School-based Health Centers : Health Care Reform and Medical Home

SCHOOL-BASED HEALTH CENTERS: HEALTH CARE REFORM AND MEDICAL HOME

NORTH CAROLINA SCHOOL COMMUNITY HEALTH ALLIANCE2012 ANNUAL CONFERENCE

OBJECTIVES Review health care reform initiatives that are

relevant to school health Discuss background information concerning

Medicaid and CHIP Examine medical home options for school-

based health centers

REFLECTIONS Shortage/maldistribution of primary care

physicians Shortage of pediatricians who choose to

enter community pediatrics The growth of ACO (Accountable Care

Organization)-type entities Failure of school-based health centers to

generate sufficient revenue to justify their existence

PEDIATRICS 2020 AND BEYOND Sick children sicker Mental health issues Families more isolated Increased diversity Transitional care

HEALTH EQUITY17% of children live in povertyPoverty affects sequential generations of

the same familiesPoverty is a key contributor to poor health

statusGenerational violence robs lives Incarcerated youth share a common historyCabinet-level attention is needed

Requires that private insurance include the following consumer protections: No annual caps on coverage No rescissions (if a child or adult gets sick, coverage

can’t be lost) Children may stay covered on their parents’ policy

until age 26 Children may not be denied

care because of a pre-existing condition

Minimum medical loss ratios Cap on out of pocket costs

for families

What insurance reforms are included in the new law?

PREVENTABLE CAUSES OF DEATH IN N.C.

Preventable Causes of Death in North Carolina (2007)

531606758910

1,3641,5161,743

2,3502,653

12,58313,720

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000

Illicit Drug UseUnsafe Sex

UninsuranceFirearms

Motor VehiclesMedical ErrorToxic Agents

Microbial AgentsAlcohol Consumption

Diet/Physical InactivityTobacco Use

Estimated Number of deathsState Center for Health Statistics, North Carolina Department of Health and Human Services, (2007).

WHAT IS A MEDICAL HOME? An approach to providing health care services in a

high-quality, comprehensive, and cost-effective manner

Provision of care through a primary care physician through partnership with other allied health care professionals and the family

Acts in best interest of children and youth to achieve maximum family potential

Many notions tested among children and youth with special health care needs – but principles and characteristics apply broadly to all children/families

MEDICAL HOME DEFINITION Primary care Family-centered partnership Community-based, interdisciplinary

approach to care Care that is: accessible, family-

centered, coordinated, compassionate, continuous, and culturally effective.

Preventive, acute and chronic care Quality improvement

ATTRIBUTES OF THE MEDICAL HOME Accessible Family Centered Continuous Comprehensive Coordinated Compassionate Culturally Competent

NCQA: PATIENT CENTERED MEDICAL HOME MEASUREMENT

Access and Communication Patient tracking and registries Care management Patient self management Electronic prescribing Test tracking Referral tracking Performance reporting and improving Enhanced electronic communications

MEDICAL HOME Pediatric Medical Home under CCNC

(Community Care of NC) Typical adult medicine medical home Information technology and the NC Health

Information Exchange School-based health centers and medical

home

CHIPRA (Children’s Health Insurance Program Reauthorization Act)

ARRA (American Recovery and Reinvestment Act)

HITECH Act Affordable Care Act (ACA)

Health Care Reform

MEDICAID AND SCHIP

Birth to 1 Year

1 to 6 Years

6 to 19 Years

0 50 100 150 200 250

185

133

100

200

200

200

SCHIP Medicaid

MEDICAID EXPANSION (2014) For patients younger than 65 who are not

pregnant and have family incomes up to 133% of poverty

2014-2016: 100% federal funding After 2020: 90% federal funding Essential Health Benefits Package Eligible adults required to enroll their children

in Medicaid/CHIP

CHIPRA COMPONENTS $32.8 billion over 4.5 years 300% FPL eligibility for CHIP match $225m for quality and health IT $100m for outreach and enrollment 8 enrollment improvements – if state chooses 5,

boosts federal funding Public/private partnership on premium subsidy –

eliminates crowd out

CHIPRA Strengthens AAP Access, Quality and Finance

Pillars Establishes Medicaid and CHIP Payment and

Access Commission Calls for development of a core set of health

care quality measures for children enrolled in Medicaid or CHIP

Directs implementation of a GAO study and report on access to primary and specialty services.

CHIPRA COMPONENTS

Immigrant Children's Health Improvement Act (ICHIA) – states can remove 5-year wait for legal immigrants

Translation Services now at 75% FMAP Coverage of pregnant women up to 200% Dental benefits required Mental health parity, if provide mental health

DAVID T. TAYLOE, JR., MD, FAAP 2706 Medical Office Place Goldsboro, NC 27534 919-734-4736 919-580-1017 (fax) dtayloe@aap.org December 4, 2012

FIRST DOLLAR COVERAGE FOR PREVENTIVE SERVICES September 23, 2010 Bright Futures: Guidelines for Health

Supervision of Infants, Children, and Adolescents (AAP, MCHB)

Does not apply to “grandfathered” plans Does not apply to Medicaid plans

HEALTH CARE HOMES Grants available to state Medicaid programs

as of January 1, 2011 Enrollees must have:2 chronic conditions1 chronic condition and at-risk for second1 serious mental health condition

CENTER FOR MEDICARE AND MEDICAID INNOVATION (CMI)

Fiscal Year 2011-2019 $5 million available to organizations for design of

projects $10 billion available for implementation of

projects Project design/regulations pending

GRANDFATHERED PLANS Existing group health plans or health

insurance coverage in which a person was enrolled as of March 23, 2010

Prohibition on Pre-existing Conditions for Children, September 23, 2010

Prohibition on Pre-existing Conditions for Adults, January 1, 2014

Coverage of and Prohibition on Co-payments and Deductibles for Preventive Care, September 23, 2010

PREVENTION AND PUBLIC HEALTH FUND $15 billion: FY 2010-2020 The fund will support programs authorized by

the Public Health Service Act for prevention, wellness, and public health activities, including prevention research and health screenings and initiatives.

www.hhs.gov/news/press/2010pres/06/20100618g.html

PREVENTION AND PUBLIC HEALTH FUND $250 million: community-based health

settings; obesity prevention and fitness; tobacco cessation; infectious disease outbreaks; CDC’s Clinical Preventive Services Task Force recommendations; public health workforce and training centers

$250 million: US primary care workforce projects (residency slots; PA’s; NP’s;nurses)

SCHOOL-BASED HEALTH CENTERS (SBHC’S)

$200 million for FY 2010-2013 Target SBHC’s that serve large numbers of

children eligible for Medicaid and CHIP Infrastructure only (not for paying for

personnel or services)

IMMUNIZATION COVERAGE IMPROVEMENT PROGRAM FY 2010-2014 Grants to states to improve the provision of

recommended immunizations to children, adolescents, and adults

Permanently reauthorizes the state immunization grant program in section 317(j) of the Public Health Service Act

COMMUNITY TRANSFORMATION GRANTS FY 2010-2014 Funds for the implementation, evaluation,

and dissemination of evidence-based community preventive health activities to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and develop a stronger evidence base of effective prevention programming.

PERSONAL RESPONSIBILITY EDUCATION

FY 2010-2014 Grants to states for programs to educate

adolescents on both abstinence and contraception and sexually transmitted infections, including HIV/AIDS

AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA)

$87b in FMAP increase Hold enrollment at 7-1-08 levels Prompt payment 6.2% minimum increase

$19b in Health IT infrastructure (2011) (HITECH Act, Title IV) 20% Medicaid patient threshold State planning and implementation grants

ARRA $10.4 billion to NIH $1 billion for Prevention and Wellness Fund $500 million to HRSA workforce development $200 million for Title VII and VIII programs $300 million for the National Health Service Corps $2 billion for Child Care Development Block Grant

PEDIATRIC ACCOUNTABLE CARE ORGANIZATION (ACO)

Incentive payments to stimulate improvements in quality and cost-effectiveness

Fee-for-service to providers who contract directly with payers

Quality improvement payments to the ACO January 1, 2012 – December 31, 2016

AAP RESOURCE State Implementation of the Patient

Protection and Affordable Care Act (ACA)

www.aap.org/moc and go to “Advocacy” (lower left hand corner), and then “State Government Affairs,” then look for the document “State Health – State Implementation of the Patient Protection and Affordable Care Act (ACA)”

FEDERAL ACA WEB PORTAL www.hhs.gov/ociio/regulations/webportal/

index/html www.healthcare.gov