Of Geriatric Care Management Fall 2013

VOLUME 23

ISSUE 2

FALL 2013

Published by the National Association of Professional Geriatric Care of Managers 3275 West Ina Road Suite 130 Tucson, Arizona Geriatric Care Management 85741 520.881.8008 / phone 520.325.7925 / fax www.caremanager.org

Care Management and the Affordable Care Act (ACA) The Possibilities, The Realities, and The Concerns

Guest Editor’s Message...... 2 Carol S. Heape, MSW, CMC Care Coordination Under the Affordable Care Act: Opportunities and Challenges for Geriatric Care Managers...... 5 Susan Emmer, Legislative Consultant NAPGCM A CLASS Act – Development until the Aftermath of its Demise...... 9 Regina M. Curran, MA, CMC The Affordable Care Act: Shaking Up the System Provides Opportunities for Care Management...... 14 Michael Newell, RN, MSN The Affordable Care Act and Its Impact on Care Management...... 18 Eric C. Rackow, MD & Claudia Fine, LSCW, MPH, CMC Beware of What You Wish for OR The Affordable Care Act and Me...... 24 Phyllis Mensh Brostoff, CISW, CMC Understanding National Health Reform: Why Big Data isn’t Enough...... 27 Natasha Dorgin, MD/PhD Candidate & Kate Lapane PhD Effects on Medicare Clients & The Affordable Care Act (ACA) ...... 32 Carol S. Heape, MSW, CMC of Geriatric Care Management Fall 2013

Guest Editor’s Message Carol S. Heape, MSW, CMC, Fellow

“The Patient Protection and to come in future months. and recognize the complexity of this legislation and how it is predicted to Affordable Care Act (ACA) is “The bill itself has many components, some of which are change healthcare as the U.S. knows the most significant health- complex topics unto themselves and it. This will also change for them care legislation enacted since involve multi-year schedules. Some how care management is viewed and create new federal offices, and others how those views will change society’s the passage of Medicare and confer authority to pursue goals and expectations. Finally, whether you, Medicaid forty-five years ago. concepts, rather than containing the Geriatric Care Manager are a sole specific program proposals. As a practitioner, consider yourself a small The new law’s full implications business with several employees, 1 result, most people at the community will not be known for years...” level did not understand the bill or the are part of a larger care management planning that went into it well enough firm or healthcare system, or are the to be able to clarify it for others.” 2 founder or owner of a large company he Affordable Care Act (ACA) offering care management, home care, is in the news almost daily as For Geriatric Care Manag- conservatorship, fiduciary services, Tits implementation approaches. ers (GCM), the ACA means one set etc., you must pay attention! The It is a moving target; with facets and of issues for their clients, the great ACA is large, complex, and has as- timelines changing in some ways in majority of whom are on Medicare. pects that will affect all Care Manag- a domino effect. Regardless of the However, Geriatric Care Managers are ers personally and professionally. controversy surrounding this massive also business owners looking for new legislation, it lumbers forward with opportunities to serve clients and per- “This legislation is not perfect. changes that already have been in haps expand their practice to include Many social workers supported a effect for several years i.e., those other populations. Care Managers are single-payer system or, at minimum, occurring this fall and more scheduled also very aware of the “world at large” continued on page 3

Editorial Board Rona Bartelstone, LCSW, CMC, C-ASWCM Fort Lauderdale, FL Phyllis Mensh Brostoff, CISW, CMC Milwaukee, WI Cathy Cress, MSW Santa Cruz, CA Lenard W. Kaye, PhD Orono, ME of Karen Knutson, MSN, MBA, RN Bryn Mawr, PA Betty Landreaux, MSSA, LCSW, CMC, NCG Journal Metairie, LA Emily Saltz, MSW, LICSW, CMC Geriatric Care Management Newton, MA Published by the: Jennifer Pilcher Warren, MS, PhD, CMC Lincoln, MA National Association of Professional Geriatric Care Managers Monika White, PhD 3275 West Ina Road, Suite 130, Tucson, Arizona 85741 • www.caremanager.org Santa Monica, CA © Copyright 2013 Editor-In-Chief Suzanne Modigliani, LICSW, CMC The Journal of Geriatric Care Management is published two times per year as a Brookline, MA membership benefit to members of the National Association of Professional Geratric Care Managers. Non-members may subscribe to Journal of Geriatric Care Management for Graphic Design $95.00 per year. Send a check for your one-year subscription to: Subscription Department, HagerDesigns NAPGCM, 3275 West Ina Road, Suite 130, Tucson, Arizona 85741. Dallas, Texas

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Geriatric Care Management be fragmented with no overall public data collection, statistics, and track- and the Affordable Care Act program in place to address long-term ing outcomes can move the profes- continued from page 2 care needs for all older Americans sion upward to the point of being who wish to age in place in their own recognized as the profession it is. The adding a public option to the ACA. homes. authors have addressed this shortfall Despite this, the legislation provides a Building on Emmer’s article and write an important message to critical framework for addressing our on the ways “person-centered care” Care Managers about the opportunity nation’s healthcare issues.” 3 and care coordination are included to participate with this effort. Through Susan Emmer, Legislative Con- throughout various aspects of the their data collection and development sultant to NAPGCM begins her article, ACA, Michael Newell, RN, MSN, of predictive models, Humana Cares/ “Care Coordination Under the Afford- “The Affordable Care Act: Shaking SeniorBridge has been able to ad- able Care Act: Opportunities & Chal- Up the System Provides Opportuni- dress these issues as well as the 30 lenges for Geriatric Care Managers” ties for Care Management” writes day readmission problem. Finally, it with a historical perspective of what how the changes occurring prior to the brings Geriatric Care Managers back to tracking statistics, diagnoses, and care coordination looked like prior to ACA have set the stage for potential identifying common problems care the passage of the ACA in 2010. She involvement and opportunities for recipients and Care Managers face brings us forward to the aspects of Geriatric care managers. Patient- together. In conclusion, these authors the ACA that focus on care coordina- centered care, Newell writes is “care stress the need for consistent, mea- tion and describes care management/ that is respectful of and responsive to surable outcomes that will track the care coordination programs such as individual patient preferences, needs processes and demonstrate a positive Community-based Care Transitions and values.” The concept of patient- outcome. Program (CTP), Affordable Care centered empowers the individual to Organizations (ACO), Health Care In- keep and review their own Personal In her article, Phyllis Brostoff ex- novation Awards, Navigator Program, Health Record brought about through amines the ACA from an employer’s Money Follows the Person, and oth- the advent of the HITECH Act and perspective, “Beware of What You ers. Her article not only explains the electronic health records (EHR). Wish For OR The Affordable Care Act terms and a summary of the programs Although challenges remain, Geriatric and Me” anticipating that by 2015, but she offers an encouraging chal- Care Managers have already begun her company will have to comply with lenge to Geriatric Care Managers to working with the EHR with their cli- the mandates set up for employers learn about new programs within the ent. Funding was included with the with 50 or more full time employ- changing healthcare landscape that ACA to facilitate and further reinforce ees. As a social worker and larger will utilize the expertise and commu- the EHR concept. Newell’s article company employer, Brostoff writes nity knowledge of the Care Manager. further explains existing and pilot of her philosophy of having universal Since 2000, Regina Curran, MA, projects and the potential develop- health coverage for everyone. Now CMC, “A CLASS Act – Development ment of opportunities for Geriatric however, she is facing the reality of Until the Aftermath of its Demise,” Care Managers around the country to an employer who has offered health has represented NAPGCM in the become involved within the contexts insurance as a benefit to employees for Leadership Council of Aging Orga- of their practice and community/state some time that now may not be suf- nizations. Curran, with NAPGCM programs being implemented for care ficient to comply with the mandates of Legislative Consultant Susan Em- coordination. the ACA. The story is not unfamiliar mer, continues to educate NAPGCM to many of us who started companies “The Affordable Care Act and as a sole practitioner, added Care membership about aging policy as Its Impact on Care Management,” well as working to have the NAPGCM Managers and administrative staff as Eric Rackow, MD and Claudia Fine, employees and then made the decision voice be heard nationally. Regina LSCW, MPH, CMC of Humana to add the home care component. In writes about national long-term care Cares/SeniorBridge shows the extent her article, Brostoff gives the specifics policy (or lack thereof) after giving us a national care management com- of the growth of her company, the ad- a background on Medicare, Medicaid, pany within the context of Humana, dition of employees that was fueled by the CLASS Act, and the establishment a national health company, can be growth and the conflict she encounters of the Commission on Long-term Care an active participant in the public as the rules of the ACA pose a fiscal under the ACA by President Obama. arena. SeniorBridge had participated and social conflict. With some of the This article not only gives Geriatric in several pilot studies, utilizes an requirements changing, it will be inter- Care Managers a historical perspec- interdisciplinary approach within esting to see what the requirements tive on healthcare legislation but is a the company (acquired by Human end up being for those of us with strong reminder of how long it takes in July 2012), and with the help of enough employees with or without the Congressional process to effect proprietary electronic health records health insurance as a current benefit in change. Finally, it reaffirms what is able to track patient outcomes. The 2015 when this portion of the ACA be- Geriatric Care Managers know. The work Humana Cares/SeniorBridge long-term care system continues to is doing is a critical example of how continued on page 4

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Geriatric Care Management Clients assisted by Geriatric history, explanation, encouragement, and the Affordable Care Act Care Managers are normally on and reality while recognizing the continued from page 3 Medicare. Such is the confusion challenges. Furthermore, reading surrounding the ACA that many the articles enclosed, you will have a comes effective. The side bar devel- of our clients are suspicious and better understanding of your role and oped by Brostoff should be helpful to unsure of how the implementation your future within the healthcare are- readers who are trying to decide how of the ACA will affect them. The na. Gone are the days when someone the employer’s portion of the ACA last article describes some of the asks you, “What is a Care Manager?” will affect them as an employer or as ways the ACA will affect the clients There is a realization that what we do an individual whose spouse/partner Geriatric Care Managers work with as Geriatric Care Managers matters. may be affected by their employer daily: “Effects on Medicare Clients We just have to move from the back and healthcare coverage. & the Affordable Care Act (ACA).” burner to the front. The Massachusetts model of Government sources say Medicare Footnotes health care coverage for its residents recipients will be affected little by was the initial model upon which the ACA although Medicare reform 1 Kaplan, R., “Older Americans, the ACA was built. In place since within the ACA aim to weed out Medicare, and the Affordable Care 2006, the Massachusetts model has waste, criminal intent and excess Act: What’s Really In It for Elders?”, undergone some changes and revi- ASA Generations, Spring 2011, 19-25. sions but continues to build on its charges while providing a better success. Natasha Doigin, MD/PhD quality of patient-centered care. 2 Browdie, R., “Health Reform, Politics, Candidate and Kate Lapane, PhD These predicted savings are expect- and Conflict: Is This Any Way to write of the state’s progression and ed to help with other expenditures Serve America’s Elders?”, ASA next steps in Understanding National within the scope of the ACA. Generations, Spring 2011, 6-10. Health Reform – Why Big Data Isn’t The challenge with this issue of 3 Gorin, S., “The Affordable Care Act Enough – Lessons from Massachu- the GCM Journal on the Affordable – A Social Work Perspective”, Social setts Health Reform. Care Act was to give readers some Work Today, Jan./Feb. 2013, 23-25.

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Care Coordination Under the Affordable Care Act: Opportunities and Challenges for Geriatric Care Managers Susan Emmer, Esq.

Summary: The Affordable Care Act (ACA) established multiple care coordination demonstrations, pilots, Fifteen years ago, policy makers were not focused and programs premised on quality on care coordination. Although lawmakers agreed and patient-centeredness. This article describes the circumstances preceding that Medicare spending was unsustainable and enactment of the ACA, summarizes subject to double or triple growth rates, they several of the new care coordination elements of the law, and explains the focused remedies on episodic care, aiming reforms benefits and risks for the geriatric only at the treatment for a specific disease. care manager community posed by the ACA’s changes.

Introduction coordinated care programs are in Medicare spending because they did n March 23, 2010, President various stages of implementation but not reduce hospital admissions (CBO Obama signed the Affordable all of them are relevant to GCMs. Issue Brief, 2012). Significantly, Care Act (ACA) into law programs that concentrated on O Care Coordination Prior transitions in care settings relied (ACA, 2010). In addition to increasing health care access and lowering to the ACA on team-based care that included costs, the ACA’s sponsors intended Fifteen years ago, policy makers a care manager and targeted high- to improve quality and incentivize were not focused on care coordination. risk enrollees were more likely to care coordination across the health Although lawmakers agreed that reduce costs and improve outcomes system’s silos. Currently the nation’s Medicare spending was unsustainable (CBO Issue Brief, 2012). The health care system is fragmented, and subject to double or triple authors of the ACA recognized providing episodic care with little growth rates, they focused remedies this and endeavored to harness the management of transitions between on episodic care, aiming reforms cost-saving attributes of coordinated care delivery points and a disjointed only at the treatment for a specific care within the framework of health approach to the social components disease. Despite agreement that reform. of a patient’s case. The ACA aims to patients with multiple co-morbidities Geriatric care managed care improve the delivery system over time had the highest costs, Congress in particular, encompass the such that all facets of the health care enacted new programs focusing on aforementioned positive, cost-saving, system coordinate seamlessly. disease management and light chronic quality- focused characteristics. In this regard, multiple sections care management rather than the “Professional geriatric care of the ACA include new care coordination of care across multiple management is a holistic, client- coordination programs relevant to disciplines. (Crippen, 2002). centered approach to caring for older geriatric care managers (GCMs). By Over time, policy makers adults... through: assessment and design, Congress aimed for “better responded to public demand and monitoring, planning and problem- integration of care, better designed increased research that called for solving, education and advocacy, services . . .better measurement tools. better coordination and care for and family caregiver coaching.” These provisions. . .will improve care patients with chronic conditions. (NAPGCM, 2013). GCMs, coordination. [They] better align Studies of ongoing pilots (34 therefore, have a place in the new incentives for quality care and move programs) demonstrated that most care coordination oriented delivery towards seamless, integrated care.” disease management and care system reforms included in the ACA. (Berwick, 2010) These new ACA coordination models did not reduce continued on page 6

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Care Coordination Under 164 ACOs provided care to Medicare found at http://innovation.cms.gov/ the Affordable Care beneficiaries across the nation. initiatives/rahnfr/. Act: Opportunities and ACO models are diverse, but there Challenges for Geriatric are multiple variations that include Health Care Innovation Awards Care Managers special benefits, such as end-of-life The Health Care Innovation continued from page 5 services that might be of interest to Awards are awarding up to $1 billion GCMs (ACO Model Summaries, to applicants across the country ACA Care Coordination 2013). Further information about the that test new payment and service Provisions program, including a list of the three delivery models for improving quality The ACA includes numerous ACO sub-types and grantees, can be and lowering costs for enrollees new Medicare and Medicaid found at http://innovation.cms.gov/ in Medicare, Medicaid, and/or the demonstrations, pilots, and programs initiatives/ACO/. Children’s Health Insurance Program that aim to improve care coordination (ACA, Sec. 3021). There currently and transitional care for beneficiaries, are 107 varied participants, many including: of which include a care manager on The Health Care their teams (Health Care Innovation Medicare Community-based Award Model Summaries). Further Care Transitions Program Innovation Awards information about the program, The Community-Based Care are awarding up including a list of grantees, can be Transitions Program (CCTP) evaluates found at http://innovation.cms.gov/ models for improving care transitions to $1 billion to initiatives/Health-Care-Innovation- Awards/. from the hospital to other health applicants across the care sites, reducing readmissions for high-risk Medicare beneficiaries, country that test new Navigator Program Under the Navigator Program, and saving Medicare funds (ACA, payment and service Sec. 3026). Community-based consumers will select new health organizations (CBOs) that partner delivery models for insurance options through the Health with hospitals with high readmission Insurance Exchanges (ACA, Sec. improving quality and rates are the intended grantees. 1311). Some states will establish CBOs must have a governing body lowering costs for a State-Based Marketplace, while that includes multiple health care others will partner with the federal stakeholders, including consumers. enrollees in Medicare, government to create a Federal- State Partnership Marketplace, and As of March, 2013, the Medicaid, and/or the a third category of states will use a Center for Medicare and Medicaid Children’s Health Federally-facilitated Marketplace Services (CMS) has awarded CCTP (CCIO In Person Assistance with the agreements to 102 sites (CCTP Site Insurance Program Health Insurance Marketplace, 2013). Summaries, 2013 and Lind, 2013). (ACA, Sec. 3021). The Navigator Program will help Services of note include: post- consumers to select health insurance discharge education, encouraging from myriad options within two of timely patient interaction with post- the three constructs: the federally acute care providers, and patient/ facilitated exchanges and the state caregiver self-management support Initiative to Reduce Avoidable partnership marketplaces. (CCTP Solicitation for Application, Hospitalization Among Nursing 2013). Further information about the Facility Residents Navigators will help consumers to prepare applications, determine program, including a list of grantees, CMS will work with non-nursing eligibility, and purchase health insur- can be found at http://innovation.cms. facility organizations to implement ance through the Marketplaces, and gov/initiatives/CCTP/. evidence-based interventions that receive financial assistance if eligible. reduce avoidable hospitalizations In addition, navigators will educate Accountable Care Organizations and improve outcomes in at least 15 consumers about the Marketplace, Accountable Care Organizations nursing facilities for Medicare and referring consumers to the health (ACOs) coordinate physicians, Medicaid beneficiaries (ACA, Sec. insurance ombudsman and consumer hospitals, and other health care 3012). Eligible organizations may assistance liaison when necessary. providers who join together to create include physician practices, care Navigators must meet stringent systems that holistically provide care management organizations, and other guidelines, participate in all types to Medicare beneficiaries. If ACOs entities. Seven organizations were of Marketplaces, be funded through improve outcomes and reduce costs, selected for this initiative (Initiative state and federal grant programs, and they can share the program savings Model Summaries, 2013). Further (ACA, Sec. 3022). As of July 1, 2013, information about the program can be continued on page 7

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Care Coordination Under GCM member and you participate agers, paperwork czars, and “quar- the Affordable Care in any of the above programs, please terbacks,” GCMs have coordinated Act: Opportunities and contact the author, NAPGCM staff, care before it became a recognized Challenges for Geriatric or NAPGCM leadership so that need, term, or was included as a major Care Managers NAPGCM can better serve the GCM focus through multiple new programs continued from page 6 community’s interests. GCMs can included in the ACA. GCMs have reach the author at emmerconsulting@ the experience and skills to participate complete comprehensive training. verizon.net. While we understand that in the care coordination models and On April 9, 2013, CMS announced most geriatric care managers are not system reform mentioned above. a funding opportunity for navigators serving as direct grantees, NAPGCM Demand. There is at least one (CCIO In Person Assistance with the hopes that members will partner or Health Insurance Marketplace, 2013). new delivery system demonstration, Further information about the program pilot, or program in every state with can be found at http://www.cms.gov/ multiple new programs in many states CCIIO/Resources/Fact-Sheets-and- By design, GCMs (CMMI Where Innovation is Happen- FAQs/navigator-foa-faq.html ing, 2013). As hospitals, health care employ a global systems, physician groups, communi- Medicaid Health Homes for perspective. GCMs ty-based organizations, and other enti- Chronic Conditions ties implement these new programs, open doors, talk States have the option under they will need the services of expe- Medicaid, as amended by the ACA, to everyone in the rienced and qualified care managers. If direct participation options are not to establish a Health Home to coordi- health delivery chain, nate care for individuals with multiple available, multiple opportunities to be chronic conditions or serious mental and refuse to see involved still exist through partnering, sub-contracting, consulting, or advis- illness (ACA, Sec. 2703). States may barriers between designate a Health Home from among ing new entities. The demands of new (1) a designated provider; (2) a team the clinical and programs and practices may leave some new entrants with questions that may include nurses as coordina- non-clinical sides tors or social workers; or (3) a health that GCMs are uniquely positioned to team that must include, among others, of patient care. The answer. nurses and social workers (Medic- GCM philosophy Holistic Approach. The new sys- aid Health Homes, 2013). Further tem embodies a global, whole-person information about the program can be meshes with the approach that represents a sea-change found at http://www.medicaid.gov/ ACA’s coordinated for health care delivery in our nation. Medicaid-CHIP-Program-Information/ Each of the new programs described By-Topics/Long-Term-Services-and- care provisions in a above is designed to promote inter- Support/Integrating-Care/Health- unique way. action and integration of providers, Homes/Health-Homes.html many of whom have not worked together in this manner before. By Money Follows the Person design, GCMs employ a global per- contract with grantees to participate in spective. GCMs open doors, talk to The ACA continued and expanded networks or provide limited services to everyone in the health delivery chain, the Money Follows the Person (MFP) core populations. We hope to compile and refuse to see barriers between Rebalancing Demonstration (ACA, a database of member involvement the clinical and non-clinical sides of Sec. 2403). The demonstration assists which can better inform the NAPGCM patient care. The GCM philosophy with the transition from institutional understanding of the new programs. meshes with the ACA’s coordinated settings to the community. The ACA care provisions in a unique way. increased eligibility for the program Benefits and Risks for to include new categories of individu- the GCM Changing Field. Increased als living in an institution. Currently, consumer demand and interest at the Not surprisingly, the passage of 45 states and the District of Columbia federal level in the wake of the ACA the ACA creates both opportunities have MFP programs (Money Follows is driving interest in the general care the Person, 2013). Further informa- and challenges for the GCM. management field. Opportunities to tion about the program can be found at History. Despite recent increased perform care coordination abound. http://medicaid.gov/Medicaid-CHIP- awareness of the care coordination Many of the new programs discussed Program-Information/By-Topics/ model, GCMs have been in the trench- above create new roles and func- Long-Term-Services-and-Support/ es performing this role since well tions that either did not exist before Balancing/Money-Follows-the-Person. before NAPGCM was created in 1985 or did not have a specific name or html (NAPGCM, 2013). As entrepreneurs, clearly defined role. As a result, there If you are a GCM and an NAP- translators, transition specialists, man- continued on page 8

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Care Coordination Under roles and opportunities to “sit at the Medicare Community-Based Care the Affordable Care table” of patient care, even if they Transition Program Solicitation for Act: Opportunities and may not be participating providers. Applications (CCTP SFA). Available at http://innovation.cms.gov/initiatives/ Challenges for Geriatric Networking, relationship-building, CCTP/. (2013). Care Managers joining task forces, having a voice continued from page 7 through education efforts and, most Medicare Health Care Innovation Awards. Available at http://innovation. of all, remaining flexible are critical cms.gov/initiatives/Health-Care- is more competition to fulfill GCM qualities to GCM success as the field Innovation-Awards/. (2013) roles than in prior years. Inevitably, undergoes rapid change. GCMs new programs increase demand and are well positioned to be leaders in Medicare Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility GCMs have more new colleagues and delivery system reform and to further Residents. Available at http://innovation. competitors where just a few years ago their unique philosophy and practice as cms.gov/initiatives/rahnfr/. (2013) there were few. the ACA is implemented over the next NAPGCM “What You Need To Know: Ownership. Unlike most few years. What is Professional Geriatric Care providers, GCMs are not defined Management” Available at http://www. by their provider type. This can References caremanager.org. (2013). Berwick, Donald M. “Strengthening contribute to successful coordination, Patient Protection and Affordable Care Medicare and Medicaid: Taking Steps to as GCMs are not easily categorized Act, Pub. L. No. 111-148, §2702, 124 or placed into preconceived roles. Modernize America’s Health Care System.” Testimony before the Senate Finance Stat. 119, 318-319 (2010). GCMs are social workers, nurses, Committee (2010) 6 – 10. Where Innovation is Happening at gerontologists, and other related CMMI. Available at http://innovation. human service professionals. This Crippen, Dan L. “Disease Management in Medicare: Data Analysis and Benefit cms.gov/initiatives/map/index.html. virtue can pose risks, however, Design Issues.” Congressional Budget (2013) because without a clearly established Office (CBO) Report (2002) 4- 9. provider identity, a GCM might find it harder to establish authority within In Person Assistance in the Health Susan Emmer has operated a team or find a place at the decision- Insurance Market. Available at http://www. cms.gov/CCIIO/Programs-and-Initiatives/ Emmer Consulting, Inc., a making table when discussing a Health-Insurance-Marketplaces/assistance. multi-client health care policy patient’s care. html. (2013). consulting and advocacy practice Federal Program Participation. Issue Brief. “Lessons from Medicare’s since September of 1999. She Some of the new ACA programs Demonstration Projects on Disease previously worked on the Senate require providers to participate in Management, Care Coordination and Value Finance Committee Member Medicare or Medicaid or otherwise Based Payment.” Congressional Budget Office (CBO) (2012) 2 – 8. staff (Majority Staff), the office function in a way that many GCMs of Sen. Bob Graham (D-FL), currently do not. Those who do Lind, Keith D. “Recent Medicare the Department of Health and Initiatives to Improve Care Coordination not participate in federal programs Human Services, and the law may find health systems difficult and Transitional Care for Chronic Conditions.” AARP Public Policy Institute firm of Foley & Lardner. Susan or almost impossible to penetrate. Fact Sheet (March 2013). Washington, DC: holds a Juris Doctorate degree For many GCMs, this could pose a AARP. from The Georgetown University barrier to entry into the “new” health Law Center and a Bachelor of system. With so many different and Medicaid Health Homes. Available at http://www.medicaid.gov/Medicaid-CHIP- Arts from Brown University. She diverse care coordination programs Program-Information/By-Topics/Long- currently represents the National in existence, it is too early to predict Term-Services-and-Support/Integrating- Association of Professional where federal involvement will evolve Care/Health-Homes/Health-Homes.html. Geriatric Care Managers in in the future. However, whether this (2013). Washington, D.C. results in Medicare reimbursement for Medicaid Money Follows the Person. a new benefit as part of the permanent Available at http://medicaid.gov/Medicaid- Susan Emmer program and/or delivery system CHIP-Program-Information/By-Topics/ [email protected] change that results less directly in Long-Term-Services-and-Support/ 7713 Oldchester Road Balancing/Money-Follows-the-Person.html Bethesda, MD 20817 the same approach, Medicare will (2013). presumably look very different in five W 301-320-3873 to ten years around the issue of care Medicare ACO Model Summaries. management. Available at http://innovation.cms.gov/ initiatives/ACO/. (2013). Conclusion Medicare Community-Based Care Transition Program Site Summaries. This is a time of great change Available at http://innovation.cms.gov/ in the coordinated care field, posing initiatives/CCTP/CCTP-Site-Summaries. both opportunities and risks for html. (2013). GCMs, who should be open to new

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A CLASS Act—Development until the Aftermath of its Demise Regina M. Curran, MA, CMC

eriatric care expenses for care those who live in Gmanagers Medicare is a health insurance program but an institutional work with clients not a long-term care insurance program. It has setting (e.g., a who are facing skilled nursing the challenges never covered long-term care expenses. Before facility) and who of aging. For Medicare existed, many older Americans were meet strict income/ each client, the asset limitations. geriatric care unable to obtain insurance to cover their healthcare Medicaid is manager develops expenses. Medicare addressed this problem. jointly funded an individualized by the federal care plan which Now many older Americans are challenged by the government and by considers cost of long-term care expenses. state governments. the client’s Beginning in abilities, lifestyle 1981, states preferences, and were allowed to financial resources. The care plan was first proposed in 1945. It took apply to the Health Care Financing must recognize that as time passes, 20 years for legislation to be enacted. Administration (HCFA), now the the client’s needs will change—and In 1972, Medicare coverage was Center for Medicare and Medicaid include steps which can be adapted for expanded to include those entitled Services (CMS), for a “1915c waiver” these changes—i.e., it must include to Social Security disability benefits which would “waive” the requirement long-term care planning. and to those with End-Stage Renal that Medicaid only pay for long-term Medicare is a health insurance Disease (PL 92-603). There is a care expenses for those living in an program but not a long-term care 24-month waiting period following institutional setting. By filing a 1915c insurance program. It has never a disability diagnosis before Social waiver application, states have to covered long-term care expenses. Security disability beneficiaries can establish that it would be less costly for Before Medicare existed, many older qualify for Medicare. Medicaid to provide these services in a Americans were unable to obtain The first significant change “home- and community-based” setting insurance to cover their healthcare to Medicare was the Medicare rather than in an institutional setting. expenses. Medicare addressed this Catastrophic Coverage Act of 1988 Each waiver application must define problem. Now many older Americans (PL 100-360). This legislation the conditions for participation and the are challenged by the cost of long- expanded Medicare coverage, added number of participants. Many of the term care expenses. coverage for prescription drugs, and states who were granted these waivers capped out-of-pocket expenses for soon had long waiting lists of potential Background – Historical Medicare beneficiaries. Although participants. Perspective these were significant improvements Private long-term care (LTC) In 1965, President Johnson signed for Medicare beneficiaries, the insurance policies exist. They have PL 89-97 which established Medicare beneficiaries themselves rebelled never been universally popular. The to provide health insurance for those when they realized that would need premiums can be significant if the who were 65 or older and Medicaid to to pay higher premiums to cover the policy is not purchased when the provide health insurance for those with cost of these improvements. The insured individual is young, healthy, very low income and assets. About voices of those who did not want and unlikely to need long-term care half of these seniors had no health to pay higher premiums were heard services for a long time. Most policies insurance before Medicare became throughout the halls of Congress. PL require medical underwriting, and available (on July 1, 1966) and many 100-360 was repealed by PL 101-234 those who might qualify for benefits were living in poverty. Government in 1989. earlier than others may be excluded sponsored health insurance for seniors Medicaid covers the long-term continued on page 10

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A CLASS Act— age during each of those three years). 1915c waiver can keep 50 percent of Development until the Premiums would have to be paid the CLASS Act daily benefit. The Aftermath of its Demise after the worker stops working. If the other 50 percent must be used to continued from page 9 worker failed to pay the premiums, cover some of the services received the coverage for CLASS Act benefits under the Medicaid 1915c waiver. from coverage. Many younger people ends. Disabled workers would not The CLASS Act would have reduced chose not to invest in these LTC be excluded from participating in the Medicaid spending. Some of the costs policies because they had different CLASS Act. They would pay premi- covered by Medicaid would be paid priorities for their spending. The lack ums and could collect benefits after from the CLASS Act benefits. of a significant pool of policy holders they were enrolled in the CLASS Act The CLASS Act benefits could has made this type of insurance less for five years. appealing for insurance companies. have supplemented benefits from When the CLASS Act was private long-term care insurance The need for a government- initially introduced, Tier I benefits policies as well. Potentially private sponsored funding source (other (initially proposed to be $50 per long-term care insurance policies than Medicaid which was taxing day) would be paid to those who would have “wrapped around” the both federal and state budgets) to were unable to perform at least two CLASS Act benefit and provided cover long-term care expenses was activities of daily living (ADLs) better coverage for the insureds. becoming increasingly obvious. On (eating, toileting, transferring, Legislation that is bipartisan November 2, 2005, Senators Kennedy bathing, dressing, and continence) and DeWine introduced S-1951, and bicameral has the best chance or who require supervision, cueing, of succeeding. When introduced in the Community Living Assistance or hands-on assistance to perform at Services and Supports (CLASS) Act. the Senate for the 109th Congress, least two activities of daily living. the CLASS Act was a bipartisan bill. The purpose of the CLASS Act was: Tier II benefits (initially proposed to However, during the 109th Congress, • To provide individuals with be $100 per day) would be paid to the CLASS Act was not introduced in functional limitations with tools those who were unable to perform the House. When the 109th Congress that will allow them to maintain or need assistance with at least adjourned, Senator Harkin was the their independence and live in the four ADLs. When a person was only cosponsor added to S-1951. On community through a new financ- determined to be eligible to receive July 10, 2007, Senators Kennedy, ing strategy for community living benefits, that individual would receive Dodd, and Harkin introduced the assistance services and supports. a daily cash benefit. This daily cash CLASS Act as S-1758 in the 110th benefit could be used to purchase • To establish an infrastructure that Congress without bipartisan support. nonmedical services and supports that 1 will help address America’s com- Three Democratic Senators were the the beneficiary needed to maintain munity living assistance services only cosponsors of S-1758 during his or her independence at home and support needs. the 110th Congress. On July 11, or in another residential setting in 2007, the CLASS Act was introduced • To alleviate burdens on family the community. For example, this by Representatives Pallone and caregivers. benefit could cover the cost of home Dingell as HR-3001 in the House. Participation in the CLASS Act modifications, adaptive technology, During the 110th Congress, eighteen was to be voluntary. The CLASS Act accessible transportation, homemaker Democratic cosponsors2 were added would be financed by monthly premi- services, respite care, personal to HR-3001. No action was taken ums (through payroll deductions) for assistance services, and home care on either S-1758 or HR-3001 during those who are working. The proposed aides. The CLASS Act beneficiary the 110th Congress. On March 25, initial monthly premium would be would decide how the benefits were 2009, Senators Kennedy, Dodd, Casey, $30. Employers would enroll their to be spent. Benefits would continue Harkin, and Whitehouse introduced employees and give them the opportu- until the beneficiary no longer met the the CLASS Act in the 111th Congress nity to “opt-out” of participating in the eligibility criteria. as S-697. Only one Democratic program. Alternative enrollment pro- Medicaid long-term care benefi- Senator3 was added as a cosponsor cedures would be available for those ciaries would also have been eligible during the 111th Congress. On March whose employers did not participate to receive CLASS Act benefits. Insti- 26, 2009, Representatives Pallone, in the automatic enrollment or who tutionalized beneficiaries could have Dingell, and Kennedy introduced the were self-employed. A person would kept five percent of the daily benefit CLASS Act in the House as HR- be eligible to receive CLASS Act in addition to their current “per- 1721. Twenty-four Democratic4 and benefits if he/she paid premiums for at sonal needs allowance.” The other 95 one Republican5 cosponsors added to least 60 months. During this five-year percent would be used toward their HR-1721 during the 111th Congress. vesting period, the enrollee would institutional care. Medicaid would The provisions of S-697 and HR have been required to work for at least have become the secondary payer after 1721 were included as Title VIII of three years (i.e., have earned at least the CLASS Act payment. Individuals PL 111-148 when it was enacted in four quarters of Social Security cover- receiving services under a Medicaid continued on page 11

page 10 of Fall 2013 Geriatric Care Management

A CLASS Act— three plans for implementation of the Bruce Chernof (president and Development until the CLASS Act. Each of the plans should CEO of the SCAN Foundation), chairs Aftermath of its Demise ensure that the program would be the Commission. Mark Warshawsky continued from page 10 actuarially sound for 75 years. Pre- (a pension expert who directs miums would be established based on retirement research at the benefits March 2010. A fourth purpose—“to these plans. There would be between firm Towers Watson and was a senior address institutional bias by providing two and six levels of available benefits Treasury Department official for 2004- mechanism that supports personal with the average benefit being no less 2006l) is the Vice-Chair6. choice and independence to live in the than $50 per day. Developing the community”—was added when this PL 112-240 states that “not plans was challenging because there longer than 6 months after the legislation was enacted. The CLASS were no models to use as a basis. Act did not receive much attention appointment of the members of when it was introduced in Congress. In October 2011, HHS Secretary the Commission, the Commission It never received any Committee Kathleen Sebelius notified Congress shall vote a comprehensive and action. Many speculate that one that HHS could not develop a detailed report” which “contains reason it was included in PL 111-148 statistically valid model to comply any recommendations or proposals was as a tribute to Senator Kennedy with the requirement that the program for legislative or administrative who died on August 25, 2009, seven be financially sound for 75 years. action as the Commission deems months before the legislation was Thus, HHS suspended implementation appropriate, including proposed enacted. of the CLASS Act. Although the legislative language to carry out the CLASS Act was then on life-support, recommendations or proposals. A As soon as PL 111-148 (Patient the American Taxpayer Relief Act of majority of Commission members Protection and Affordable Care 2012 (PL 112-240) signed the death must support the proposed Act—ACA) was enacted, efforts certificate. legislation.” began to repeal it—either completely If the Commission created a bill or by repealing specific sections so Current Perspective that it would be hard to implement which included its recommendations, the program successfully. There This newest legislation (PL this bill would have been introduced were also legal challenges to several 112-240) attempted to address the in the Senate and in the House on parts of the ACA. In June 2012, issue of long-term care needs by the next legislative day when these the Supreme Court ruled that most creating a “Commission on Long chambers are in session. of the significant parts of the ACA Term Care” (section 643 of the Act). On September 12, 2013, nine were constitutional. There were no This Commission was to include 15 of the 15 Commissioners voted legal challenges raised specifically members (The President, the Speaker to put forward a report containing for the CLASS Act section of the of the House, the Minority Leader in recommendations. There was ACA. However, there were several the House, the Majority Leader in the bipartisan support for these legislative attempts undertaken in Senate, and the Minority Leader in recommendations. The Commission the 111th Congress and in the 112th the Senate. Each would appoint three report did not contain specific Congress to repeal the CLASS Act. Commissioners.) The legislation recommendations for legislative required that the Commissioners consideration. The main objection to the CLASS be appointed within 30 days after Act was that it could become another enactment of PL 112-240. This Among the recommendations are: underfunded federal entitlement requirement was not met. The last • Provide services in the least re- program. Programs comparable to three Commissioners were appointed strictive setting the CLASS Act exist in Germany, on March 13, 2013. • Establish a single point of contact Japan, and the Netherlands. However, for these services on the care team in these countries, enrollment The task of the Commission is to is mandatory—not voluntary. “develop a plan for the establishment, • Use a person/family centered ap- Enrollment in the CLASS Act would implementation, and financing of proach to integrate services be voluntary. There was no model a comprehensive, coordinated, and • Use technology effectively high-quality system that ensures the to predict the number of people who • Create livable communities would enroll. There was a concern availability of long-term services and • Design a simple, standard assess- that if the only enrollees were those supports for individuals in need of ment mechanism to be used in all who were already disabled or those such services and supports, including settings who had a high likelihood of being elderly individuals, individuals with disabled in the future, the CLASS Act substantial cognitive or functional • Expand “No Wrong Door” could not be financially viable. limitations, other individuals who • Provide information and assistance require assistance to perform activities The enacted legislation required to consumers/family caregivers of daily living, and individuals in advance of time of transition the Secretary of Health and Human desiring to plan for future long-term Services (HHS) to develop at least between settings care needs.” continued on page 12

page 11 of Geriatric Care Management Fall 2013

A CLASS Act— islation was enacted to significantly Endnotes Development until the change Medicare and those changes 1 Senators Whitehouse, Obama and Aftermath of its Demise were repealed before they were imple- Clinton continued from page 11 mented. Some coverages, specifically 2 Representatives Boucher, Carson, • Advocate for public funding on the Medicare prescription drug coverage—i.e., “Medicare Part D,” but not Conyers, DeLauro, Fattah, Filner, Frank, basis of service rather than setting Green, Hastings, Kaptur, Kennedy, all, of the Medicare changes proposed • Encourage caregiver interventions Loebsack, Nadler, Pastor, Rothman, in PL 100-360 were enacted in 2003 Solis, Space, Van Hollen including respite as part of PL 108-173, the Medicare • Revise scope of practice to Prescription Drug, Improvement and 3 Senator Gillibrand broaden opportunities for profes- Modernization Act of 2003. Other 4 Representatives Bishop, Carnahan, sional and direct care workers with changes enacted in PL 100-360—e.g., Carson, DeGette, Doyle, Filner, Frank, demonstrated competency a cap on “out of pocket” expenses Hare, Holt, Jackson, Kildee, Kilroy, • National criminal background for Medicare beneficiaries—are not Lewis, Loebsack, McCollum, Nadler, available for Medicare beneficiaries in Rothman, Ryan, Sarbanes, Schakowsky, checks for all long-term-care Sires, Slaughter, Tonko, Tsongas workers 2013. Eight years have passed since the CLASS Act was first introduced. 5 Representative LaTourette • Create career ladder for direct care We can’t afford to wait another 12 workers 6 The other commissioners are: Javaid years before we address the need for Anwar, CEO of Quality Care Consul- • Integrate direct care workers in the government sponsored long-term care care team tants, LLC; Judy Brachman, Chair, financing. Congressional legislators Jewish Federation of North America’s • Encourage states to improve stan- will only tackle this issue if there is Aging and Family Caregiving Commit- dards and establish a certification significant pressure by constituents for tee; Laphonza Butler, President SEIU process for home-care workers a program similar to the CLASS Act. ULTCW; Henry Claypool, Executive VP Constituents tend to think they are of American Association of People with • Create a demonstration project for Disabilities; Judy Feder, Institute Fellow Medicaid coverage for disabled never going to need long term care— at the urban Institute; Stephen Guillard, workers while they are employed thus they do not raise this topic with CEO and President of Belmont Nursing their Congressional legislators. • Eliminate three night hospital stay Center Corp.; Julian Harris, Massachu- Geriatric care managers could setts Medicaid Director; Chris Jacobs, for Medicare coverage at a skilled Senior Policy Analyst at the Heritage nursing facility have benefited significantly if the Foundation; Neil Pruitt, Chairman and • Reconsider “homebound” require- CLASS Act was implemented. Po- CEO of UHS-Pruitt Organization; Carol ment for Medicare home health tential clients could have used these Raphael, Vice Chairman of the Board of services benefits to pay for services recom- AARP; Judy Stein, Executive Director mended and monitored by geriatric of the Center for Medicare Advocacy; • Allow individuals/families with Grace Marie Turner, President of the care managers. Potential clients could significant disabilities to access Galen Institute; George Vradenburg, educational savings programs to have used their benefits to pay for the Chairman and Co-founder of USAgain- assist with current or future care services of a geriatric care manager. stAlzheimer’s. needs Geriatric care managers should be leaders in an effort to pressure Con- • Create a national advisory com- gressional legislators to enact legisla- Regina Curran has been a geriatric mittee to consider Commission’s tion which would fill the void left by care manager in the Baltimore area recommendations and recommend the repeal of the CLASS Act. for 17 years. She has represented funding frameworks NAPGCM at the Leadership The challenge of financing long- Additional Information Council of Aging Organizations, term care did not disappear when a coalition of over 60 nonprofit the CLASS Act was repealed. The http://thomas.loc.gov (information on organizations with interest in public Long-Term Care Commission could all public laws and bills introduced in the 93rd and subsequent Congresses.) policy issues related to aging, not recommend a specific pathway to since 2000. She was an adjunct address this challenge. The demand http://www.socialsecurity.gov/OP_Home/ professor at the Notre Dame of for long-term care services is going comp2/F089-097.html (information on Maryland University from 2004 PL 89-97, 79 Stat.286, Social Security to increase significantly as the “baby Amendments of 1965) until 2007 teaching public policy in boomer” generation approaches the the graduate gerontology program. age when its members will need long- http://www.socialsecurity.gov/OP_Home/ term care services and support. comp2/F092-603.html (information on Regina M. Curran, MA, CMC PL 92-603, 86 Stat 1329, Social Security PO Box 20414 It took 20 years for this country Amendments of 1972) Baltimore, MD 21284-0414 to acknowledge the fact that a health [email protected] http://www.LTCcommission.senate.gov 7 care program (Medicare) was needed. (information on the Commission on Long 410-661-1988 Another 20 years passed before leg- Term Care)

page 12 of Fall 2013 Geriatric Care Management Unlock Inner Strength

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page 13 of Geriatric Care Management Fall 2013

The Affordable Care Act: Shaking Up the System Provides Opportunities for Care Management Michael Newell, RN, MSN

he Patient Protec- presented to patients as they tion and Afford- leave after the office visit. This able Care Act is The national discussion now documentation specifies the T reason the patient presented a complex but sweep- occurring as provisions of the ing piece of legislation ACA become reality is also themselves, the diagnosis, aimed at reengineering sparked by such facts as: the plan of care, referrals, the health financing of prescriptions, etc. that will the American Health An estimated 32 million new assist patients and families to Care System so as to people will have access to coordinate their own care. improve the quality and healthcare services starting • The support of “Patient- lower the cost. The ACA, in 2014 that did not have such Centered Care.” The Institute of along with mandated access before.2 Medicine (IOM) defines patient- changes in the use of centered care as “care that is technology prescribed by With new influx of patients respectful of and responsive to 1 the HITECH Act, also and not enough primary care individual patient preferences, ushers in new challenges providers (PCP), many people needs, and values” and that and opportunities for will have difficulty getting an ensures “that patient values those who practice care appointment with their own PCP. guide all clinical decisions.”4 management. Features of the ACA supporting The national care management services in discussion now occurring principle include a renewed focus as provisions of the ACA become as Physician Assistants and Nurse on chronic care management. This reality is also sparked by such facts as: Practitioner who can do diagnosis includes coordination of care and • An estimated 32 million new and drug prescriptions, simple health advocacy for individuals as people will have access to x-rays, and suturing. They do well as “population health.” healthcare services starting in not take Medicaid, but specialize • Care innovations such as 2014 that did not have such in those with commercial health Accountable Care Organizations access before.2 insurance, workers’ compensation (ACOs) are expected to use a insurance, and cash for such • With new influx of patients variety of methods motivated services as school/team physicals, by a split of any savings that and not enough primary care drug screening, etc.3 providers (PCP), many people accrue from improvements in will have difficulty getting an • The advent of Electronic Health health delivery with Medicare. appointment with their own PCP. Records (EHR), including Since these entities have In Massachusetts, this has led to an individual person keeping no outreach ability in the Urgi-Centers or walk-in clinics to their own Personal Health community, Care Managers fill the gaps for non-emergency Record (PHR), along with the who are knowledgeable about care. These clinics are usually “Meaningful Use” provisions of the service area are in an placed on major highways near the HITECH Act on EHRs. Part ideal situation to assist these light industry and/or restaurants of the meaningful use criteria organizations. includes improved documentation and use physician extenders such continued on page 15

page 14 of Fall 2013 Geriatric Care Management

The Affordable Care Act: program tests models for The Opportunities for Shaking Up the System improving care transitions from Care Managers Provides Opportunities for the hospital to other settings and The opportunities for Care Care Management reducing readmissions for high- Managers will vary according to continued from page 14 risk Medicare beneficiaries. The how the ACA plays out in each 112 participating organizations state and locality. Questions for • Enhanced Primary Care or are paid an all-inclusive care Care Managers to ask themselves the “Medical Home” model management fee per eligible to assess readiness to address these has already demonstrated discharge that is based on the opportunities include: significant savings, partially due cost of providing care to the to improved care coordination.5 patient and implementing the What payment model does Again, these organizations systemic reforms at the hospital the Care Manager/Care will need care coordination in level7. Management entity use? the community to assist them • Federally Qualified Health • The private pay model may in managing those high-risk Centers (FQHCs) that provide be enhanced due to increased individuals with three or more Primary Care in a clinic setting awareness of the complexity chronic conditions. with extensive use of “physician of the health system and the • Bundled Payments. In order extenders.” Nurse Practitioners need for coordinated care. to achieve meaningful savings and Physician Assistants are The ability to understand in the inpatient setting, the expected to perform care coordination of benefits rules Center for Medicare & Med- coordination activities for their and familiarity working with icaid Innovation (CMMI) has constituents, including health diagnosis codes, CPT codes, introduced bundled payments,6 coaching, wellness activities, and appeal processes will be as a model for hospital payment and community outreach8. helpful. and delivery reform. A bundled These centers have been in • Those who are conversant with payment is a fixed payment for existence for many years, and the local social service system a comprehensive set of hospi- have focused on geographic and have the ability to commu- tal and/or post-acute services, areas such as inner city or the nicate in languages other than including services associated rural poor, those with Medicaid English will have a competitive with readmissions. Moving or those lacking any health advantage if they can convince from individual payments for coverage at all. local providers of their worth. different services to a bundled • Additional incentives are As new innovations take hold payment for a set of services intended to support the (e.g., ACOs or bundled pay- across providers and care set- coordination of primary care, ment models that prospectively tings encourages integration mental health, and addiction provide per-member-per-month and coordination of care that services.9 The goal is enhanced payments to provider organi- should raise care quality and community-based service zations to care for high-risk reduce readmissions. Variants options for individuals with a or high-utilizer subsets of on bundled payments are being mental health and/or substance patients) there is an opportu- demonstrated and differ in the use conditions. Medicaid state nity for Care Managers to be scope of services included in plan changes and demonstration paid by the organization rather the bundle and whether pay- grants are already expanding than the insurance company or ment is retrospective—based on these services for individuals by private pay. The requisite shared Medicare savings—or who have long-term care needs expertise will be the ability prospective. This may intensify (e.g., dual-eligible, high-risk to navigate the various local the financial risk and return Medicare beneficiaries, Money systems: health care, social to investing in changes to the Follows the Person and other service, surrogate courts (i.e., efficiency and quality of care. Medicaid Waiver changes dealing with lost capacity and Currently, 467 health care or- that will evolve based on state guardianship), church groups, ganizations across 46 states are applications). In addition, and volunteer organizations engaged in the bundled payment the CLASS Act (Community that may assist in optimizing initiative. Living Assistance Services the health and functioning of • Community-based Care and Supports Act) creates those who have traditionally Transitions Program (CCTP), a self-funding initiative for fallen through the cracks on the created by Section 3026 of individuals who need home- social safety net. the Affordable Care Act. This and community-based services. continued on page 16

page 15 of Geriatric Care Management Fall 2013

The Affordable Care Act: researching drugs and their side- Shaking Up the System effects, tracking appointments, Michael Newell, RN, MSN, Provides Opportunities for tracking productivity for billing) CCM is founder president of Care Management will be essential in the present LifeSpan Care Management LLC, continued from page 15 and near future. Haddonfield, N.J. Michael is the author of two nursing texts: Does the Care Manager Endnotes Using Nursing Case Management have current knowledge and 1 http://www.healthit.gov/policy- to Improve Health Outcomes and working relationships with the researchers-implementers/hitech-act-0 Reinventing Your Nursing Career. types of health providers that He is also an adjunct clinical can assist managing those 2 Health Reform’s Next Challenge: instructor for the nursing program with chronic illness? Who Will Care For The Newly Insured? http://www. at Thomas Jefferson University • Relationships with hospital amednews.com/article/20100412/ and lectures widely on topics of discharge planners and social profession/304129957/1/ medical case management. workers, sub-acute providers, 3 http://www.ucaoa.org/docs/ adult day-care providers, home WhitePaperTheCaseforUrgentCare. health and therapy providers, pdf etc. are essential elements that 4 Michael J. Barry, M.D., and Susan most medical providers and Edgman-Levitan, P.A. (2012) Shared acute care hospitals do not have, Decision Making — The Pinnacle of Patient-Centered Care. http:// and will need if they intend to www.nejm.org/doi/full/10.1056/ be successful managing those NEJMp1109283 with chronic illness. 5 Michael L. Paustian, Jeffrey A. Alexander, Darline K. El Reda, Can the Care Manager act in a Chris G. Wise, Lee A. Green, and consulting function to assist Michael D. Fettersm(2013) Partial hospitals, ACOs, FQHCs and and Incremental PCMH Practice: other provider organizations Transformation: Implications for to manage their high risk Quality and Costs Health Services chronically ill patients in the Research. Published online on 5 JUL 2013. DOI: 10.1111/1475-6773.12085 community? • Those who have special 6 Centers for Medicare & Medicaid Services. Bundled Payments for expertise with classes of clients Care Improvement Initiative. http:// such as Alzheimer’s, brain innovation.cms.gov/initiatives/ injury, cancer, diabetes, chronic bundled-payments/ heart disease, psychiatric 7 http://innovation.cms.gov/initiatives/ illness, and substance abuse will CCTP/index.html be in a position to impact the 8 http://www.cms.gov/Outreach-and- care of high-risk patients. Education/Medicare-Learning- Network-MLN/MLNProducts/ Is the Care Manager willing to downloads/fqhcfactsheet.pdf invest in new technology and 9 http://www.samhsa.gov/ learn new skills to keep up samhsaNewsletter/Volume_18_ with Electronic Health Records Number_3/AffordableHealthCareAct. and the new standards of aspx documentation mandated by the meaningful use10,11 10 Blumenthal, D., Tavenner, M. (2010). The “Meaningful Use” Regulation for expectations of the HITECH Electronic Health Records. The New Act? England Journal of Medicine, 363, • At a minimum, the Care 501-504. Manager will need to be 11 Halamka, John D. (2009). Making conversant with the conventions Smart Investments in Health of using Microsoft Word and Information Technology: Core Principles. Health Affairs. 385-289. Outlook, navigating the web DOI: 10.1377/hlthaff.28.2.w385 and using email and texting. The use of smartphone technology, including the applications available (e.g.,

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The Affordable Care Act and Its Impact on Care Management Eric C. Rackow, MD and Claudia Fine, LSCW, MPH, CMC

Executive Summary half (47 percent) of total hospital costs.4 But are these seniors really he Patient Protection and There is broad sicker? Alarmingly, only half recall Affordable Care Act (ACA), understanding that receiving self-care instruction5 or signed into law in March 2010, T people with chronic seeing a doctor after discharge,6 mandates widespread coverage of suggesting that a substantial number of health benefits. Many recognize that disease face a greater rehospitalizations could be prevented. to meet the cost of universal cover- risk of having deficits age, the most expensive, most com- in instrumental This article discusses the opportunities for and threats to plex care must be better managed. activities of daily There is growing recognition that the geriatric care management practice baby boomer generation will expo- living (IADL) and as a result of care utilization, recent nentially affect the cost of long-term activities of daily health legislation, and industry trends care as a result of increasing longev- living (ADL). In in response to these changes. ity and incidents of complex chronic recent years, care. While this phenomenon is not Background numerous studies new, it is being newly examined due SeniorBridge is a national care- to concerns about shifting demo- have linked management company with a 13-year graphics, the growing cost of health high rates of heritage of managing the care of people care, and consumer perceptions. hospitalization and with complex chronic conditions There is broad understanding emergency room in their homes. These clients spend between $1,000 and $6,000 per month that people with chronic disease face visits among seniors a greater risk of having deficits in because they cannot manage their own to complex chronic instrumental activities of daily living care. (IADL) and activities of daily living conditions and The company’s interdisciplinary (ADL). In recent years, numerous functional limitations. approach utilizes an integrated care- studies have linked high rates of management team of nurses and hospitalization and emergency room social workers to address functional, visits among seniors to complex Rehabilitation that the cost increases environmental, behavioral, and chronic conditions and functional are attributed to greater frequency of medical needs. SeniorBridge’s limitations. care events (e.g., hospital admissions, proprietary web-based electronic In fact, according to a outpatient visits) rather than an health-record platform documents data LewinGroup analysis of medical ex- increase in the intensity of those about clients’ medical, behavioral, penditures published in 2010, seniors events.1 and functional health; environment; with multiple chronic conditions who Rehospitalizations are of social supports; and financial and received help with IADL and ADL particular concern. According to legal status. Assessments from deficits were seven times more likely recent research published in the New multiple providers include medical to be among the top five percent of England Journal of Medicine, one in diagnoses, history of treatments, and the costliest patients to treat as de- five seniors are rehospitalized within hospitalizations. The breadth of this fined by total-medical-claims expense 30 days of being discharged from medical record enables SeniorBridge’s in the prior 12-month period — more a hospital,2 fueling the reality that care managers to monitor and than twice the rate of those with mul- Medicare beneficiaries account for address the full array of issues as tiple chronic conditions alone. 15 percent of the US population3 but they affect clients’ chronic care needs Chan et al. reported in the more than two-thirds (37 percent) and preferences. Furthermore, the Archives of Physical Medicine and of hospitalizations and almost continued on page 19

page 18 of Fall 2013 Geriatric Care Management

The Affordable Care Act total-medical-claims expense in the A Brief History of Care and Its Impact on Care prior 12-month period, SeniorBridge Management Management reduced hospital admissions by 70 The birth of care management can continued from page 18 percent — meaning two in three be traced to two distinct beginnings. high-cost hospitalizations were electronic health record facilitates One was a response to pressures averted; a 54 percent reduction in real-time communication between to control costs of health care for total emergency room visits; and a 48 care managers and health-care hospitals, providers, insurance percent savings in health-care costs.7 providers to assure that the services companies, and other health industry in the home are consistent with the In addition to these utilization companies. We usually think of this physician-driven plan of care. In this and financial results, a satisfaction category as “case management.” manner, the care manager becomes survey of the customers enrolled This model is grounded in the the physician extender in the home in the program indicated that 100 need to manage health utilization setting while assuring maximum percent of those who responded costs. Positive outcomes of case use of primary care to forestall strongly agreed that the care management are financial: “I paid X to preventable use of emergency management program met their the nurse case manager, and it reduced room visits and hospitalizations. expectations, and 85 percent said they the cost of care by X dollars.” Importantly, the data can also be used strongly agree that the program also The second beginning was to track trends in hospitalizations, improved their experience with their driven by consumer demand for diagnoses, challenges, and successful physician. support and advocacy to cope interventions. The outcomes helped to define with illness, caregiver stress, and In 2010, when health-care reform successful care management increased out-of-pocket cost to the legislation was first discussed as a approaches for patients with complex individual. This demand was, in part, viable option, SeniorBridge’s data medical conditions and functional stimulated by a health-care policy showed that clients receiving the limitations and to fundamentally shift that determined payment for firm’s integrated care had 90 percent change how care is provided to the hospitalizations by Diagnostic Related fewer emergency room admissions, frailest seniors in our health system. Groupings (DRG). This policy shift, 80 percent fewer hospitalizations, The results also opened the door to in turn, shortened the time patients and 70 percent fewer 30-day scale the model to more individuals. could remain in the hospital and left rehospitalizations compared with In July 2012, Humana, a consumers with more responsibility national data. These clients were, national health company, acquired for managing their own care. Positive on average, age 80 and older, had SeniorBridge and merged it with outcomes of care management multiple chronic illnesses, five deficits its telephonic care management included client satisfaction measured of activities of daily living (ADLs) or organization, Humana Cares, in order in a fee-for-service environment by Independent Activities of Daily Living to improve health outcomes and cost client retention and word-of-mouth (IADLs), and frequently had limited efficiencies among frail members and referrals. family and social support or other tasked a combined team of Humana Over the last two decades, in psychosocial factors that placed them Cares / SeniorBridge care managers the face of an aging demographic, at the highest risk for hospitalization to support 200,000 individuals. increasing medical costs, and the and costly care. It enabled SeniorBridge’s demand for more universal health Recognizing the incentives and private-pay clients to benefit from coverage, Centers for Medicare & penalties set out by the Affordable Humana’s vision, robust health Medicaid Services (CMS) started Care Act, SeniorBridge approached programs, and technology. The move issuing requests for proposals (RFPs) health plans, hospital groups, and also provided best-practice insights for demonstration projects to test and provider groups with the opportunity for the care management industry into measure the impact of these models. to capitalize on SeniorBridge’s how to capitalize on and prepare for The Congressional Budget Office model. SeniorBridge’s approach opportunities and threats associated (CBO) reviewed the independently had demonstrated improved health with the Affordable Care Act. Most evaluated outcomes of ten major outcomes and patient satisfaction importantly, it validated the field of demonstrations. The evaluations while reducing health-care costs care management and expanded its showed that most demonstration among frail individuals who were reach to those who cannot afford to projects have not reduced Medicare likely to need the most costly care. pay privately. In fact, Humana Cares/ spending. Programs in which care SeniorBridge invested in several SeniorBridge care management managers had substantial direct pilot studies that produced promising programs are at the forefront of interaction with physicians and results. In one study of individuals Humana’s ongoing business strategy significant in-person interaction who were among a physician group’s given its success in improving the with patients were more likely to top five percent most chronically health of its members while reducing reduce Medicare spending than other ill and costly to treat as defined by overall health-care costs. continued on page 20

page 19 of Geriatric Care Management Fall 2013

The Affordable Care Act Unlike these demonstration the industry and demonstrate that care and Its Impact on Care programs that produced successful management is a proven model for Management health outcomes but failed in their health organizations to capitalize on continued from page 19 return on investment and ability to Affordable Care Act incentives and penalties for improving outcomes, programs, but on average even those become self-sustaining, SeniorBridge reducing overall health-care costs, and programs did not achieve enough and Humana have produced an improving consumer satisfaction. savings to offset their fees. evidence-based program that demonstrates a sustainable business Results from demonstrations model that facilitates good social Key Learnings – of value-based payment systems policy without additional investment Message to Care were mixed. In one of the four of public funds. Managers demonstrations examined, Medicare “With our program, we’re able to made bundled payments that covered I. Data: The Opportunity reach people who ordinarily wouldn’t all hospital and physician services for be able to access care managers. We’re To attract industry partnerships, heart bypass surgeries; Medicare’s able to make an impact on a whole we must be more data-driven about spending for those services was new population,” explained Mary care-management outcomes. Beyond reduced by about ten percent under the Wegman, RN, CCM, GCM of the client satisfaction, we must be demonstration. Other demonstrations Humana Cares / SeniorBridge care able measure what we do and its of value-based payment appear to management network. attributable health outcome in order to have produced little or no savings for These data are a turning point for Medicare. continued on page 21

Figure 1

SeniorBridge Clients 1 SeniorBridge Have 80% Fewer Falls than Nursing Home Residents

1 1 Rubenstein LZ, et al. Falls in the nursing Nursing Home Residents home. Annals of Internal Medicine 1994;121:442–51.

0% 10%20% 30%40% 50%60% 70%80%

Figure 2

SeniorBridge Clients 2 SeniorBridge Have 60% Fewer Falls than Community Residents

2 Hausdorff JM, et al. Gait variability and fall 2 risk in community–living older adults: a 1– Community Residents year prospective study. Archives of Physical Medicine and rehabilitation 2001;82:1050

0% 5% 10%15% 20%25% 30%35%

page 20 of Fall 2013 Geriatric Care Management

The Affordable Care Act care-only companies; less than the events. Hospitalizations and emergency and Its Impact on Care general population at same-age room visits are a failure of our Management grouping who are not receiving home health-care system to provide needed continued from page 20 care; and dramatically less than support, and we needed to identify persuade industries to invest in our same-age groupings of nursing-home individuals who would benefit from care interventions. residents. (See figures 1 and 2.) management early in the process. Industry partnerships are an Clearly, care managers need to “As a result of Humana’s predictive opportunity for all care managers invest in information technology models, we’re having an opportunity — both as an immediate revenue and understand outcome research. to intervene earlier in the progression stream and as a validation of the Small care-management businesses, of disease and functional decline than care-management model that will unfortunately, have limited resources we were able to with private pay clients stimulate greater acceptance of to invest. As an industry, we have who often come to us after a crises,” the cost of care management in an opportunity to work together to said Humana Cares / SeniorBridge’s relationship to the value. spearhead an initiative to standardize Wegman. “That’s substantial because key metrics and consolidate data for we can truly focus on empowering and If insurance companies, the profession through professional on preserving independence.” hospitals, and doctors pay for care organizations, such as the National management, families will also Interventions need to be tailored Association of Professional Geriatric want to pay for it — so long as they to members’ individual needs based on Care Managers (NAPGCM) and the can compare it with a standard of their functional limitations and disease Case Management Society of America practice. Private care managers will severity through telephone calls, video, (CMSA). then need to produce metrics to help and in-home visits. These measures families make informed choices. II. The 80-20 Rule – Identifying can be augmented with technology Where Care Management Can interventions, including biometric Challenges of Not Having Data Be Most Effective monitoring, motion sensors, and interactive voice response. Data is essential to Recognizing that the Affordable understanding trends in your Care Act puts added pressure on health III. The 30-Day Readmission customer base, your successful organizations to reduce overall health Problem interventions, and your return costs, care managers now have more To respond to incentives and on investment. Often we make incentive to develop interventions penalties set out by ACA legislation, assumptions about what is successful and best practices that improve health outcomes, member satisfaction, and special programs need to address the without fully understanding the 30-days-after-hospital and sub-acute cost efficiencies among individuals outcomes of our efforts. discharge, when seniors are most with the most complex needs. At SeniorBridge, even as we vulnerable for a readmission. It is recognized that a large major- collected data, we weren’t always These transition programs differ looking at trends. In 2008, we ity of resources are used on a small from transition services provided in a believed a large number of clients — fraction of individuals. Industry data fee-for-service world, where length of at least 30 percent — were struggling demonstrate that 16 percent of Medi- service is tailored to meet individual with psychiatric illness. But once care members account for 63 percent needs and resources. Rather, a limited 8 we collected data on diagnoses over of costs. Among Humana members, amount of time to support these patients time, we learned that in fact only 20 percent of care recipients drive 75 means care managers need to provide ten to 12 percent had a primary percent of cost.9 a systematic, strategic approach that is highly personalized. In 30 days, care psychiatric diagnosis. These data Together with Humana, the managers must rank and triage problems influenced not just our marketing SeniorBridge leadership team to provide support that is scalable. efforts but also our training and our evaluated data and best practices to long-term strategic planning. develop core programs that would “We have to demonstrate results quickly so we have to be very focused,” Care-management companies address the needs of the 20 percent continued Wegman. who don’t document incidents lack of Humana members who account access to trends in falls, bed sores, for 75 percent of health-care costs IV. Engagement – A New Approach ADL, cognitive impairment, and by providing one-on-one coaching One surprise faced by SeniorBridge hospitalizations, as opposed to tailored to member needs. care managers is the difficulty in merely monitoring nursing home By understanding the engaging members. One might surmise admissions. commonalities among this population, that being skilled in demonstrating the At SeniorBridge, we were able we were able to develop predictive value of care management to families to show fall rates were significantly models to anticipate needs, intervene who are willing to pay for services less than for clients of other home- as appropriate, and avert adverse continued on page 22

page 21 of Geriatric Care Management Fall 2013

The Affordable Care Act than private-pay clients because confusing or intimidating, and these and Its Impact on Care they lack financial means to access challenges can lessen engagement and Management transportation and buy things like reduce efficiencies. Care managers continued from page 21 healthy food and diabetes test strips; need to both learn the restrictions they face limited health literacy about and be creative in overcoming these would make it simple and easy to their disease; and they do not have hurdles. provide a service for free. However, access to basic technology like a enrollment into these transition “We have streamlined processes phone. These are unique problems programs is a challenge. that allow us to be more efficient, but that as care managers we must we also are faced with restrictions on Rather than interacting primarily cultivate expertise,” Gregg A. Billeter, how we can interact with members with family caregivers, care managers RN, BSN, CCM, GCN in this model often involve the care and what resources we can utilize,” continued Wegman. recipient as the key decision-maker. V. Regulation and Simplicity: Initial research demonstrated that Tensions Affecting Patient VI. Implications of Mistakes these individuals, even when no fee is Satisfaction involved, were resistant to agreeing to Scalability of processes and In the private-pay world, we often programs they didn’t understand and/ quality control are paramount. Unlike describe the care recipient (the older or that implied they needed help. the private-pay world, where a mistake person) as the client. But in fact, generally results in a lost client, Techniques to engage members we work with a system of support in the care-management process are working in highly regulated industries including family caregivers, doctors, poses greater risks: one mistake can unique in the health plan universe lawyers, and other supports. When and require an identification of care jeopardize a contract — or thousands working with a highly regulated of clients. recipient influencers and unique Medicare environment, the exchange language that will resonate. of information that is so important In reaction to health reform, care Furthermore, the types of in integrating care and empowering managers need to have consistent, problems we are addressing as care family caregivers may be more measurable processes that will track managers are different. challenging because of privacy processes and demonstrate positive outcomes. “The care recipients I serve regulations. today are frequently more at risk for Consent forms and other Initial outcomes from the Humana hospitalizations and complications regulatory requirements may be continued on page 23

Figure 3

Humana Chronic Care Program Humana Care / SeniorBridge Averts Hospitalizations Transitions Program (OUTGOING) Reduces Readmissions (30-DAY PROGRAM)

1,001 33% Fewer 25% 60% Fewer 674

10%

N= N= 82,189 4,054 Number of Hospitalizations per thousand Number of 30-Day Readmissions EXPECTED ACTUAL EXPECTED ACTUAL

page 22 of Fall 2013 Geriatric Care Management

The Affordable Care Act and cognitive function that puts them and Its Impact on Care at risk for adverse events. Does the Claudia Fine, LCSW, MPH, CMC, Management patient have food in the refrigerator CCM continued from page 22 to ensure adequate nutrition and hydration? Is the patient taking Chief of Professional Services Cares / SeniorBridge Transitions medications or vitamins you don’t Claudia Fine spearheads clinical program show more than 33 percent know about? Are there support training and communications at reduced hospitalizations among the limitations preventing the patient from the combined Humana Cares / 20 percent most high-risk individuals complying with a discharge plan? SeniorBridge organization. A and 60 percent reduced hospital pioneer in the field of geriatric readmissions. (See Figure 3.) We must do this in an efficient and scalable way. And we must care management she has served Summary prioritize to meet the needs of the care in industry and community recipient and the system. Finally, we leadership roles throughout The Affordable Care Act provides her 30-year career in elder payments, incentives, and penalties for must do this with the same consumer- centric principles on which care care including as one of the successful outcomes and moves away first presidents of the National from simply paying for interventions. management in the private world was founded. Association of Professional Care management is a proven Geriatric Care Managers. process for improving outcomes, cost efficiencies, and consumer Endnotes satisfaction – all of which are at the 1 LewinGroup® analysis of 2006 Eric C. Rackow, MD heart of the Affordable Care Act. Medical Expenditures Panel Survey, President of Humana Cares / Health organizations will no doubt 2010 SeniorBridge continue to look to care management as a solution. 2 Jencks, New England Journal of Eric C. Rackow, MD, heads Medicine, 2009 SeniorBridge and Humana Cares Considering the prevalence of as an integrated organization and chronic conditions and functional 3 “The Medicare Beneficiary Population is responsible for the growth and Fact Sheet”, AARP, 2007 http:// limitations among our elderly, it is no continuing success of the division. surprise that Medicare beneficiaries assets.aarp.org/rgcenter/health/fs149_ medicare.pdf Additionally, Dr. Rackow serves 65 years and older account for 12 as a Professor of Medicine at the percent of the U.S. population but 4 “Medicare Hospital Stays: New York University School of more than one-third of hospitalizations Comparisons between the Fee-for- Medicine. Prior, Dr. Rackow had and almost half of total hospital Service Plan and Alternative Plans: numerous roles in hospitals in the costs. Emergency room visits and Statistics Brief #66,” Healthcare Cost greater New York area, including and Utilization Project http://www. hospital admissions are failures of the president of NYU Hospitals Center. healthcare system to provide timely, hcup-us.ahrq.gov/reports/statbriefs/ effective care. sb66.jsp The problem stems from our 5 Flacker, J Hospital Medicine, 2007 healthcare system’s focus on disease 6 Jencks, N Engl J Med, 2009 management and a lack of attention to the reality that activity limitation is an 7 “Two in Three Hospital Admissions independent risk factor for increased Averted and Care Costs in Half in a health-care costs. One-Year Study of High-Risk Medicare Members Enrolled in Metropolitan’s It is now recognized that when Medical Home Model of Care with patients with complicated medical, SeniorBridge Care Management” (June functional, and cognitive conditions 2012) Metcare and SeniorBridge receive care coordination in the Websites http://finance.boston.com/ home by specially trained geriatric boston/news/read/21604819/two_in_ care managers, hospitalizations and three_hospital_admissions_averted_ emergency room admissions are and_care_costs_cut_in_half_in_a_one substantially reduced. 8 Chronic Conditions Among Medicare As an industry, we must identify Beneficiaries (CMS) 2012 http:// patients with these functional www.cms.gov/Research-Statistics- limitations as being at risk of Data-and-Systems/Statistics-Trends- rehospitalizations. We must ensure and-Reports/Chronic-Conditions/ Downloads/2012Chartbook.pdf that such patients have the proper support system that goes beyond 9 Humana Data 2012 medical needs to address physical

page 23 of Geriatric Care Management Fall 2013

Beware of What You Wish for OR The Affordable Care Act and Me Phyllis Mensh Brostoff, CISW, ACSW, CMC

”To follow what’s happen- administratively (five percent the decision to go into “home ing with the new health care overhead) and competing for business care” and hired our first caregiver, with the private system. That was my Sherry, to work with H. To this day law right now, you have to ideal scenario, but that was not to be. Sherry still works for the company. understand that for all the deep The only thing that could be wrestled Over the years she has asked for a divisions on the issue, there’s through the Congress in 2010 was the variety of benefits, i.e., training as actually a real bipartisan con- Affordable Care Act. As it begins a certified nurse’s aide, in-service sensus about how the American to go from the paper it was written training opportunities to keep up her health care system ought to on into implementation, it turns out certification, health insurance, paid it may not be very affordable. If leave, and a 401-k. Over the years be reformed. Or rather, there most of a company’s employees are the company has added these benefits are two of them — a for our other full-time dishonest consensus employees (those who among politicians work at least 30 hours and an honest con- Oh, how fervently I wished for everyone a week). In 1988 the in the US to have health insurance but not company joined the local sensus among people Chamber of Commerce who study public through their employer! I wanted Medicare to access a chamber- policy for a living. for all – a national system already in sponsored health ...Obamacare has an place, paid for through payroll taxes, very insurance plan, and after a few years, consolidated unwieldy, Franken- efficient administratively (five percent stein’s monster qual- our insurance business overhead) and competing for business through an insurance ity in part because with the private system. That was my ideal broker for all our the law is trying to insurance needs. scenario, but that was not to be. serve both consensus- The company es at once... the White began expanding and House’s decision [to growing in the 1990s. suspend the employer man- comparatively low wage earners and Currently we have about 150 date] is a step toward honesty it is a “large” employer (defined as caregivers, eight care managers, in policy-making. It takes us a having more than 50 FTE employees), an executive director, a clinical it may cost more than anticipated. director, schedulers, recruiters, and little closer to a world where an accounting department. Combined Our company, Stowell & politicians of both parties actu- staff are about 175, more than half Associates, started in 1983 providing of them working a minimum of 30 ally level with the public, and only care management services to hours a week or more. This number acknowledge that employer- elderly and disabled adults. In 1985 of employees puts us squarely into provided health insurance is an one of our clients needed a special the category of a large employer (50 type of caregiver. We could not idea whose time has passed.” or more FTE employees) that must find a caregiver with these special provide affordable health insurance skills among the existing home care to our employees. In the past when h, how fervently I wished agencies in our community. Our reviewing our agency profile, we for everyone in the US client, H, was chronically mentally had little bargaining power and to have health insurance ill, 55 years old, and desperately O were considered a “bad” group from but not through their employer! I wanted to live on her own in a condo an underwriting point of view: too wanted Medicare for all – a national she owned. She had no friends and many woman (99 percent), too old system already in place, paid for very little in the way of homemaking through payroll taxes, very efficient skills or experience. So we made continued on page 25

page 24 of Fall 2013 Geriatric Care Management

Beware of What You Wish From an administrative point this insurance may still be too much for OR The Affordable Care of view, I want all of our employees for our lower wage employees. Our Act and Me to have health insurance. Office plan is that we’ll probably add a continued from page 24 employees who have access to second choice that will meet the primary care can obtain preventative “affordability” rule. We will not know (average age 50) and too low income care. Caregivers can get help with what the 2014 rates will be until (averaging close to $13 per hour for health issues that might save them November of this year. our caregivers). This was a concern from work injuries. We have offered as we moved into understanding the Most members of NAPGCM will this benefit for more than 20 years, regulations within the Affordable Care not be in the position our agency is and it only seems fair that everyone Act. in because they are considered small have health insurance. Our client fees employers. If they are not offering Based on medical underwriting have reflected the ongoing insurance health insurance now, they and their standards and age tiers, the average cost to us, so we do not anticipate employees can use the Marketplace cost per employee for a single plan increasing our fees. (formerly called an “Exchange”) to had been about $820 per month. There is a requirement within the find insurance. It is designed to be Only one-third (33%)of our eligible Affordable Care Act (ACA) that has an on-line tool that will look like the employees (full time, defined by potential for affecting our company Medicare Plan Advisor or Expedia. working on the average 30 hours and employees. One interesting Since all employees will, in theory or more per week) actually enroll outcome of the ACA’s requirement for anyway, be required to have health in the company’s health insurance. community rating (i.e., underwriting insurance, it would seem that all Eighteen percent (18% ) have other can’t be based on your group’s health businesses will adjust fees to manage insurance. Twenty-one percent (21%) histories, just age, size of family, this expense. But, everything is still have government insurance, i.e., smoker/not, and location) is that our up in the air. Personally I think it Medicare. Fifteen percent (15%) insurance premium may actually will take at least five years before have no insurance coverage at this be reduced in 2014. Based on the the ACA will be fully implemented time because it is unaffordable for demographics of our workforce, we and fully integrated into the fabric them. There are thirteen percent have already been paying a higher of the country. To repeat myself, I (13%) whose reasons for not having rate for years. Employers having would have preferred just paying a the company plan are unknown. this number of employees or more payroll tax and including everyone in The company currently pays sixty with a lot of young workers are likely Medicare (or a Medicare-like system), percent (60%) of the plan cost. On to be stuck with a large increase of but they didn’t listen to me! average an employee in the company- premiums since premiums for younger sponsored health plan pays $328 workers may rise. This is not relevant Reference per month for individual coverage. to us. A Hidden Consensus on Health Care, Unfortunately those employees by Ross Douthat, New York Times, making approximately $13 per hour Now that the employer mandate July 6, 2013 http://www.nytimes. cannot afford the cost and remain is suspended for a year, we won’t com/2013/07/07/opinion/sunday/douthat- uninsured– and it is two times the be penalized if the cost is not a-hidden-consensus-on-health-care. amount that is defined as “affordable” “affordable.” However, the cost of html?ref=rossdouthat#comments under the Affordable Care Act for a caregiver working an average of 30 hours a week ($20,000 per year). According to the ACA and the Most members of NAPGCM will not be in the way the math works, no plan can cost position our agency is in because they are more than $1,900, or $158 a month, for our lowest paid full-time caregiver considered small employers. If they are not offering to be considered affordable by the health insurance now, they and their employees ACA (9.5 percent of their gross wage). And to make matters worse for these can use the Marketplace (formerly called an hourly paid employees, Wisconsin’s “Exchange”) to find insurance. It is designed to be governor refused the Federal extended Medicaid benefit for single adults an on-line tool that will look like the Medicare Plan which would cover those with incomes up to 130 percent of poverty. Advisor or Expedia. However, Wisconsin will have a federal health insurance exchange because the governor refused to set up a state-run exchange.

page 25 of Geriatric Care Management Fall 2013

Beware of What You Wish for OR The Affordable Care Act and Me continued from page 25

Affordable Care Act (ACA) Overview

Purpose of Affordable Care • Silver: designed to pay 70 percent services and chronic disease Act (ACA): increasing access to of covered claims costs. management, pediatric services health insurance so that, in theory, • Bronze: designed to pay 60 including pediatric dental and everyone has access to affordable percent of covered claims costs. vision care. health care. Individual Subsidies: Available Minimum Value (MV): Consumer Protections in to individuals with income up to Employee plan must have actuarial ACA: Prohibition against pre- 400 percent of Federal poverty level value of at least 60 percent. existing conditions limiting access without access to affordable employer https://s3.amazonaws.com/ to insurance, continuation of sponsored coverage. Individual public-inspection.federalregister. coverage of adult children to 26, applies for health insurance coverage gov/2013-10463.pdf guaranteed issuance, subsidies for through an Exchange/Marketplace and individuals between 100 percent it will certify if individual is eligible References - 400 percent of Federal poverty for subsidy. All definitions and information level, no more than 90-day waiting above from Anthonie(TJ) Goedheer, period before obtaining coverage. Affordable Employer Sponsored Consultant, Employee Benefits, Coverage: Cost of employee only Diversified Insurance Services, 100 N. Definitions coverage to the employee can be no Corporate Drive, Suite 100, Brookfield, Employer Mandate: more than 9.5 percent of their income. WI 53045 [email protected]. “Applicable large employer” is See Henry J. Kaiser Foundation Penalties: There are employer defined as having employed 50 or website for a tool that calculates penalties if the employer does not more individuals who worked on “affordability” based on employee’s the average 30 hours or more a offer minimum essential coverage to wages: www.kff.org/interactive/ week in the prior calendar year. all FTE employees and at least one subsidy-calculator employee receives a subsidy through Individual Mandates: All an Exchange/Marketplace but this individuals are to have health was suspended until 2015. There are employee penalties if they do not insurance or face tax penalties. Phyllis Mensh Brostoff, get health insurance ($95 per adult Full-Time Employee: Works CISW, ACSW, CMC is the and $47.50 per child, up to $285 per CEO and co-founder of on the average 30 hours or more a family, or 1 percent of family income week for employer Stowell Associates, providing in 2014; $325 per adult, $162.50 geriatric care management per child up to $975 per family or 2 Marketplace/Exchange: and care managed home Entity set up to allow the public percent of family income in 2015; care services to the elderly, to compare health care insurance $696 per adult and $347.50 per child disabled adults and their options electronically, run by up to $2,085 per family or 2.5 percent families since 1983. individual states, or the Federal of family income in 2016). government if a state refuses. Minimum Essential Coverage Phyllis is a founding member of the National Association Coverage Options: (MEC): Coverage has to include 10 essential health benefits; ambulatory/ of Professional Geriatric • Platinum: designed to pay outpatient, emergency, hospitalization, Care Managers and was the 90 percent of covered claims maternity and newborn care, mental President of the National costs. health and substance use, prescription Board in 2009 and President of the Midwest Chapter • Gold: designed to pay 80 drugs, rehabilitative and habilitative Board 2006-2008. percent of covered claims services and devices, laboratory costs. services, preventive and wellness

page 26 of Fall 2013 Geriatric Care Management

Understanding National Health Reform: Why Big Data isn’t Enough Lessons from Massachusetts Health Reform Natasha Dolgin, MD/PhD Candidate and Kate Lapane PhD

The authors gratefully acknowledge As the primary body responsible differing priorities, leaders will need our colleagues Jay Himmelstein, for implementing National Health to take outcomes measurement beyond for reviewing an earlier version of Reform, the federal Centers for what is required by CMS. As such, this paper and providing insight and Medicaid and Medicare Services it is important for the public health expertise, and Gillian Griffith for her (CMS) will depend on standardized community to take an active role in help in reviewing the final draft. systems for measuring the progress defining and measuring public health of its state subsidiaries in meeting outcomes of interest to the relatively Introduction the goals of Health Reform. State silent but ultimately most important The National Health Reform accountability to CMS may involve stakeholders in Health Reform, the bill signed in March 2010, known as measuring and reporting up to 1,000 general public. the Affordable Care Act (ACA), was process and outcomes metrics in the future (Kaiser 2011). States are Section 1: Modernizing designed based on the Massachusetts Informatics Systems & Health Reform bill signed by undergoing massive systems overhauls Governor Mitt Romney in 2006 in order to modernize their processes Processes (Chapter 58). The frameworks for MA and informatics systems. Based on The national healthcare and National Health Reform share Massachusetts’ experience with Health paradigm is undergoing dramatic core similarities such as the creation Reform, Health and Human Services transformations through the new role of Marketplaces1 (The Massachusetts (HHS) named Massachusetts one of 7 of government in the health insurance Health Connector), expansion of “early innovator” states, and provided market. An overwhelming magnitude Medicaid (MassHealth), tax subsidies funding for these states to help lead of systems change is happening almost for working low-income families, and the way in National Health Reform simultaneously. At the same time as the concept of “shared responsibility” (HHS 2011). marketplaces are being launched at between government, employers, and The paper seeks to describe both the Federal and State levels, state individuals. both the benefits of CMS reporting Medicaid systems are expanding, While the frameworks for the requirements as well as their and eligibility and enrollment two bills are similar, the economic limitations in being able to provide (E&E) processes, previously run and political environments in which meaningful public health data, such independently by states’ Medicaid they were passed could not be more as data on healthcare access and programs, are being integrated with different. Years of incremental health outcomes. CMS reporting federal data systems through a new changes preceded the official signing requirements are powerful in “Federal Data Services Hub,” created of Chapter 58 in Massachusetts and its that they establish the precedent and operated by CMS. There will signing predated the economic crash and infrastructure for outcomes also be various levels of integration of 2008. The bill had been generally measurement. However, even with a between E&E processes within well received by the public, whereas seemingly infinite pool of standardized states’ Medicaid and Marketplace political strife characterizes National CMS outcomes measures, every systems. This new integrated system Health Reform, with Republicans stakeholder in National Health is designed to promote efficiency in now pursuing their 41st vote against Reform (federal government, state E&E processes, but it also serves “Obamacare” as of September 2013 governments, vendors, the public, an important purpose for CMS: the (Whitaker). In this era of instability etc.) will have a different agenda ability to monitor systems and reduce and uncertainty, the public will want as far as what defines “successful” system abuses through the validation Health Reform, and to address these to see results… and fast. continued on page 28

page 27 of Geriatric Care Management Fall 2013

Understanding National invaluable to states internally, as it will analyzing this data: the new Consumer Health Reform: Why Big empower them to identify areas that Information and Insurance Oversight Data isn’t Enough need improvement and have a means (CCIIO) division of CMS created by continued from page 26 for continuous evaluation of targeted ACA will be in charge of State-Based interventions. Marketplace oversight. Based on the of personal information with federal experience with the Massachusetts data sources, such as the IRS for Health Connector, private vendors example. that are working with SBMs today The new “Hub” is a revolution in The new “Hub” (such as Xerox, IBM, Deloitte) may decades-old insurance E&E processes. expect and conduct more sophisticated States are in the process of either is a revolution business and “big data” market completely replacing or updating analytics than CCIIO requirements in decades-old their Medicaid informatics systems for data reporting. These additional in order to be compatible with the insurance E&E mechanisms for state-centric outcomes new streamlined process. The new measurement will enable states to informatics systems are a prerequisite processes. States refine their business models to suit the for states to operate the new programs are in the process needs of their own population. being implemented under reform, and However, while CMS those working in the healthcare field of either completely requirements will capture data are all too familiar with the challenges on Medicaid and Marketplace of transitioning from outdated paper- replacing or updating operations and vendors may capture based systems to electronic systems their Medicaid additional data on insurance market (Electronic Medical Records). In dynamics overall, none of the planned summary, CMS is responsible for informatics systems reporting requirements alone or in immense program implementation in order to be combination will sufficiently address and management that the agency is the implications of health reform on approaching very systematically, with compatible with the public health issues of health care diligent progress measurement along new streamlined access and outcomes. Analyzing the the way. process. implications of health reform from Section 2: CMS– a public health perspective will best be served by pooling data from many Agency Operations different sources including both Measurement publicly and privately derived data. CMS Measurement Agencies CMS Outcomes Measurement Section 3: The As part of its approach to CMS will be tracking Medicaid Intersection of managing the massive, multi-level and SBM process outcomes through Government and system change effectively, CMS will aggregate data submission by Insurance Data be holding states accountable for respective agencies. Reporting Interests reporting progress in implementing metrics include agency efficiency at processing applications, call center the new E&E processes. With so “Big” Utilization Data many different models of health volumes, and volume of consumer complaints. State Medicaid systems The new paradigm of government reform across states (some with State- collaboration with the health insurance Based Marketplaces while most have will be required to report on such metrics to CMS on a monthly basis industry creates new avenues for Federally Facilitated Marketplaces, big data analysis surrounding issues some expanding Medicaid others (weekly during open enrollment during Fall 2013). of healthcare utilization, outcomes, are not), standardized process and and costs. Research has shown that outcomes measurement will allow While CMS will be able to healthcare utilization increases when states to share a common denominator directly monitor the processes individuals acquire health insurance in the path toward successfully of the Federally Facilitated (Anderson et al 2012). At the same implementing Healthcare Reform. Marketplace (FFM) that it itself will time as national implementation of The reports will help CMS to identify be operating, states that have state- insurance reform, many states are states and processes that need support, based marketplaces (SBMs) will be turning away from fee-for-service as well as highlight state models that required to report on metrics along healthcare models in favor of adopting are successful so that other states the same lines with what is required Managed Care models that aim to may benefit from the knowledge as of Medicaid systems. The differences incentivize better health outcomes well. Mandating states to create the will lie in the specific metrics required, and drive costs down. Managed care infrastructure, and precedent, for timing of reporting (quarterly) and the measuring their processes will also be agency responsible for collecting and continued on page 29

page 28 of Fall 2013 Geriatric Care Management

Understanding National health provides a limited perspective, the unique issues pertaining to health Health Reform: Why Big in that these databases only provide reform. For example, while the Data isn’t Enough transactional data, and only include aforementioned HCUP surveys could continued from page 28 those that are insured and actively provide data on overall Emergency using the healthcare system. Granted, Department utilization across states, models facilitate the evaluation of as we work toward achieving universal the MHRS was able to provide healthcare utilization, outcomes, and coverage, these databases will grow data from the patient perspective, costs on a population health level in value. However, there are other addressing issues pertaining to the because the claims data collected domains important to public health health needs of the population, covers a wide range of health services beyond transactional encounter data, and it shed light on identifying the that patients utilize, from hospital such as understanding where patients reasons underlying the utilization admissions to community care are having difficulty with scheduling trends observed in large databases. providers. In this way, utilization or accessing healthcare since reform, For example, it asked whether the data is sometimes used as a proxy patients’ own perceptions of their respondent did not receive needed to understand the more complicated health quality or quality of life, and medical treatment or preventative outcome to measure directly, health the effect of policies on availability care in the last year, and whether they quality, and utilization data is also and utilization of free care services. attributed any of their unmet medical a keystone for analyzing costs to needs to the costs of healthcare. These the healthcare system overall. In sample outcomes showed significant Massachusetts and many other states, improvement over the course of MA an All Payers Claims Database Health Reform, particularly for the (APCD) is one avenue through which The MHRS proved lower socioeconomic demographic population-level health activity to be an incredible (Long et al 2013). The MHRS and outcomes can be evaluated. In proved to be an incredible resource addition to APCDs, there are national resource for for understanding Massachusetts databases that collect data on health understanding Health Reform. At the same time, utilization and trends through the there is still much work to be done on American Healthcare Quality and Massachusetts understanding the impact of Reform Research division of Health and Health Reform. on health outcomes in MA, a more Human Services (AHRQ), which hosts complex and challenging outcome to the Health Care Utilization Project At the same time, measure. (HCUP) for example. there is still much In Massachusetts, the APCD is work to be done on Section 4. The managed by what was formerly known Importance of as the “Division of Health Policy understanding the including Public and Finance.” However, and perhaps impact of Reform on Health Stakeholders signifying the potential power of such health outcomes in in the Health Reform a database for understanding state Conversation trends, this center was re-mastered to MA, a more complex become what is now the “Center for The general public is the ultimate Health Information and Analysis,” and challenging stakeholder in Health Reform, both fondly referred to as CHIA (mass. outcome to measure. as investors and as those that are gov 2012). CHIA was created in ultimately impacted by Reform. November 2012, when a new wave However, unlike the implementers of Health Reform that focuses on cost of health reform such as CMS, the containment and quality was signed Explaining “Big” Utilization Data public cannot design and implement reporting requirements that enforce (Chapter 224). Prior to the creation In Massachusetts, data on the government accountability for of CHIA, Massachusetts did not have impacts of Reform on health were measuring public health outcomes a designated center for measuring, contributed by many independent in the way CMS is holding states analyzing, and producing timely sources, ranging from national and accountable for implementing reform. reports on Massachusetts Health state surveys to universities and Incorporating the priorities of long- Reform. private sector research. In addition to term public health interests into the existing surveys such as the National CHIA is designed as a center baseline measurement of reform today Health Interview Survey (NHIS), for collecting data and reports from is particularly challenging as states Blue Cross Blue Shield Foundation different sources reporting on MA scramble to rise to the challenge created the Massachusetts Health Health Reform to paint a greater of basic process reporting required Reform Survey (MHRS) in 2006 overall picture of outcomes than by CMS and vendors. Despite this, what APCD can offer alone. Relying (BCBS Foundation 2011). This survey on claims data to understand public was specifically designed to measure continued on page 30

page 29 of Geriatric Care Management Fall 2013

Understanding National risk for having a shortage crisis. The makers and Departments of Public Health Reform: Why Big DPH was successfully able to form a Health, universities, patient advocacy Data isn’t Enough coalition and campaign for a solution, organizations and think tanks will continued from page 29 to which policy makers responded be important for implementing and together with insurance companies measuring the goals of National it is important that those affected to create a system in which insurance Health Reform. For example, in by Reform have a voice, whether companies contributed to a state 2012, the Massachusetts Department through states’ Departments of Public fund for childhood immunizations. of Public Health created a Statewide Health (DPH), patient advocacy While this is an example of a reactive Quality Advisory Committee groups, public health researchers, or measure taken by DPH in response administered in collaboration with otherwise. to a sudden change, it is an example CHIA, in an effort to help define Despite the reality that that shows the key role that public and support research in healthcare Departments of Public Health play a health stakeholders have in advocating outcomes and quality. crucial role in implementing Health for the public need throughout health In summary, this paper Reform through the administration reform. recommends public patience and of public services, caution in interpreting early data they are not implicitly in health reform, and to avoid included or funded overestimating the value of “big as part of CMS plans We will all be eager to data.” It advocates for strategic and for measuring Health quality data collection and analysis Reform. Health Reform see outcomes as soon as that will be able to address the in Massachusetts was possible, but reality is that implications of health reform, beyond primary designed the measurement of its short-term through conversations with such immense program implementation processes. between policy transformation, we may not makers and insurance companies, while the have access to reliable data Department of Public Kate Lapane PhD Health did not get a seat in the earliest phases of at the table until much implementation. Professor in the Division of of the plan was already Epidemiology of Chronic Diseases in place (Auerbach and Vulnerable Populations 2013). In transitioning Director of the Doctoral Program to an insurance-based system, public Conclusion in Clinical and Population Health services in Massachusetts saw The nation will be watching what Research (CPHR) dramatic shifts in free care and “safety happens with National Health Reform Associate Dean in the Graduate net” utilization and funding (Nardin, with great anticipation and for many, School of Biomedical Sciences Auerbach). Auerbach reflects that apprehension. We will all be eager in retrospect, had the Department of to see outcomes as soon as possible, University of Massachusetts Public Health established a strategy but reality is that with such immense School of Medicine for program evaluation from the program transformation, we may not Kate Lapane has published exten- beginning (perhaps he would say in have access to reliable data in the sively on pharmacoepidemiology a similar manner to CMS strategy in earliest phases of implementation. In and building and using creative National Health Reform now), it could addition, based on the Massachusetts data sources to estimate health have adjusted much more quickly and experience, early data may be risks. Her methodological work appropriately to these shifts. Instead, misrepresentative of the overall has focused on the robustness of the voice of our Department of Public direction of Health Reform, as trends techniques and appropriate ap- Health was often reactive rather than take time to stabilize. plication of techniques often used anticipatory. On the other hand, it is important in non-experimental comparative Auerbach describes one to begin tracking valuable data on effectiveness research. example where the Department of healthcare access and outcomes She is committed to advancing Public Health played a crucial role issues early in order to compare later fundamental knowledge of issues in bringing public health priorities data to state baselines. Measuring central to the improvement of to the forefront for policy makers: healthcare quality is difficult due to population health by focusing on when the state decided to cut $52m in nebulous definitions, challenging understanding the complex inter- funding for childhood immunization measurement mechanisms, and actions between biological, psy- programs. This shifted the cost and the time it takes for downstream administrative burden to providers consequences of an intervention to be so suddenly, that the state was at revealed. Partnerships between policy continued on page 31

page 30 of Fall 2013 Geriatric Care Management

Understanding National States Leading the Way on Implementa- role of public health in health care reform. Health Reform: Why Big tion: HHS Awards “Early Innovator” J Public Health Manag Pract. 2013 Sep- Data isn’t Enough Grants to Seven States. Health and Oct;19(5):488-91. Human Services News Release. Febru- continued from page 30 ary 16, 2011. http://www.hhs.gov/news/ Dr. Rachel Nardin, Dr. David Himmelstein, press/2011pres/02/20110216a.html Dr. Steffie Woolhandler. Massachusetts’ Plan: A Failed Model for Health Care Re- Performance Measurement Under Health form. Harvard Medical School. cho-social, and economical forces Reform: Proposed Measures For Eligibility and Enrollment Systems and Key Issues Hanchate AD, Lasser KE, Kapoor A, Rosen which impact disease production. J, McCormick D, D’Amore MM, Kressin She has made a wide range of and Trade-offs to Consider. Kaiser Foun- dation December 01 2011. NR. Massachusetts reform and disparities reports and oral presentations and in inpatient care utilization. Med Care. 2012 has publications and citations in a The Health Connector. Report to the Mas- Jul;50(7):569-77. sachusetts Legislature: Implementation number of highly-ranked multidis- Cohen RA, Ward BW, and Schiller JS. ciplinary, biomedical and clinical of Health Care Reform, Fiscal Year 2012. December 2012. Health Insurance Coverage: Early release of peer-reviewed journals, mainly in estimates from the National Health Interview the field of geriatric pharmacoepi- Anderson M, Dobkin C, Gross T. The Ef- Survey, 2010. National Center for Health demiology. fect of Health Insurance Coverage on the Statistics. June 2011. Available from: http:// Use of Medical Services. American Eco- www.cdc.gov/nchs/nhis.htm. nomic Journal: Economic Policy, Ameri- Dorn S, Hill I, Hogan S. The Secrets of can Economic Association, vol. 4(1), pages Massachusetts’ Success: Why 97 Percent of 1 -27, February 2012. Natasha Dolgin State Residents Have Health Coverage. State Commonwealth of Massachusetts. Divi- Health Access Reform Evaluation, a national MD/PhD Candidate sion of Health Care Finance and Policy. program of the Robert Wood Johnson Foun- Important Information about the Division dation. The Urban Institute, Washington, DC. Clinical and Population Health 2009 November. Research of Health Care Finance and Policy and the Center for Health Information and Analy- John E. McDonough, Brian Rosman, Fawn University of Massachusetts sis. November 2, 2012. Web. 17 Sept 2013. Phelps and Melissa Shannon. The Third School of Medicine Lessons from the Implementation of Mas- Wave of Massachusetts Health Care Access Reform. Health Affairs, 25, no. 6 (2006): Anticipated year of graduation: sachusetts Health Reform. BCBS Founda- w420-w431 (published online September 14, tion. March 2011. 2017 2006; 10.1377/hlthaff.25.w420) Natasha Dolgin is an MD/PhD Long SK, Stockley K, Nordahl KW. student and 2013 Quality Scholar Coverage, access, and affordability under Footnotes with the American College of health reform: learning from the Mas- sachusetts model. Inquiry. 2012-2013 1 Current nomenclature refers to exchanges Medical Quality. She finished Winter;49(4):303-16. as “Health Benefits Marketplaces.” Other her 3rd year of medical school names used in the past include Health at University of Massachusetts Auerbach J. Lessons from the front line: Insurance Marketplaces and Health Insurance Exchanges. and is now working on her PhD the Massachusetts experience of the in the department of Clinical and Population Health Research. She worked with Jay Himmelstein MD NATIONAL ACADEMY OF CERTIFIED CARE MANAGERS NATIONAL ACADEMY OF CERTIFIED CARE MANAGERS

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of Geriatric Care Management Fall 2013

Effects on Medicare Clients & the Affordable Care Act (ACA) Carol S. Heape, MSW, CMC, Fellow

“The ACA’s elements were also cuts to vision and dental care within the capitated programs. Medicare so numerous that the media and “The ACA directs Advantage programs will continue to local service network executives some of its most be available but with the possibility of rarely understood what was significant financial increased co-pays and premiums as the 14 percent payout is discontinued. in there. Many still don’t. As changes at Medicare With older adults utilizing more a result, most people were Part C, the managed of the healthcare system dollars, the uncomfortable with any part care component ACA is looking at policies that reduce of the topic, and rather than of the Medicare hospitalizations and readmissions to not discussing it as objectively as program” which only reduce Medicare costs but also to improve the quality of patient care. possible, they simply said they currently pays 14 1 “The main focus of the ACA’s didn’t really know.” percent more per nursing home initiatives is to patient than the require that additional nursing home edia reports state consistently traditional Medicare information be included in the existing that individuals who already Nursing Home Compare tool on Mhave health insurance will program. Medicare’s website. In addition, there not be affected to a large degree with is a requirement that criminal violations the implementation of the Affordable and civil penalties be publicly Care Act. For those on Medicare, the Medicare Trust Fund by 12 more disclosed which may add weight to the the changes that have already begun years which should more than double sanctions.” 5 and will continue may be subtle the solvency of Medicare for the near enough that older individuals may not future. sense much of a change at all. The Carol S. Heape, MSW, CMC, following information may be helpful On prescription drug coverage Fellow is founder and CEO of Elder when questions arise about the effects (Medicare Part D), “the new law Options, Inc., Placerville, CA. She of the ACA and Medicare: reduces the donut hole by decreasing has served on both the Western an enrollee’s cost responsibility in Chapter & National NAPGCM “The ACA adds “annual wellness this coverage gap from 100 percent Boards and been an active member visits.” These include comprehensive to 25 percent over the next ten of NAPGCM since 1995. risk assessment and a personalized years.” 3 There are increased costs for prevention plan. It includes medical upper-income Medicare beneficiaries and family history, various biometrics as the ACA increases the premium such as body mass index and blood for these recipients. Endnotes pressure, cognitive impairments, and 1 Browdie, R., “Health Reform, Politics, a five to 10 year schedule of screening “The ACA directs some of its most significant financial changes and Conflict: Is This Any Way to Serve tests. These services will be provided America’s Elders?”, ASA Generations, by the Medicare program at no charge at Medicare Part C, the managed Spring 2011, 6-10. care component of the Medicare to the enrollee no deductibles or 4 2 Kaplan, R., “Older Americans, co-payment obligations will apply to program” which currently pays 14 percent more per patient than Medicare, and the Affordable Care Act: wellness visits.”2 What’s Really In It for Elders?”, ASA the traditional Medicare program. Generations, Spring 2011, 19-25. Bruce Chernof writes in “The Known as the Medicare Advantage Three Spheres of Aging in America: programs, the ACA makes budgetary 3 Ibid. The Affordable Care Takes on cuts to these plans which may st 4 Ibid. Long-Term Care Reform for the 21 change the benefit structure for the Century” that the ACA does extend individual enrollee. There may be 5 Ibid.

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