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Nurse Navigators and the Changing Healthcare Landscape

Nurse Navigators and the Changing Healthcare Landscape. 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)

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Nurse Navigators and the Changing Healthcare Landscape

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  1. Nurse Navigators and the Changing Healthcare Landscape Carol Bush, BS RN Coordinator, ONS Nurse Navigator SIG Nurse Consultant, Remedy Healthcare

  2. 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

  3. Health Reform & the ACAWhat Is It?

  4. “The legislation provides a road map for healthcare reform, the only problem is that there is no road.” unknown

  5. Health Coverage in America Access Cost Quality

  6. Access 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. www.kff.org

  7. Cost Taxes • Medical Devices : 2.3% • Indoor Tanning : 10% • Individuals; Earn > $200K: 0.9% Fees • Insurance Companies: $8 Billion • Pharmaceuticals : $3 Billion Cuts • Medicare & Medicaid Kaiser Family Foundation. www.kff.org

  8. Quality • 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 Priority Kaiser Family Foundation. www.kff.org

  9. Quality • 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 Priority

  10. 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 New Revenue:Tax on high-cost health plans Cancer Action Network Website. (2013) acscan.org/healthcare

  11. What does this mean forCancer Care Close to Home?

  12. Goodbye Donut Hole! • 2010 = $250 rebate • 2011 = Discounts while in donut hole • 50% name brand & 7% generic • Gap to close by 2020. cancercare.org 2013

  13. 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   cancercare.org 2013

  14. 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. cancercare.org 2013

  15. 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 acscan.org (2013)

  16. Prevention, 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 acscan.org (2013)

  17. Clinical Trials Coverage • All group or individual commercial plans must cover routine patient care costs for trials participation • Includes FEHBP plans, but not self-insured plans (ERISA plans) • Preemption provision protects existing state laws & voluntary agreements acscan.org(2013)

  18. Businesses • < 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 acscan.org (2013)

  19. Providers • 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 www.asco.org/ASCOv2/Education

  20. 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 Connector HealthCareandYou.org 2013

  21. 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 cost HealthCareandYou.org 2013

  22. Florida at a Glance

  23. Cancer Incidence Trends: State vs USPercentage of change over 5 years* Breast Colon Kidney Lung Melanoma Non-Hodgkin Pancreas Lymphoma *Data are for 2004-2008. Source: National Cancer Institute and the Centers for Disease Control and Prevention. http://statecancerprofiles.cancer.gov/recenttrend/recenttrend.html.

  24. Payer Mix: State vs US1 * † 32% 26% % of Medicare beneficiaries enrolled in Medicare Advantage plans2 950,816 9,771,658 Lives 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. • Kaiser Family Foundation. http://www.statehealthfacts.kff.org/comparecat.jsp?cat=3&rgn=11&rgn=1. • Kaiser Family Foundation. http://www.statehealthfacts.kff.org/comparecat.jsp?cat=6&rgn=11&rgn=1.

  25. Payer Mix: State vs US1 * † 32% 26% % of Medicare beneficiaries enrolled in Medicare Advantage plans2 950,816 9,771,658 Lives 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. • Kaiser Family Foundation. http://www.statehealthfacts.kff.org/comparecat.jsp?cat=3&rgn=11&rgn=1. • Kaiser Family Foundation. http://www.statehealthfacts.kff.org/comparecat.jsp?cat=6&rgn=11&rgn=1.

  26. Employment and Health Coverage: State vs US (January) (January) (October) (October) Unemployed1 (2011) Uninsured2(2011) 1. Kaiser Family Foundation. http://www.statehealthfacts.org/comparetable.jsp?ind=23&cat=1&print=1. 2. HealthLeaders-InterStudy. Florida health plan data. January 2011.

  27. Medicare and Medicaid: State vs USPercentage of the total population 1 18% 21% Dual eligibles as a % of Medicare enrollees2 87% 86% Medicare population with prescription drug coverage (2010)3 Note: Medicaid, Medicare and dual eligibles data are for 2008-2009. 1. Kaiser Family Foundation. http://www.statehealthfacts.kff.org/comparecat.jsp?cat=3&rgn=11&rgn=1. 2. Kaiser Family Foundation. http://www.statehealthfacts.kff.org/comparecat.jsp?cat=6&rgn=11&rgn=1. 3. Kaiser Family Foundation. http://www.statehealthfacts.org/profileind.jsp?cat=6&sub=77&rgn=11.

  28. Medicaid: State vs USPercentage of the total population* *Data are for 2008-2009. 28 Source: Kaiser Family Foundation. http://www.statehealthfacts.org/mfs.jsp?rgn=11&rgn=1&x=13&y=18.

  29. Medicaid in Florida Source: HealthLeaders-InterStudy. Miami Market Overview. March 2011.

  30. Medicaid Expansion State – US Comparison

  31. Nurse Navigator Focus in Healthcare Transformation

  32. 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. Source:http://www.squidoo.com/linchpin Book:Linchpin: Are You Indespensible?

  33. Nurse Navigator Focus in Healthcare Transformation Models of Care Process Improvement Establish and Maintain Relationships Community Outreach

  34. Oncology Nurse Navigator Impact Models of Care • Coordinate Care Transitions • Identify & Share EBP • Employ mobile technology American Nurses Association 2012

  35. Oncology Nurse Navigator Impact Team Leadership • Relationship Building • Strengthen Multi-Disc Team Communication • Change Management American Nurses Association 2012

  36. 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

  37. Oncology Nurse Navigator Impact Community Outreach • Broaden Innovation Skill Set • Engage new community partners • Coach cross-community team members

  38. Need More Info? Most comprehensive www.kff.org White House version www.whitehouse.gov/healthreform User friendly www.healthcareandyou.org

  39. Special Thanks to…. ONS Nurse Navigator SIG Mario Quitoriano, MSN, RN (video editor, extraordinaire)

  40. Time for Q&A:Exchange ideas and experiences carol@remedyrn.com

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