Hospital Revenue Streams and
Health Care Reform
Opportunities
Ruth Ann Norton, GHHI
Jack Rayburn, Trust for America’s Health
Beth Bafford, Calvert Foundation
Michael McKnight, GHHI (moderator)
May 29, 2014
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Health Care Reform Opportunities
National Healthy Homes Conference
May 29, 2014
Jack Rayburn
Senior Government Relations Manager
@ jjrayburn
Overview
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Prevention opportunities in ACA
CDC and community-based prevention
Medicaid rule change opportunity
Hospitals and Community Benefit
About TFAH: Who We Are

Trust for America’s Health (TFAH) is a non-profit, nonpartisan organization dedicated to saving lives by protecting
the health of every community and working to make disease
prevention a national priority.
The Affordable Care Act
ACA & The Road to Health
The Affordable Care Act recognizes that health means more
than the absence of disease and that every part of our life
must be focused on creating health
 Clinical preventive services like screenings and
counseling
 All parts of society must work together to make the
healthy choices the easy choice
 Each of us as individuals has a responsibility to be as
healthy as we can be
Prevention in ACA
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Insurance matters
Coverage for preventive services
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Every new health plan, since 2010, must include coverage of
evidence-based, effective preventive services, such as
screenings for type 2 diabetes, immunizations and
mammograms, without co-pays.
Since January 1, 2011, seniors on Medicare receive many
preventive services, with no co-payments–such as annual
wellness visits, cervical cancer screening, diabetes screening,
mammograms and immunizations for the flu and pneumonia.
National Prevention Strategy

Four strategic
directions
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Healthy and Safe
Community
Environment
Clinical and
Community Preventive
Services
Empowered People
Elimination of Health
Disparities
Healthy and Safe Environments

Businesses and employers can:

“Ensure that homes and workplaces are healthy,
including eliminating safety hazards (e.g., trip
hazards, unsafe stairs), ensuring that buildings are
free of water intrusion, indoor environmental
pollutants (e.g., radon, mold, tobacco smoke), and
pests, and performing regular maintenance of
heating and cooling systems.”

National Prevention Strategy, page 17
Recent Community Prevention
Investments
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Communities Putting Prevention to Work (CPPW)
Prevention and Public Health Fund
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Community Transformation Grants (CTG)
Tobacco Prevention, Quitlines, National Media Campaign
Coordinated core chronic disease funding for state health departments
And…
Prevention Investments 2014
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PICH grants (not PPHF)
Preventive Health and Health Services block grants to states
Immunizations
Diabetes Prevention
Heart Disease and Stroke Prevention
Racial and Ethnic Approaches to Health (REACH)
And much more…
Partnerships to Improve Community
Health (PICH)

“PICH is a new 3-year initiative to improve health and reduce the
burden of chronic diseases. Eligible applicants include a variety of
governmental agencies and non-governmental organizations,
including local public health departments, school districts, local
housing authorities, local transportation authorities, and American
Indian tribes…to work through multi-sectoral community
coalitions.”

Letters of Intent due June 5, 2014

www.cdc.gov/chronicdisease/ for more information
Community-based Prevention

Future of this work to be determined by:

Success of current efforts
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Letting the world know of those successes
Creating partnerships that go deeply into the
transforming health system
Creating sustainable resources by leveraging new
funding streams
Medicaid Support for Community
Prevention

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Recent Medicaid EHB rule change to allow
reimbursement for non-licensed providers
Waivers and other CMS authorities to pay for
additional covered services, or to pay additional
entities, or for services in non-traditional setting
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MA Pediatric Asthma 1115 Waiver
Diabetes Prevention Program
TX 1115 Waiver
Coverage of tobacco quit lines in Medicaid
Medicaid Payment for Non-licensed
Providers
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Centers for Medicare and Medicaid Services (CMS)
clarified the statute in the recently issued Essential
Health Benefits rule.
Medicaid will now reimburse for preventive services
recommended by licensed providers and provided, at
state option, by non-licensed providers.
What is the Opportunity for
Community Prevention?
A broader array of
health professionals
could be reimbursed
for providing
preventive services to
Medicaid beneficiaries
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Health Educators
Community health workers
Care Coordinators
Home Visiting Staff
Lactation Consultation
Developmental screening
YMCA Diabetes Prevention
Program
Parenting Education
What are the Steps?
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Define what you want to do.
Gather the required information.
Meet with your state Medicaid agency to
request that they submit a State Plan
Amendment (SPA).
Meet with local Managed Care Organizations
(MCOs) to explore workforce innovation
partnerships.
Describe the Issue and Solution
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Explain the health issue you are addressing.
Describe the intervention.
Provide the evidence of effectiveness and, if
available, return on investment.
Define the Change
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What provider(s) do you propose?
What services will they provide?
Which Medicaid beneficiaries would be
eligible for the services?
Specify Provider Qualifications
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Educational background
Training
Experience
Credentialing or registering
Employment model
Explain Service Delivery
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What preventive services
Evidence of effectiveness
Referral process (from licensed provider)
Unit of service
Service limitations if any
Location limits or requirements if any
Reimbursement level
Hospitals as Community Health Leaders
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ACA Sec. 9007
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Expands and clarifies not-for-profit community benefit
requirements
IRS proposed rules; awaiting final rule
Seek out completed needs assessments, comment,
and offer to partner
http://cdc.gov/policy/chna
Aligning fiscal incentives (i.e., via ACOs) may offer
other opportunities to partner.
Partner and Persevere
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Collaborate with state Medicaid agency to submit
state plan, implement, monitor, improve.
Negotiate with Managed Care Organizations to
implement, monitor, improve.
Partner with health care delivery system to
implement and measure outcomes/savings.
Work with public health agency to implement and
measure outcomes.
For more information
Please visit www.healthyamericans.org to view the
full range of Trust for America’s health policy
reports. Or www.healthyamericans.org/healthreform for health reform implementation
information.
Email: jrayburn@tfah.org
Twitter: @jjrayburn or @healthyAmerica1
There are 5 major trends happening in the health system today,
most driven by changes in the ACA
Government
Providers
Integrated
health
systems
5
Gov’t as
innovator
1
Physician &
hospital
consolidation
2
Coordination
of care
3
New payment
models
4
Consumerism
Within the current system, there are certain trends that favor
community health management…
Government
Understand who
is at risk for
patient care &
show savings
Providers
Integrated
health
systems
Gov’t as
innovator
Physician &
hospital
consolidation
Coordination
of care
New payment
models
Consumerism
…but the most relevant trend is the rise of integrated health
systems
Integrated systems
are likely more willing
and well-equipped to
discuss payments for
community health
Providers
Government
Integrated
health
systems
Gov’t as
innovator
Physician &
hospital
consolidation
Coordination of
care
New payment
models
Consumerism
Addressing Root Causes
Energy Inefficient,
Unhealthy Home
Treatment/
Inhaler
Asthmatic
Child
Hospital
Visit
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A Model That Benefits Families
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Health Impact & Benefits of GHHI
•
•
Over 5,000 GHHI units completed nationwide
Impact on asthma:
o 60-67% reduction in asthma-related client hospitalizations
o 25-60% reduction in asthma ER visits
o 50% increase in participants never having to visit the doctor’s office
due to asthma episodes
o 55% increase in participants reporting their child’s asthma as well
controlled
o 62% increase in participants reporting asthma-related perfect
attendance for their child (0 school absences due to asthma
episodes)
o 88% increase in participants reporting never having to miss a day of
work due to their child’s asthma episodes
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Sustainable Funding for Healthy Homes
•
Without health care sector investment, not enough healthy homes
funds to meet the need
•
Impact on costs makes healthy homes ideal for new, sustainable
investment from the health care sector - business case
•
Increased emphasis on community health and prevention aligns with
healthy homes
•
Around the country several programs have gotten reimbursement
from Medicaid, hospitals, and managed care organizations
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Medicaid Rule Change implications
• Education delivered to families
• Case Management
• To take advantage, each state has to submit
a State Plan Amendment (SPA) to CMS
outlining services, payment structure, and what certifications will
be used for those professionals
• Rule changes “Who” but not “What” for the services that are
eligible – some structural remediation is still beyond CMS’ current
scope.
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Reimbursement models
Multnomah County Environmental Health Services (MCEHS)
•
Began with HUD Healthy Homes program for in-home nursing care
management, environmental assessments, education, and supplies to reduce
asthma triggers, as well as connecting families with community resources.
• Expanded to the Community Asthma Inspection and Referral (CAIR) program.
Community Health Nurse and Community Health Worker conducts 7 visits.
• In 2010 MCEHS negotiated with OR Department of Medical Assistance
Programs and CMS to develop Healthy Homes targeted case management,
allowing for Medicaid reimbursement.
• Kim Tierney serving on a panel at NHHC for more information
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Reimbursement models
Asthma Network of West Michigan (ANWM)
• Karen Meyerson – Provides comprehensive home-based case management,
environmental assessment, and education.
• Health outcomes and cost savings (64% reduction in hospitalizations, 60%
reduction in ER) from ANWM home visiting program led to partnership with
Priority Health, a managed care organization
• Has seen net savings of $800/year for each child
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Medicaid MCOs
• Companies that agree to provide most Medicaid benefits to
people in exchange for a monthly payment from the state
• More flexibility in what MCOs provide under that contract than
what can be provided in traditional fee-for-service Medicaid
reimbursement. Incentivized to deliver cost effective services
• Monroe Plan for Medical Care, in NY, an EPA Asthma Leadership
Award winner, launched a program that
included educational materials, home
environmental assessments, and supplies.
For every $1 spent, $1.48 was saved in
direct medical costs through a 60%
reduction in hospitalizations and 78% fewer ED visits.
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Healthy Homes Waiver
Massachusetts Pediatric Asthma Pilot
•
MA expanded a 1115 waiver to allow expenditures for services:
o home visits, education, care coordination by community health
workers, and environmental supplies for asthma
• 5-year period
• Focus is on high-risk pediatric asthma cases – patients with hospitalizations
or emergency room visits for asthma
• Aim is to satisfy cost savings requirement from reduced hospitalizations and
emergency room visits to counteract costs of additional services. Still
working on programmatic details to start reimbursement.
• Speak with Stacey Chacker, Director, Health Resources in Action
Environmental Health Department for more information
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Making it happen
• Relationships are key – getting to the right decision makers
• Process will take time
• Make life easier for state Medicaid offices
• Waiver is a more rigorous process than State Plan Amendment
• Data is key including costs and impact, make the business case
• Do not reinvent the wheel – reach out to partners across the
country who have undergone the process
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State Innovation Models Initiative
• CMS providing $730 million
for developing state models
for multi-payer
payment and health care
system delivery transformation
• MD designed their proposal
on creating Hubs that will connect
community based services with medical services. Used asthma and
home-based services as their model. The grant would pay for services
in Year 1-3, if ROI is proven, MD payers will pay for those services Year
4-5
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Opportunities from Hospital
Community Benefits
• Community benefit investments can
encompass “physical improvements and
housing” and “environmental improvements.”
• According to AHA there are 2,894
Nongovernment Not-for-profit hospitals and 1,037 state and
local government community hospitals
• Connect with the right office at the hospital – title may be
Community Health Development but it varies (e.g. marketing)
• Become part of the stakeholder group looking at community
health needs. Does the community have an asthma issue? Does
the community have a lead poisoning issue?
• Stress the incentive of having their community benefit
investments go towards something that also produces cost savings
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Hospital Incentives – Reducing
Readmissions
• ACA set up Hospital Readmissions
Reduction Program
• Reduced payments for excess
readmissions
• First three conditions are:
AMI (heart attack), pneumonia, and heart failure
• COPD and THA/TKA (total hip and total knee arthroplasty) will be
added in October 2014
• ACA also encourages the formation of Accountable Care
Organizations for Medicare, incentivizing providers to keep patients
healthy
• Maryland has new global waiver for hospitals (per capita payments)
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Questions?
Ruth Ann Norton
President & CEO, Green & Healthy Homes Initiative
ranorton@ghhi.org
410-534-6447
Jack Rayburn
Senior Government Relations Manager, Trust For America’s Health
jrayburn@tfah.org
202-223-9870
Beth Bafford
Senior Officer of Strategic Initiatives, The Calvert Foundation
Beth.Bafford@calvertfoundation.org
Michael McKnight
Senior Program Officer, Green & Healthy Homes Initiative
mmcknight@ghhi.org
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