Health Care Reform Implementation:
Innovation and Funding Opportunities
Sarah Mutinsky
NAPH Counsel, Ropes & Gray, LLP
Claudine Swartz
Assistant Vice President for Policy, NAPH
June 3, 2010
National Association of Public Hospitals and Health Systems
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Objectives
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Highlight key innovation and funding
opportunities in the health reform law
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Begin ongoing dialogue
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Suggest ways to identify and prioritize
opportunities
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Answer your questions
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NAPH Reform Implementation Webinars
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April 22 – Reform Overview (webcast available)
May 6 – Coverage Expansion Issues (webcast available)
May 20 – Provider Payment Issues (webcast available)
June 3 – Innovation & Funding Issues
June 17 – Exchange & Health Plan Issues
July 1 – Primary Care & CHC Issues
July 15 – Compliance Issues
July 29 – Employer Issues
All webinars begin at 2:00 PM Eastern
For more info, visit the Health Reform Implementation section on
NAPH’s website: www.naph.org
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Innovation and Funding Opportunities:
Stimulating health system changes
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Innovation & Funding Opportunities:
Overview
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Funding and/or program opportunities to:
 Drive delivery system reform
 Create a stronger workforce
 Improve access
 Better manage care
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Many funds & programs require change and improvement
– there may be associated opportunity costs
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Innovation & Funding Opportunities:
Overview
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Innovation & opportunities funded via:
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Medicare
 Medicaid /State waivers
 Discretionary funding:
 Directly funded in law
 Specific funding level stated in law & subject to
congressional appropriations
 No specific funding level stated in law & subject to
congressional appropriations process
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In many cases, funding mechanisms are unknown
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Innovation & Funding Opportunities:
Awaiting Answers….Providing Guidance
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Agency (principally HHS) must implement. Requires
staffing, technical expertise.
Many key questions outstanding:
 Will programs actually be funded?
 Will programs be implemented on time?
 What guidance will HHS provide – who will be eligible
to participate and what is criteria?
 How will programs fit together?
Questions create opportunities for NAPH and safety net
hospital guidance
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Keeping Track of Opportunities
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NAPH Innovation & Funding Opportunities Chart
 Check often for updates
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What are the Funding Opportunities?
Delivery System Reforms Workforce & Training
 CMS Innovation Center
 Primary Care
 Payment Demonstrations
 Care Coordination
Coverage & Access
 Trauma Care
 Primary Care
 Long Term Care
 Vulnerable Patients
 Prevention & Chronic Disease
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Innovation & Funding Opportunities:
Delivery System Reforms
Center for Medicare and Medicaid Innovation
What?
Design, implement, test, evaluate and expand payment
models & methodologies under Medicare, Medicaid, &
CHIP that foster patient‐centered care, improve quality, &
reduce the cost of care.
When?
Operational by Jan. 2011
How much? $5 million in FY2010 and $10 billion for FY2011-FY2019
What’s next? Innovation Center lead, Tony Rodgers, developing
framework for Center. Consider possible projects in
statute. Consider recently announced Advanced Primary
Care Practice Demonstration. NAPH and members to
shape safety net models.
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Innovation & Funding Opportunities:
Delivery System Reforms
Payment Demonstrations:
Medicare Shared Savings/ACO Program
What?
Permits providers or provider groups to be
recognized as ACOs and share in cost savings
above a certain threshold if quality standards
are met.
When?
Begins Jan 2012
What’s next? Monitor developments in market via
Premier, Brookings, etc. Engage in
regional discussions. Develop Medicaid
models with NAPH.
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Innovation & Funding Opportunities:
Delivery System Reforms
Payment Demonstrations:
Medicare Shared Savings/ACO Program
• No payment penalty/withhold for participation.
• Consider size of your Medicare population related to investment.
• At least 5,000 participating Medicare beneficiaries in ACO
• 3 year commitment
• Legal structure to permit ACO to receive and distribute
payments for shared savings
• Quality reporting, activities to promote care coordination and
patient-centeredness
• Consider level of integration/relationships with other primary care
providers and community hospitals in your area
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Innovation & Funding Opportunities:
Delivery System Reforms
Payment Demonstrations:
Medicaid Pediatric ACO Program
What?
Permits pediatric providers or provider groups to
be recognized as ACOs similar to Medicare model
When?
Begins Jan 2012
What’s next? Engage in discussions with states. Consider
opportunities for ACO models for low-income
adults through Innovation Center and waivers
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Innovation & Funding Opportunities:
Delivery System Reforms
Payment Demonstrations:
Medicaid Global Payment System Demonstration
What?
Allows up to 5 states to alter Medicaid
payments to large safety net hospital systems
to a capitated, global payment structure.
When?
FY2010-FY2012
How much? “Such sums as necessary” authorized
What’s next? Assess how quickly CMS will move given
short time frame. Discuss alternatives with
state. Consider link with waivers.
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Innovation & Funding Opportunities:
Delivery System Reforms
Payment Demonstrations:
Medicare Bundled Payment Pilot Program
What?
Medicare pilot to evaluate alternative
payment methodologies that promote care
coordination for 10 conditions selected by
HHS
When?
January 2013 - 2018
How much? No additional funds authorized (via Medicare
payments)
What’s next? Await guidance from HHS on relevant
conditions. Proactively suggest alternatives
for evaluation.
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Innovation & Funding Opportunities:
Delivery System Reforms
Payment Demonstrations:
Medicaid Demonstration to Evaluate Integrated Care
around a Hospitalization
What?
Eight state Medicaid demo under which states
would make a bundled payment for physician
and hospital services for an episode of care
When?
January 2012 – Dec 2016
How much? No additional funds authorized (via Medicaid
payments)
What’s next? Discuss alternatives with state. Consider
appropriate “bundles” and advise state &
NAPH.
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Innovation & Funding Opportunities:
Delivery System Reforms
Care Coordination:
Community-Based Collaborative Care Networks
What?
Grant program for safety net providers to
create collaborative care networks to provide
low-income patients with comprehensive
coordinated care
When?
FY 2011-2015
How much? “Such sums as necessary”
What’s next? Join NAPH efforts to secure funding via
Congressional appropriations process.
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Innovation & Funding Opportunities:
Delivery System Reforms
Care Coordination:
State Option to Provide Health Homes for Medicaid
Enrollees with Chronic Conditions
What?
States, through a state plan amendment, can
allow Medicaid beneficiaries with chronic
conditions to select a “health home” consisting
of a designated provider or a team of
professionals. States make Medicaid
payments to “health home” using state
methodology approved by HHS.
When?
State option begins Jan 1, 2011
How much? No additional funding authorized
What’s next? Discuss with state.
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Innovation & Funding Opportunities:
Delivery System Reforms
Trauma Care
Competitive Grants for Regionalized Systems for
Emergency Care Response
What?
When?
How Much?
What’s Next?
At least four multiyear contracts or competitive
grants to eligible entities to support pilots that
design, implement, and evaluate innovative
models of regionalized, comprehensive, and
accountable emergency care and trauma systems
Participating states must agree to a non-federal
contribution no less than $1 for every $3 of federal
funds
Appropriates $24 million for each of FYs 2010-2014
Look for guidance from HHS. Begin, or build on,
discussion with regional partners
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Innovation & Funding Opportunities:
Delivery System Reforms
Trauma Care – cont’d
Trauma Care Centers and Service Availability Grants
What?
HHS is directed to establish 3 grant programs to
qualified public, nonprofit Indian Health Services,
Indian tribal, and urban Indian trauma centers to
strengthen the country’s trauma care by, for
example, assisting in defraying substantial
uncompensated care costs
When?
FY 2009
How Much? Authorizes $100 million for FY2009 and “such sums
as necessary” for FYs 2010-2015
What’s Next? Monitor whether funds are appropriated. Then, look
for HHS guidance.
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Innovation & Funding Opportunities:
Delivery System Reforms
Trauma Care – cont’d
Grants to States for Trauma Service Availability
What?
Grants to promote universal access to
trauma care provided by trauma centers and
trauma-related physician services. States
must allocate at least 40% of their grants to
safety net public or nonprofit trauma centers
When?
FY 2010
How Much?
Authorizes $100 million for FY2010-2015
What’s Next? Monitor whether funds are appropriated, then
look to HHS for guidance.
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Innovations & Funding Opportunities:
Delivery System Reforms
Long Term Care
Independence at Home Demonstration
What?
Will test payment incentive and delivery model
that utilizes physician and nurse practitioner
directed home-based primary care teams to
reduce costs and improve outcomes for
certain Medicare beneficiaries
When?
Program to begin no later than Jan 2012
How Much? Authorizes $5 million for each of FYs 20102015
What’s Next? Monitor appropriations process
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Innovations & Funding Opportunities:
Delivery System Reforms
Long Term Care
State Balancing Incentive Program
What?
Program that enhances federal matching
payments to eligible states to increase the
proportion of non-institutionally-based long
term care services.
When?
Effective FY2012-FY2015
How Much?
Select state will generally be eligible for 2
percentage point increase in FMAP (5
percentage points in certain states)
What’s Next? Assess whether your state is interested in
pursuing and ways to collaborate.
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Innovations & Funding Opportunities:
Workforce and Training
Primary Care & Preventive Medicine Training Programs
Preventive Medicine & Public Health Training Grant Program
What?
Grants or contracts for eligible entities to plan,
develop, operate, or participate in an
accredited residency or internship in
preventive medicine or public health. Eligible
entities include, but are not limited to, public or
private nonprofit hospitals.
When?
Beginning in FY 2011
How Much?
Appropriates $43 million for FY2011, and
“such sums as necessary” for each of the FYs
2012-2015.
What’s Next? Assess your participation. Look for guidance
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from HHS.
Innovations & Funding Opportunities:
Workforce and Training
Primary Care & Preventive Medicine Training - cont’d
Primary Care Training and Enhancement
What?
5-year grants or contracts to support and develop
primary care training programs through accredited
public or nonprofit hospitals, schools of medicine,
physician assistant training programs or other
public/nonprofit entities.
When?
FY 2010
How Much? Authorizes $125 million for FY2010 and “such sums
as necessary” for FYs 2011-2014. Authorizes $75
million for each FY2010-2014 for grants or
contracts with medical schools
What’s Next? Monitor appropriations process. Begin discussing
opportunities with affiliated medical schools. 25
Innovations & Funding Opportunities:
Coverage and Access
Programs to Expand Access to Primary Care
Teaching Health Centers Development Grants
What?
Grants to teaching health centers to establish
new accredited or expanded primary care
residency programs.
When?
FY 2010
How Much?
Authorizes $25 million for FY2010, $50 million
for FY2011, $50 million for FY2012, and “such
sums as may be necessary” for each fiscal
year thereafter
What’s Next? Watch for CMS guidance
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Innovations & Funding Opportunities:
Workforce and Training
Programs to Expand Access to Primary Care
Program of Payments to Teaching Health Centers that
Operate GME Programs
What?
Payments for direct and indirect operational
expenses to qualified teaching health centers
that are listed as sponsoring institutions by the
relevant accrediting body for expansion of
existing or establishment of new approved
graduate medical residency training programs
When?
FY 2011
How Much?
Up to $230 million is appropriated for FYs 2011
through 2015
What’s Next? Look for CMS guidance.
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Innovations & Funding Opportunities:
Coverage and Access
Programs to Expand Access to Primary Care
Community Health Centers Fund
What?
Community Health Center Fund established
for expanded and sustained national
investment in community health centers.
When?
FY 2011
How Much? Appropriates $9.5 billion from FY2011 to
FY2015
What’s Next? Look for HRSA guidance on qualifying
criteria.
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Innovation & Funding Opportunities:
Coverage and Access
Vulnerable Patients
Demonstration Project to Provide Access to Affordable
Care for the Uninsured
What?
A three-year demonstration in up to ten states to
provide access to comprehensive health care
services to the uninsured at reduced fees
When?
Must be established 6 months after enactment
How much? Authorizes such sums as necessary. Max
each state can receive is $2 million.
What’s next? Watch for CMS guidance. Approach state
about interest. Beyond this demo, consider
opportunities for transitional local coverage
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programs under a waiver.
Innovation & Funding Opportunities:
Coverage and Access
Prevention & Chronic Disease
Community Transformation Grants
What?
Competitive grant program for State and local
governmental agencies and communitybased organizations to implement, evaluate,
and disseminate evidence-based community
preventive health activities to address chronic
disease and health disparities
When?
No start date specified
How much? No funds authorized. No less than 20% of
grants awarded to rural and frontier areas
What’s next? Monitor appropriations.
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Innovation & Funding Opportunities:
The Million Dollar Question
WHICH OPPORTUNIT(IES)
TO PURSUE?
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Innovation & Funding Opportunities:
How to prioritize?
Consider:
• Are programs funded?
• Duration and start date
• Interplay with state?
• How do programs fit with their priorities?
• What will they have the resources to focus on?
• What is the combination of opportunities you are pursuing via
federal reform -- are they complementary?
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Innovation & Funding Opportunities:
How to prioritize?
Look internally and at your market first and consider:
• Competitive positioning:
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Where does your hospital need to be in the next 5 years?
Which programs help you get there and/or may give you a leg up?
• Focus:
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Key service areas that need strengthened?
Recurring problems?
Focal patients or conditions?
• Strengths and Weaknesses:
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How do community relationships, integration, etc position you for
opportunities?
Can you build your open pilot programs via initiatives --- models you
want to further test?
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Innovation & Funding Opportunities:
How to prioritize?
Consider:
• Resources:
•
•
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Where do you have resource gaps?
Do you have sufficient staff time and resources to devote? Is there an
opportunity cost of the project?
How will incoming resources interact/affect other funds flow?
• Culture & Collaboration:
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Is cultural change necessary in your organization/community necessary
to implement?
How must you work with your state and/or partners to access
opportunities?
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Innovation & Funding Opportunities:
Implementation
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HHS prioritizing all health reform activities based on
implementation timeline
Agency staffing and restructuring top priority:
 CMS awaiting confirmation of CMS Administrator, Dr.
Donald Berwick
 Peter Lee – new Director of Delivery System Reform in
the HHS Office of Health Reform
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Innovation & Funding Opportunities:
What to Expect Next
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As implementation deadlines draw near, HHS and its
agencies issue program details via guidance, call for
proposals, and regulations
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Look for NAPH updates:
 Innovations & Funding Opportunities Chart
 Read Newsline (weekly newsletter)
 Website
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Suggested Next Steps
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Provide feedback to NAPH about this call
Inform NAPH of your opportunities of interest
Invite your colleagues to next webinar on
Exchanges & Health Plan Issues:
 Health System CEO
 Health Plan CEO
 Chief Financial Officer
 Government Relations Director
 Others
June 17 at 2PM ET
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NAPH Resources
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www.naph.org – Health Reform Implementation Section
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NEW Innovations & Funding Opportunities Chart
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Summary of safety net Issues in reform law
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Timeline for reform implementation
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Newsline – NAPH’s weekly e-newsletter
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NAPH staff and counsel:
 Sarah Mutinsky: sarah.mutinsky@ropesgray.com
 Claudine Swartz: cswartz@naph.org
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