This presentation is intended to provide a comprehensive overview of the ACA for health professionals . It is motivated by the observation that while a good deal of information is available on many of the subjects specified by the law – obtaining a digestible overview of its entirety seemed to be unavailable.

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These are a portion of our national circumstances The famous baby boomer generation is aging and a large “bubble” of their number are entering retirement age in the next few years. The demand for health care services increases with age. Since the federal government pays for tremendous amount of these it becomes a matter of national management to not only provide an equitable distribution, but to do so efficiently and effectively, and using the most contemporary management processes and procedures available to hold down costs. By 2019 the number of uninsured will grow by more than 30% in 29 states and 10% in every state. Insurance premiums for businesses more than doubled since 2000 – a rate 3 times faster than the growth of wages. A broad variety of information has demonstrated that the national population appears to be becoming increasingly unhealthy with large numbers of people overweight or obese, and many of them sustaining a large number of chronic diseases. Our national circumstances are such that we tend to provide healthcare services to those with presenting symptoms, and only a small portion being made available that if successful would hold down costs in the long pull.

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It is well-known that the cost of healthcare is the fastest increasing component of the national cost-of-living. Service providers seek to increase their reimbursement; this in turn has required them to act aggressively to keep their costs low in order to attract purchasers. This has often resulted in curtailments of services and service quality. Physicians, acting to increase their revenues have tended to specialize. The result has been a diminishment in the number of primary care physicians that are available for first contact by individuals. Insurance companies, seeking to hold their premiums low, have tended to restrict the benefits that they pay for with the premiums they receive. Therefore, driven by many forces, mainly the aging of the population and the tremendous advances of expensive medical technology, the cost of healthcare have continued to increase.

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In recent years the federal government and numerous private foundations and study groups have analyzed the status of the national population’s health and published information that reports that status among states, population groups, etc. This slide reports information compiled by the authoritative Commonwealth Fund on the health status and health costs in New Jersey. As is noted New Jersey does not rank high by certain measures and thereby demonstrates a need for improvement. One of the central features of the Affordable Care Act is to comprehensively address such problems with a combination of intensified services, better management, increased accountability, and the provision of information that describes the problem, and to report the success or failure of attempted solutions by publishing to the industry and the general public.

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Is this law a band aid? Not enough?

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Or is it a monster? Is it a government takeover of personal and private institutional decisions? There is a good deal of myth and speculation on what it intended.

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This slide describes just a few of the law’s many goals. Controlling costs of service delivery is central but dependent upon management action in several areas. We know from studies conducted at Dartmouth that there are numerous imbalances in the way that health care services are delivered in different geographic locations. Some of these differences represent waste and inefficiency. We know that revising existing practices and service models and creating new ones may help control costs and improve the quality of care. However, it is not likely that the broad spectrum of physicians, hospitals, and other institutions are likely to easily or willingly initiate these changes since they are pursuing cost-cutting and other activities to increase reimbursements. Revising practices seems to require outside organizations such as foundations and study groups to identify and bring new practices to bear. The Affordable Care Act will require, encourage and initiate some new practices. There will be a strong emphasis on preventive services. It is well known that there are several chronic conditions including diabetes, arthritis, obesity and asthma, with the probability of later expensive hospitalization, that if addressed early can significantly reduce that possibility. Since it is not likely that existing healthcare service providers will initiate programs of prevention since there is no financial incentive to do so, it again remains the province of the federal government and major foundations and study groups

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to provide leadership and experimentation in this area. The Affordable Care Act will improve the transparency of health services delivery operations and is expected to publish the results of health care practices that will be available to the industry and the general public. This will not only increase accountability, but should act as a motivation to make improvements when the areas of great deficiency are observed. For example, recently the Consumers Union, the publisher of Consumer Reports, devoted part of one of their issues to the subject of patient safety in hospitals making use of a national database of the type that will be developed further in consequence of the affordable care act’s intent. Attempts will be made to create new service models that integrate health services. A person discharged from a hospital will be tracked through subsequent services they may receive by visiting nurse services, and outpatient and physician experiences. Incentives will be created to identify the patient’s needs throughout this tracking. Reimbursement for these services will be linked to measures of their efficiency and effectiveness.

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In short – its comprehensive and somewhat groundbreaking with what it intends It is worth the attention of health professionals to see what has happened during the last two years, and what is intended in the months to come. Regardless of what our Supreme Court decides in June – It is worth your own independent professional judgment of its components to determine if they are desirable

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Most of you know the drill . . . After the law was passed it immediately passed into implementation. Federal government administrative implementation machinery was adapted and created, and the states were contacted to move them into readiness for implementation where that may have been required. Similarly, federal grants to states were adjusted to require conformance to many of the features of the Affordable Care Act. For example the 10-year-old system of New Jersey County cancer coalitions was abandoned in 2012, and replaced with organizations that will focus on chronic disease, and preventive activities.

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No one department has service level oversight of the law and what is happening in NJ. A variety of jurisdictions are involved: NJDSS NJDHS Banking and Insurance Children and Families Labor and Workforce Development To find out what is happening will require inquiry and research by providers of health and human services as the law affects their interests.

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The Big Picture The first four titles are likely to be the most relevant for those of us involved with private and governmental public health service delivery. Some suggestions for your inquiry will be identified later in the presentation.

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There is more to these titles than is shown on the slide. VI – Among other things- look for conflicts of interest and duplicationsof efforts by privately owned facilities and businesses (For examples: Hospitals, long term care facilities, equipment manufacturers and physicians; VII – Seems to address the licensing of many products not now required to be controlled

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This title identifies70 + regulatory specifications of which these are only a few. It is primarily directed to hospitals and insurance companies and their activities. Makes insurance available to the great majority of people where they may have been in eligible for insurance coverage previously. Makes more insurance information available to the public in a uniform manner thereby assisting and easier understanding of insurance regulations and contract provisions by the general public Eliminates many restrictions put into place by insurance companies, such as: Limitations on the value of benefits Pre-existing conditions Provide subsidies and tax credits to businesses to encourage the insuring of their employees The item in red and italics have been the most controversial – as you can see there is more to the law than that requirement

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As many of you know the expansion of insurance to the general public. Features a considerable expansion of the Medicaid program. At this time, negotiations are taking place in New Jersey and other states to revise Medicaid provisions for particular state requirements. For example, some states have significant Native American populations, while others have significant populations recently immigrated to the United States Lots of demonstration projects

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The subjects addressed are comprehensive as you can see on the slide. Hospitals will be reviewed to determine if they have a disproportionate share of low income and Medicaid patients that require additional funding for their services delivery. Measures will be created to improve the level of quality service delivery. Reimbursement to some institutions will be adjusted to account for the poor services delivery that might be offered. For example, there is a higher rate of hospital and long-term care based infections, and high incidence of events that are caused by poor patient safety procedures. Programs will be initiated to educate the Medicaid and other populations on the responsibilities they have to maintain their own health. Health homes will be created to take care of people with chronic conditions in both inpatient, outpatient, and private medical practice settings. Reimbursement will depend on the appropriate integration of the services delivered by those sources.

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Here again, we can see something of the range of detail of services to be provided under the law. As you can see these new services include demonstration projects as a means of testing some of the new ideas and new service models that will be originated.

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This title states many of the management requirements that will be brought to bear on all aspects of health services. Here is where we will begin to find policies and practices stated that in many instances will be linked to reimbursement. We are being asked to justify what it is we do. The National Strategy was published in March, 2011 and is available online We’ll be hearing more about: Evidence based practices Measured Outcomes These will be directed to licensed institutions but will also be applied to community, home and outpatient settings

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You can expect the resulting strategies and measures and requirements to be applied to private and governmental public health practices.

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Reports are now being produced: example: Surgical Care Improvement Project Concern with hospital infections Comparative Physician experience database: Example: Why are ceasarean births at exceptionally higher rates in one region of the nation than in another?

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As you can see here, we are moving away from the traditional fee-for-service that has been prevalent throughout our nation for many years. Those fees for services were normally predicated on the idea that a single provider would be reimbursed for the provision of a single set of services. This would happen again as the patient might have had to move to a different provider for the continuation of treatment. The new system will include approaches to the integration of these services and reimbursement for them as a single entity of service delivery.

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Shared services are an approach to such integration. As many of you know New Jersey has passed legislation permitting the creation of Accountable Care Organizations that will seek to reduce the incidence of people purchasing medical services through their insurance companies or government programs in a duplicates is way, and to reduce the incidence of unnecessary visits to hospital emergency departments. This particular form of organization will reward savings accomplished by sharing those savings with the accountable care organizations that produce them

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Here again we see the intent to integrate care and to bundle payments. Again, demonstration projects are featured. And the intent to start a new system will be accompanied by health systems research, and federal oversight with the Medicare Advisory Board

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Teams of new service providers will be created to support patients who may be living at home

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This title features the new importance being placed on preventive care National Strategy first published in June, 2011 and is available online Should be of particular interest to public health professionals

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With Prevention we are getting closer to our interests in public health

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Here we see a more specific application of preventive care which is now being implemented in New Jersey Shaping NJ Community Transformation Program Both programs are in existence at this time

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There is a Clinical Guide to Preventive Services. Available Now: he Guide to Clinical Preventive Services includes U.S. Preventive Services Task Force (USPSTF) recommendations on screening, counseling, and preventive medication topics and includes clinical considerations for each topic. This new pocket guide is an authoritative source for making decisions about preventive services. The Guide to Community Preventive Services is a free resource to help you choose programs and policies to improve health and prevent disease in your community. Systematic reviews are used to answer these questions: What are the proven best practices that can be brought to bear locally? Are there evidence based procedures that can be brought to bear and provide some assurance of local success? Guide to Community Preventive Services available now – Obesity is 44 pages of policies, strategies and practices

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Some of the prevention services will be authenticated by the Preventive Services Task Force, and the Community Preventive Services Task Force. Some of their recent findings have been controversial. For example, they have stated that the PSI test used to detect prostate cancer cannot be shown to have a measured effect on the saving of life. This does not mean that it cannot be used any longer, since it often indicates the presence of prostate cancer, but it does indicate that some insurance companies and perhaps the federal government may not authorize reimbursement in case it is used as a test. The basic premise, of course, is not to pay for tests and diagnoses that are not proven to be effective.

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This program is primarily focused on school children in disadvantaged areas where the incidence of poor health and nutrition and some specific pathologies such as asthma and diabetes have a higher incidence rates than in other parts of the country

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The annual wellness visit program is already in place

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We’ve already spoken to the community transformation grants, and this is the description of what they intend to accomplish. In New Jersey, all of the counties that have over a 500,000 population have been solicited to join the program. As a second effort the 13 counties in New Jersey with less than 500,000 population have been the subject of a separate effort. We’re working on that now in Morris County. Once in place, and assessments are conducted, and priorities are established, it is expected that large sums of money will be awarded locally to address the needs and implement the priorities.

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Note that this is baby boomer related – addresses those on their way to being high utilization elderly

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Strongly related to strengthening FQHC’s. Large sums of money have already been provided to these organizations to expand their physical plant and staff Money flowing now

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Again, funds are being made available to research how prevention can best be achieved.

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Here we see that development of the new health services workforce that will be required will be the subject of education and training funded through the new law. There is a need for new disciplines, such as the community health workers that have been established in New York City and elsewhere in the United States. Such workers are recruited locally, and are part of the culture of the target population.

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The provisions for service delivery and their reports to be as transparent and available to the public is included in this title. It is also a title that picks up on the special needs of elderly persons. As you are aware our national population is aging and as larger numbers of elderly people come into the health system it will become increasingly necessaryto provide some of the services that are unique to their particular condition. Elder Violence Elder neglect Adult Protective Services

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