hospital readmission reduction program
– Reduced payment for “excess” readmissions for 3
high cost/high volume procedures (acute MI, HF,
• Public reports of readmission rates on Hospital Compare
• Assistance for hospitals with high rates of readmission
• Reduced payment for hospital/healthcare acquired
conditions (e.g., bedsores, complications from extended use of
catheters, injuries caused by falls) in the 25 percent of hospitals
with highest rates)
Payment reform
Payment to incent improvement
• Bundled payments encourage individual and
shared accountability for entire episodes of
care (including acute and post-acute care) or
for a bundle of services
– Reimbursement for all the services needed by a
patient for a treatment or condition across
multiple providers or settings
Delivery reform
ACA: strengthen primary care
• Increase payment to primary care providers
(Medicare bonuses, Medicare rates for Medicaid
• Establishing community health teams to support
PCMH (grants, contracts)
• Support for training clinicians in primary care
• Community-based collaborative care networks
(with FHQCs) to serve low-income individuals
• ACOs, PCMH pilots
Accountability/transparency/public reporting
ACA: advance accountability, reward
good quality, greater efficiency
• Physicians rewarded for P4R through 2014, then
those who fail to report lose $
• Physicians participating in MOC eligible for bonuses
• HHS to provide physicians with information on their
resource use
• In 2013, public reporting on Physician Compare
• “Value-modifier” to reward physicians who deliver
better care, lower costs
“Meaningful use”
• “Meaningful Use” Use of technology to achieve
significant improvement in care
• Financial incentives ties payment specifically to
the achievement of advances in health care
processes and outcomes
• Stage 1 identifies core objectives
– basic functions to enable an EHR to support care
improvement (vital signs, demographics,
medications, allergies, problem list, smoking status)
– Provide patients with electronic versions of their
health information
Summary of ACA steps to improve quality:
an advocacy agenda
Build the evidence base: comparative effectiveness research
Incent HIT and data exchange
Promote accountability through transparency/public reporting
Align payment with performance
Improve health service delivery
Bundled, episode-based payments
Penalties for preventable re-hospitalizations
MA bonuses for attainment/improvement in quality
Primary care; Medical homes; ACOs
Care coordination
Promote wellness and prevention
Adopt enhanced role for patients through shared decision
making and greater engagement through self-efficacy
Public Policies to Support Patient Engagement
Provider payment to incent patient-centered delivery of care
Publication of patient experience and patient-reported
Shared decision making grounded in evidence
Value-based benefit design to encourage better patient choices
Encourage patient-centered delivery Investment in and support
of EHR adoption to facilitate patient access to their health
information; enhance communication with clinicians; and
enhance care coordination
Encourage patient-centered delivery models through support
of primary care, shared savings, etc.
Potential Saved if USA “bends the curve” of
Health Care Spending
NHE in trillions
Current projection (6.7% annual growth)
Constant (2009) proportion of GDP (4.7% annual growth)
We are here
Yellow line =
CBO Estimated savings achieved
by ACA
Total National Health Expenditures, 2009–2020, Current Projection and Alternative Scenario
Will all these ideas work?
Core Goals and Priorities for
Health System Performance Improvement
Getting the right
Coordinated care
Safe care
Source: Commonwealth Fund Commission on a High Performance Health System.
Medicare Reform
Current Financing Unsustainable in Long-Term
• ACA Improved Short Term Outlook (10 yrs)
• Medicare’s share of GDP: Long Term Outlook
(20 yrs+)
3.7 % GDP in 2011
4.2 % GDP by 2022
6% GDP by 2040
• Cost Growth in Medicare caused by:
– Health care cost growth
– Aging of the population
System-wide and Medicare
cost containment
one and the same
Medicare Savings from the ACA
2013–2022 (billions)
Skilled Nursing
Home Health
All Other Services
Medicare Advantage
Other Medicare
***Other provisions include increases in Medicare payments to Disproportionate Share Hospitals that serve many low-income
uninsured persons, effect on federal spending for prescription drugs and biologics (including savings from eliminating the provisions
that close the donut hole), and repeal of IPAB.
Bipartisan Policy Center Debt
Reduction Task Force
Deficit Reduction Proposals (Round I)
National Commission on Fiscal Responsibility and Reform
Reform Sustainable Growth Rate mechanism
for determining Medicare physician fee
updates (costs $240B)
Reform or repeal CLASS Act (costs $76B)
Extend Medicaid rebates to
Medicare/Medicaid dual eligibles in Medicare
Part D (saves $49B)
Reduce Medicare payments to hospitals for
graduate medical education (saves $60B)
Reform Medicare cost-sharing rules, cap
beneficiary out-of-pocket spending, restrict
first-dollar coverage in Medicare
supplemental insurance (saves $110B)
Restrict first-dollar coverage in TRICARE for
Life (saves $38B)
Enact malpractice reform (saves $17B)
Enact premium support pilot for federal
employees (saves $18B)
Reduce Medicare fraud (saves $9B)
Phase out tax exclusion for employer-sponsored
health insurance beginning in 2018 (saves
Cut Medicare payments to providers for bad
debts (saves $23B)
Raise Medicare Part B premiums (saves 123B)*
Accelerate home health payment changes in
the ACA (saves $9B)
Redesign Medicare cost-sharing (saves $14B)*
Place dual eligibles in Medicaid managed
care ($12B)
Reduce funding for Medicaid administrative
costs ($2B)
Broaden scope of Independent Payment
Advisory Board to all federal health spending
Increase rebates for Part D drugs (saves $100B)*
Bundle Medicare payment for acute and postacute care (saves $5B)*
Transition Medicare to premium support,
beginning in 2018 (saves $172B)
Eliminate barriers to enrollment in managed care
options for dual eligibles (saves $5B)*
Incentivize government to control Medicaid cost
growth (saves $20B)
Cap non-economic and punitive damages for
malpractice (saves $48B)
Introduce excise tax on sweetened beverages
(saves $156B)
Source: Commonwealth Fund
Major Health Policies Proposed in
Deficit Reduction Proposals (Round II)
House Republican Budget
President’s Framework
Assumes “doc fixes” are continued and fully offset
Assumes continuation of “doc Fixes”
Repeals the tax and coverage provisions from
health care reform, but keeps most Medicare
savings (but not the Independent Payment Advisory
Proposes health care savings from standardizing the
Medicaid matching rate, prescription drug reforms,
patient safety initiatives, and anti-fraud measures
Block-grants Medicaid in 2013 and holds growth to
rate of inflation plus population growth
Strengthens Independent Payment Advisory Board
by broadening its mandate and limiting Medicare per
beneficiary growth to GDP+0.5% instead of
Enacts tort reform
Transforms Medicare to premium support program
in 2022 and limits per beneficiary growth of
premium support inflation
SOURCE: Committee for a Responsible Federal Budget, Summary Table of Fiscal Plans, April 2011, available at
Characteristics of the Medicare Population
Percent of total Medicare population:
Income <200% FPL
($21,660 in 2010)
3+ Chronic Conditions
Cognitive/Mental Impairment
Fair/Poor Health
Under-65 Disabled
2+ ADL Limitations
Age 85+
Long-term Care Facility
NOTE: ADL is activity of daily living.
SOURCE: Income data for 2009 from U.S. Census Bureau, Current Population Survey, 2009 Annual Social and Economic Supplement. All other
data from Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2008 Access to Care
Sequestration: percentage reductions
for FY 2013 by category of spending
• Non-exempt defense discretionary
• Non-exempt nondefense discretionary (afterschool programs, special ed, reduced FBI, border
security, reductions in oversight of air traffic
control, food inspection, water, air protection,
NIH research, FEMA, 8.2
• Medicare 2.0
• Nonexempt defense mandatory 7.6
• Nonexempt nondefense mandatory 10.0
Impact of Sequestration
on Older Adults (NCOA)
$54.5 billion in non-defense discretionary cuts in FY13
• 17 million fewer congregate and home-delivered meals for
• 1.9 million fewer senior transportation rides to medical
appointments, grocery shopping, and other needs
• 1.5 million fewer people receiving personal care services,
such as in-home help with bathing and dressing
• 290,000 senior households losing their heat due to a $285
million cut in the Low-Income Home Energy Assistance
• 6,400 fewer unemployed low-income older adults getting
hired and paid because of cuts to the Senior Community
Service Employment Program
Conclusion: Consumer have a horse in the

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