Patient Care in the Trenches: Oncology Nurse Navigation & the ACA

Carol Bush, BS RN
Coordinator, ONS Nurse Navigator SIG
Nurse Consultant, Remedy Healthcare
Presentation Objectives
 Describe the key provisions of the 2010 Affordable
Care Act (ACA)
 Identify major issues, challenges and opportunities
that healthcare reform presents for cancer patients
 As oncology nurse navigators practicing in the era of
the ACA, identify core clinical competencies, patient
care coordination strategies and opportunities for
professional collaboration
Health Reform & the ACA
What Is It?
“The legislation provides a
road map for healthcare
reform, the only problem is
that there is no road.” unknown
Health Coverage in America
Extends Coverage - 3 Major Ways:
 Requires Employers to provide coverage
 Expands Medicaid → $24, 350 per family
 Continues Children’s Health Insurance Program
(CHIP) funding
30 million more Americans will be insured
Kaiser Family Foundation.
 Medical Devices : 2.3%
 Indoor Tanning : 10%
 Individuals; Earn > $200K: 0.9%
 Insurance Companies: $8 Billion
 Pharmaceuticals : $3 Billion
 Medicare & Medicaid
Kaiser Family Foundation.
 Patient Centered Outcomes Research Institute
 What works in EBP?
 Pay for performance of Quality Measures
 Medicare VBP; hospitals, SNFs, ASC’s, others
Healthcare Quality is a Legislative
Kaiser Family Foundation.
 CMS Innovation Center
 Improve quality, reduce cost via pilot projects
 ACOs
 Providers organize; meet quality thresholds; realize
Medicare cost savings
Healthcare Quality is a Legislative
Coverage: Medicaid expansion, major insurance reforms (eg, guaranteed
issue, rating rules, no pre-ex for adults) insurance exchanges, premium /
cost sharing subsidies, individual / employer responsibility requirements
Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review
Coverage: Small business premium tax credit
Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates
Medicare Savings: MA payment reductions, productivity offset to FFS updates
Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal
Delivery System Reform: Center for Medicare and Medicaid Innovation
Delivery System Reform: ACOs, hospital value-based purchasing
Delivery System Reform: Hospital readmissions, payment bundling
Delivery System Reform: Physician quality reporting penalties
New Revenue: Tax on prescription drug manufacturers
New Revenue: Excise tax on medical device makers, Medicare tax on high earners
New Revenue: Tax on health insurers
Cancer Action Network Website. (2013)
New Revenue: Tax on
high-cost health plans
What does this mean for
Cancer Care Close to
Goodbye Donut Hole!
 2010 = $250 rebate
 2011 = Discounts while in donut hole
 50% name brand & 7% generic
 Gap to close by 2020. 2013
Let’s hear it for the Kids!
 Coverage for YA’s up to 26 years old
 Health plans
 prohibited from denying coverage to children up to age
19 years with pre-existing conditions (such as cancer)
 Have a child who is a survivor?
 no longer need to worry about insurance continuing if
you change jobs 2013
The Well is Deeper
 Bans on setting lifetime dollar limits
 Annual dollar limits on coverage will be tightly
restricted for most plans and will be eliminated
altogether in 2014. Patients will no longer have to put off
treatment, waiting for the new plan year to start. 2013
Raise your Right Hand & Repeat
 Health plans take a vow
 Insurers are barred from dropping people from coverage
when they get sick. In other words, you can’t lose your
insurance if diagnosed with cancer (2013)
Prevention, Prevention,
 Coverage is guaranteed; out-of-pocket costs will
be eliminated
 There are over 30 such services, ie Mammography
immunizations, colon cancer screening
 Incentives for smoking cessation & weight reduction (2013)
Clinical Trials Coverage
• All group or individual commercial plans
must cover routine patient care costs for
trials participation
• Includes FEHBP plans, but not selfinsured plans (ERISA plans)
• Preemption provision protects existing
state laws & voluntary agreements (2013)
 < 25 employees:
 Not required to provide coverage; tax credits available
 By 2017, Small Biz Exchange
 > 50 employees:
 Provide coverage or face a fine
 > 200 employees:
 Automatic enroll employees in plan
 Opt out available (2013)
 Millions added to insurance pool
 Bonuses for quality available
 10% to PCPs and Gen Surgeons in certain areas
 Enhanced training
 Scholarships & loans
 Innovation Models
 Medical Home & Medical Neighborhood
Moy, B. et al
Exchanges Explained
New Marketplaces
People w/o employer-sponsored plans
 Small Businesses (through separate exchanges)
One in Every State
Federally run, if not State-run
 Ready for sign up October 2013
 Plan year begins Jan 1, 2014
 Effective Practice--Massachusetts—Health
 2013
Exchanges Explained
Subsidies via sliding scale
133 to 400% FPL = up to $88K for family of 4
The Hope
Consumer friendly comparisons
 Internet portal; assistance in real-time
 Provide choice, flexibility and drive down
 2013
Cancer Incidence Trends: State vs US
Percentage of change over 5 years*
Melanoma Non-Hodgkin Pancreas
*Data are for 2004-2008.
Source: National Cancer Institute and the Centers for Disease Control and Prevention.
Payer Mix: State vs
enrolled in Medicare Advantage plans2
% of Medicare beneficiaries
Notes: Data are for 2008-2009, latest year available for all categories. Percentages may not add up to 100% due to rounding effects.
*Dual eligibles are included in the Medicare population.
†Medicare Advantage beneficiaries are not included in the “Private” totals.
1. Kaiser Family Foundation.
2. Kaiser Family Foundation.
Payer Mix: State vs US1
% of Medicare beneficiaries enrolled in Medicare Advantage plans 2
Notes: Data are for 2008-2009, latest year available for all categories. Percentages may not add up to 100% due to rounding effects.
*Dual eligibles are included in the Medicare population.
†Medicare Advantage beneficiaries are not included in the “Private” totals.
1. Kaiser Family Foundation.
2. Kaiser Family Foundation.
Employment and Health Coverage:
State vs US
Unemployed1 (2011)
1. Kaiser Family Foundation.
2. HealthLeaders-InterStudy. Florida health plan data. January 2011.
Uninsured2 (2011)
Medicare and Medicaid: State vs US
Percentage of the total population
Dual eligibles as a % of Medicare enrollees2
Medicare population with prescription drug coverage (2010)3
Note: Medicaid, Medicare and dual eligibles data are for 2008-2009.
1. Kaiser Family Foundation.
2. Kaiser Family Foundation.
3. Kaiser Family Foundation.
Medicaid: State vs US
Percentage of the total population*
*Data are for 2008-2009.
Source: Kaiser Family Foundation.
Medicaid in Florida
Florida’s Medicaid program includes:
̶ HMOs and provider service networks (PSNs)
̶ MediPass, a primary-care case management program
̶ Florida KidCare, the Children’s Health Insurance Program, including MediKids for
those under age 5, Florida Healthy Kids for those ages 5 to 18, and the Children’s
Medical Services Network for those 18 and younger with special health care needs
Florida’s Medicaid enrollment has swelled under continuing joblessness and is expected to
surpass 3 million in the 2011-2012 fiscal year. This is resulting in thousands of beneficiaries
being added to the state’s fee-for-service (FFS) and Medicaid HMO programs and tighter
control by the HMOs over prescription drug use
The Legislature is expanding Medicaid reform by increasing the use of HMOs to deliver
care to Florida’s Medicaid beneficiaries. In the 5 counties currently under a Medicaid
reform pilot, enrollment in an HMO or a PSN is mandatory. Legislation requires most PSNs
to apply for conversion from a FFS to a capitated payment model by September 2012,
raising doubts about whether FFS can survive reform
Medicaid rates are different for each county and are based on FFS and financial data. A 5%
reimbursement cut for providers has been proposed
Source: HealthLeaders-InterStudy. Miami Market Overview. March 2011.
Medicaid Expansion State – US Comparison
United States
Current Status
of Medicaid
25 Moving
Forward at this
30 Supports;
22 Not Moving
Forward at this
Not Moving
Forward at this
Not Moving
Forward at this
8 In Session Year
5 Weighing
1 In Regular
Session and
Special Session
Weighing Options
Out of Session
Key Legislative
42 Out of Session;
16 Opposes;
4 Debate Ongoing
2013 Legislative
Session Status
Out of Session
Legislative session
ended with no
authorizing the
Nurse Navigator Focus in
Healthcare Transformation
Linchpin Manifesto
I am an artist. • I take initiative • I do the work, not the job. •
Without critics, there is no art. • I am a Linchpin. I am
not easily replaced. • If it’s never been done before, even
better. • I make it happen. Every day. • Every interaction
is an opportunity to make a connection. • Energy
is contagious. The more I put in, the more the world gives
back. • I raise the bar. I know yesterday’s innovation is today’s
standard. • Rule-breaking works better and is
worth the effort. • I will not be brainwashed into
believing in the status quo. • There is no resistance if I don’t
allow it to defeat me. • I embrace a lack of structure
to find a new path. • I am surprising. (And often
surprised). • I donate energy and risk to the cause. • I turn
charisma into leadership. • The work matters.
Go. Make something happen.
Book: Linchpin: Are You Indespensible?
Nurse Navigator Focus in
Healthcare Transformation
Models of Care
Process Improvement
Establish and Maintain Relationships
Community Outreach
Oncology Nurse Navigator Impact
Models of Care
 Coordinate Care Transitions
 Identify & Share EBP
 Employ mobile technology
American Nurses Association 2012
Oncology Nurse Navigator Impact
Team Leadership
 Relationship Building
 Strengthen Multi-Disc Team Communication
 Change Management
American Nurses Association 2012
Oncology Nurse Navigator Impact
Cost Containment
 Metrics
Nurse Navigator as best in class partner for IT
Clinical Care outcomes
Return On Investment
American Nurses Association 2012
Oncology Nurse Navigator Impact
Community Outreach
 Broaden Innovation Skill Set
 Engage new community partners
 Coach cross-community team members
Need More Info?
Most comprehensive
White House version
User friendly
Special Thanks to….
ONS Nurse Navigator SIG
Mario Quitoriano, MSN, RN
(video editor, extraordinaire)
Time for Q&A:
Exchange ideas and experiences
[email protected]

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