The document discusses key provisions of the Patient Protection and Affordable Care Act (PPACA) related to sexually transmitted infections (STIs). It notes that PPACA expands insurance coverage and requires coverage of preventive services like chlamydia screening. However, it also raises potential challenges such as confidentiality issues for young adults remaining on parents' insurance plans and shortages of providers to screen and treat for STIs. The document provides an overview of PPACA provisions related to essential health benefits, prevention and wellness, delivery system reforms like medical homes, and health insurance exchanges.

1. Implementation of Health Reform
Legislation: Implications for STD Prevention
National Chlamydia Coalition
Annual Meeting
October 29, 2010
Enrique Martinez-Vidal
Vice President, AcademyHealth
Director, State Coverage Initiatives

2. About State Coverage Initiatives
 The State Coverage Initiatives (SCI) program
provides timely, experience-based information and
assistance to state leaders in order to help them
move health care reform forward at the state level
– Supports a community of state officials
– Provides unbiased information
– Offers responsive policy and technical
assistance
 National program office of the Robert Wood Johnson
Foundation
 www.statecoverage.org
 www.statecoverage.org/health-reform-resources

3. Presentation Overview
 Essential Benefits Package
 Population Health, Prevention and
Wellness Provisions in PPACA
 Delivery System Reform: Medical Homes
 Health Insurance Exchanges
 Questions Moving Forward

4. Essential Benefits Package

5.  Plans may not discriminate against
health care providers who act within the
scope of their licenses and State laws
 All plans must comply with annual cost-
sharing limitations for plans sold in the
Exchanges and must include the
essential benefits package…
Health Insurance Markets:
Plan Benefit Requirements
PPACA
Sec.1201

6. The scope of benefits to be included in the essential
health benefits package has yet to be determined. It
must cover the following general categories of
service:
Health Insurance Markets:
Plan Benefit Requirements
-Ambulatory patient services
-Emergency services
-Hospitalization
-Maternity and newborn care
-Prescription drugs
-Preventative and wellness
services and chronic
diseases management
-Mental health and substance
abuse disorder services
-Rehabilitative and habilitative
services and devices
-Laboratory services
-Pediatric services, including
oral and vision care
PPACA
Sec.1302

7. PPACA: Screening for Chlamydia Infection
Insurance
 Full insurance payment
for priority preventative
screening services
recommended by the
U.S. Preventive Services
Task Force (USPSTF)
 Applies only to new
private plan years
beginning on or after
September 23, 2010
Covered Screening
Recommendations
 All sexually active,
non-pregnant women
aged 24 and younger
and older women who
are at increased risk
 All pregnant women
aged 24 and younger
and older pregnant
women who are at
increased risk

8. Population Health, Prevention
and Wellness Provisions in
PPACA

9. PPACA:
Promoting Population Health & Wellness
 Implement a National Wellness Plan
– The Secretary shall develop and support a broad effort to promote
population health and wellness by March 2011.
 Prevention Fund
– Appropriations rise from $500M in FY10 to $2B in FY15+
– Usable to advance national strategy for prevention and health
promotion
 Benefit Designs to Promote Wellness
– Coverage for preventive services and incentives for wellness are
fostered in Medicare, Medicaid and for private coverage.
 Encourage Employer Wellness Programs
– Employers’ efforts to promote wellness are fostered through multiple
vehicles.

10. Population Health, Prevention and Wellness:
State Opportunities in PPACA
 Preventive Services Measures (Medicaid/CHIP)
– Chronic Disease Incentive Payment Program (§4108)
• Grants ($100m) for incentives to join programs that reduce obesity,
tobacco, blood pressure, diabetes, etc.
– Elimination of exclusion of coverage of drugs that promote
smoking cessation, including FDA-approved OTC (§2502)
– Medical Homes for Enrollees with Chronic Conditions;
Planning Grants (§2703)
– Enhanced FMAP for eliminating cost-sharing reqs for clinical
preventive services and adult vaccination (§4106)
– Coverage of Tobacco Cessation Services for Pregnant
Women - Effective October 2010 (§4107)
– Extension of CHIP Childhood Obesity Demo (§4306)

11. Population Health, Prevention and Wellness:
State Opportunities in PPACA
 Preventive Services Measures (cont) – CDC
– Community Transformation Grants - program to
promote evidence-based community preventive health
activities intended to reduce chronic disease rates, and
address health disparities (§4201)
– Healthy Aging, Living Well Public Health Grant Program
- grants for pilots to provide public health community
interventions, referrals, and screenings for heart
disease, stroke, and diabetes for individuals between
ages 55 and 64 (§4202)

12. Population Health, Prevention and Wellness:
State Opportunities in PPACA
 Preventive Services Measures (cont) – CDC
– Immunization Coverage Improvement Program - demo
grants to improve immunization coverage for children,
adolescents, and adults (§4204)
– Epidemiology Laboratory Capacity Grants - grants to
develop an information exchange and improve
surveillance and response to infectious diseases
(§4304)
– State Authority to Purchase Recommended Vaccines
for Adults Program - states may obtain adult vaccines
through manufacturers at price negotiated by HHS
(§4204)

13. Population Health, Prevention and Wellness:
State Opportunities in PPACA
 Preventive Services Measures (Other)
– Prevention and Public Health Fund (§4002)
– Primary Care Extension Program (§5405)
– School-Based Health Centers (§4101)
• Grants to provide comprehensive preventive/primary care services
– Personal Responsibility Education Grant Program (§2953)
• Educate adolescents about abstinence/contraception
– Wellness Program Demonstration (§2705)
• 10-state health promotion program in Individual Market
• Allows 30% premium reduction
– Health Plan Coverage of Preventive Health Services - no cost
sharing for preventive services - Beginning 9.23.2010 (§2713)
– Essential Health Benefits Package in Exchange (§1302)
• Preventive services will not be subject to deductibles

14. Population Health, Prevention and Wellness:
State Opportunities in PPACA
 Public Health Workforce
– Loan Repayment Program for Public Health Professionals (§5204)
– Health Care Workforce Development - Planning and
Implementation grants (§5102)
– Public Health Training for Mid-Career Professionals (§5206)
– Promote Community Health Workforce – CDC will award grants to
states to use community health workers to promote positive health
behaviors and outcomes in medically underserved communities
(§5313)
– State and Regional Ctrs for Health Workforce Analysis (§5103)
– Fellowship Training in Public Health - Activities to address
documented workforce shortages in state and local health
departments in the areas of applied public health epidemiology,
public health laboratory science, and informatics and may expand
the Epidemic Intelligence Service (§5314)

15. Prevention and Wellness Initiatives
• Some states have already put some of these
ideas into practice:
Vermont’s Blueprint pilot programs link public health
and health reform by embedding community health
teams in community-based primary care practices.

16. Health IT Framework
Global Information Framework
Evaluation Framework
Operations
Blueprint Integrated Pilots
Coordinated Health System
PCMH
PCMH
PCMH
PCMH
Hospitals
Public Health Prevention
Community Care Team
Nurse Coordinator
Social Workers
Dieticians
Community Health Workers
OVHA Care Coordinators
Public Health Prevention Specialist
Mental Health
& Substance
Use Disorders

17. Delivery System Reform
Medical Homes

18. Multi-Payer Medical Home Initiatives (1)
• Multi-payer medical home projects bring major
insurers in a state together to implement changes in
the interaction between primary care providers and
patients.
• Typically, these changes have meant investing more
money into primary care, with the additional funds
being tied to various performance measures.
• Payers must decide how much reimbursement
should be tied to structure and process (use of
EMRs) or outcome measures (reduce ER visits).

19. Multi-Payer Medical Home Initiatives (2)
• Funding of extra medical home services was initially
achieved by increasing funding to the system, as
opposed to using savings from elsewhere in the
system.
• The economic downturn has forced states to find
more creative ways to fund medical home initiatives,
including:
 Requiring insurers to find cost neutral ways to increase
primary care funding without raising premiums (as is done in
Rhode Island)
 Shared savings models
 And other strategies that reward physicians for savings
achieved.

20. Why the Medical Home?
 Primary care-oriented health systems generate lower cost,
higher quality, fewer disparities (Starfield).
 The Chronic Care Model – the chassis for much of the NCQA
standards – has been heavily evaluated and found to improve
quality. There have been fewer evaluations of cost and
utilization impact, but most findings have been positive (Wagner,
RAND).
 Primary care supply is declining nationwide and shortages will
extend without change.
– 2% of graduating medical students pursuing Internal Medicine intend to
become primary care providers (JAMA, 2008)
 Increasing evidence from medical home pilots of effectiveness
in improving quality, reducing costs and ER & IP utilization,
and/or improving clinician satisfaction.

21. Eight Distinguishing Characteristics
 Personal physician (clinician)
 Team-based care
 Proactive planned visits instead of reactive, episodic
care
 Tracking patients and their needed care using special
software (patient registry)
 Support for self-management of chronic conditions (e.g.,
asthma, diabetes, heart disease)
 Patient involvement in decision making
 Coordinated care across all settings
 Enhanced access (e.g., secure e-mail)

22. Current U.S. Medical Home Initiatives
 Current initiatives take many different forms, with
variation in:
– Practice transformation emphasis
– Payment design
– Sponsorship
– Involvement
 Tremendous learning underway
 Medical Home design issues
– Practice Redesign
– Consumer Engagement Beyond Primary Care Setting
– Incentive Alignment
– Evaluation
 Risk: moving on to the next new thing (e.g., the ACO)
before perfecting the medical home

23. State Medical Home Initiatives
• Over 30 states have engaged in efforts to
implement programs to advance Medical
Homes in Medicaid/CHIP
• States working across payers on Medical
Homes Programs include CO, LA, MA, MD,
MN, NH, NY, PA, RI, VT, WA, and WV
• Three leading initiatives – all state-
sponsored: PA, RI and VT
– All dealt with anti-trust concerns by having the state take
“state action” and play a leadership and facilitative role
– Legislation necessary only in VT for an intransigent payer,
but can be helpful in defining the role of the state

24. Payment Reform/Care Coordination:
State Opportunities in PPACA
 Medicaid
– Medical Homes – State Plan Option (§2703)
• Enhanced FMAP of 90% for medical home service costs during
the first two years of the program
• Grants to help develop medical home State Plan amendment
– Community Health Teams for PCMHs – Grants (§3502)
– Pediatric ACO (§2706)
– Primary Care Extension Program (§5405)
– Bundled payment for hospital and physician services -
Demo (§2704) – Up to 8 states (2012-2016)
– Chronic care prevention activities – Grants (§4108)

25. Health Insurance Exchanges

26. Health Insurance Exchanges
 Minimum Requirements under PPACA
 Why Do It?
 Defining Goals
 Structuring Exchanges
 Impact of Current Markets

27. Minimum Requirements under PPACA:
Structural
 Primary purpose is to array coverage options for
consumers (individuals & employers)
– Traditionally has been a lack of information/high search costs
– Creates better balance for the purchasing side of the transaction
 Operated by state agency or state-established, non-profit
entity
 Choice of state-wide, subsidiary exchanges across state,
or multi-state
 Requires an exchange in the individual and small group
markets
– Exchanges may be combined
– Markets may be combined

28. Minimum Requirements under PPACA:
Administrative
 Certify, recertify, and decertify qualified health
plans based on HHS criteria
 Toll-free hotline
 Web site with standardized comparative
information
 Rate qualified health plans per federal
standards
 Present plan options in standard format (four
plan benefit options in standardized manner –
bronze; silver; gold; platinum; catastrophic for
young adults/exemptions)

29. Minimum Requirements under PPACA:
Administrative
 Determine and inform individuals of eligibility
for public programs (Medicaid/CHIP/Other
State programs) and enroll members
 Provide economic calculator for consumers
 Determine whether individuals are exempt
from individual mandate
 Communicate with Treasury Department
(eligibles and exempts)
 Inform employers regarding changes in
coverage of employees

30. Minimum Requirements under PPACA:
Consumer Assistance
 Operate a Navigator program
– Provide culturally/linguistically appropriate
public education
– Facilitate enrollment in qualified health plans
– Refer consumers with complaints/questions to
appropriate agencies
 Brokers/agents
– States may let brokers/agents sell coverage
offered in exchange

31. Minimum Requirements under PPACA:
Accountability
 Consultation and stakeholder participation
 Accountability to federal government
– Annual report to HHS Secretary on activities,
receipts, and expenditures
 Transparency
– Publish average costs of licensing, regulatory
fees, administrative costs, monies lost to
waste, fraud, abuse, etc.

32. Potential Value of State-Based
Insurance Exchange
 Maintain regulatory authority over large share of
market
 Prevent risk selection issues caused by varying
rating/underwriting rules inside/outside the
exchange
 State is better positioned to coordinate benefits
and eligibility across state programs
 Powerful state tool to help advance other health
care priorities

33. Potential Risks of State-Based
Insurance Exchange
Challenges of creating new institutions
Must be self-sustaining by 2015
Tension between demands to keep fees low
and demands for high quality customer service

34. What Are A State’s Policy Goals?
 Make health insurance and care more like consumer-
driven markets?
 Increase health insurers’ accountability?
 To drive system affordability and cost containment?
 To transform the way carriers do business and contract
with providers?
 To build an easy-to-use shopping tool for consumers?
 To help ease the transition for safety-net providers from
reliance on disproportionate share payments and other
uncompensated care funding to commercial insurance
reimbursement?
 To moderate premium increases?

35. How to Structure an Exchange
 Market Organizer (e.g., Utah Health Exchange)
– Impartial source of information on health plans
– Provides structure to market to enable consumers to compare health plans and
purchase coverage
 Selective Contracting Agent (e.g., Massachusetts Connector)
– Market organizer + attempts to influence market and enhance competition
• Contracts with limited number of carriers; offers limited number of plans
– Provides structure to market to enable consumers to compare health plans and
purchase coverage
– Does not necessarily negotiate premiums with carriers but can “encourage” carriers
to “sharpen their pencils”
 Active Purchaser
– Plays a more active role in the market (e.g., establishing plan designs; purchasing
coverage like a large employer procures health benefits for employees)
– May be necessary to get the best prices where competition is limited
– Can push insurers to invest in quality improvements and delivery system changes
– Can aim to elicit more consumer information to be used to negotiate and remove
problematic plans and protect consumers from unexpected barriers

36. How Local Conditions May
Affect Policy Decisions – Part I
 How many carriers are in the state? How competitive
are the carriers for the non-group and small group
market populations?
 Should non-group/small group markets be merged?
 How competitive are the provider systems? Is physician
access currently adequate?
 Are there regional variations regarding carriers and
providers that require special consideration?

37. How Local Conditions May
Affect Policy Decisions – Part II
 What is the nature of insurance market reforms
inside/outside the exchange? Should exchange rules be
extended outside the exchange?
 How will adverse selection be addressed for the
exchange? Impact on reinsurance/risk adjustment
requirements?
 Should the exchange be the sole distribution channel for
a market segment such as non-group? (impact on
undocumented)
 What are the mandated benefits in the state?

38. PPACA: Opportunities and Challenges
Related to STIs
 Opportunities:
– Increase of individuals who have not had regular
health care = increased identification of STIs
 Challenges:
– Dependents will be permitted to remain on their
parents’ insurance plan until their 26th birthday
• Includes dependents that no longer live with their
parents, are not a dependent on a parent’s tax return,
are no longer a student, or are married
– What will be the possible issues of confidentiality
for a young adult on their parents’ insurance with
STIs?

39. PPACA: More Challenges Related to STIs
 Shortages of health care providers to screen
and treat for STIs
 Individual may still not have the funds to
purchase needed medications and follow up
care
 Due to state and local budget cuts, public
health has decreased ability to follow up on
STIs to assure individual and their contacts
are treated = increase risk of spread of STIs

40. Questions Moving Forward
 How will states ensure that populations that remain without
adequate insurance coverage obtain the health care they need?
 How will the safety net prepare for the likely changes in benefits
that are covered by commercial or public insurers?
 How should the public health infrastructure leverage the
demonstration projects, grant opportunities, and other features
of reform to augment its resources, increase its effectiveness,
and enhance its impact?
 How will states facilitate the coordination of safety net services
in the reformed health care system while identifying both
persistent and new unmet needs and coordinating safety net
care delivery?
 What should be expected of traditional safety net providers in an
environment in which more individuals have insurance coverage,
and how can the capacity of these providers be leveraged and
fostered?