CareDeliveryRequirements, ProvisionsandAgendas fromthe AffordableCareAct

Presentationtothe AllianceofCommunityHealthPlans March21,2011

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ThenewHealthCareReformBill (ACA)isoftendescribedasabill thatisfocusedexclusivelyon insuranceissues. Thatisinaccurate.

Thebillexplicitlyandverydirectlymandates morethaneightyspecificcaredelivery,care qualityandcareeffectivenessprograms, functions,goalsandmeasurements.Thebillalso setsupanumberofprogramsdesignedtohelp caregiversimprovecare. ThefollowingslidesoutlineACAcareprovisions.

ACAPROVISIONRELATINGTOCARE

MandatesNationalQualityPlan
ThebillrequirestheHHSSecretarytodevelopa NationalStrategytoImproveHealthCareQuality to improvehealthoutcomesandefficiency,identifyareas forimprovement,addressgapsincomparative effectivenessinformationanddatagathering,and improveresearchanddisseminationofbestpractices. Thenationalhealthcarequalityplanandstrategy mustbeupdatedannually.

ACAPROVISIONRELATINGTOCARE

RequiresQualityMeasurementstoTrack AnnualQualityStrategy
ThebillrequirestheSecretaryinconjunctionwith AHRQandCMStodevelopqualitymeasuresconforming totheNationalQualityStrategy TheSecretarymust develop,andperiodicallyupdateproviderleveloutcome measuresforhospitalsandphysicians,including:

ACAPROVISIONRELATINGTOCARE

AcuteandChronicCareDiseaseMeasures
Billrequiresthedevelopmentof10specifichigh valueoutcomemeasurementsforacutecareand chronicdiseasesbyMarch2012,forthecountry.

ACAPROVISIONRELATINGTOCARE

PrimaryandPreventiveCareMeasures
Billrequiresthedevelopmentof10outcome measurementsforbothprimarycareand preventivecarebyMarch2013forthecountry.

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ReducesHospitalAcquiredInfections PenalizesWorstHospitals
ReducesMedicarepaymentstohospitalsfor hospitalacquiredconditions,hospitalacquired infections,andpreventablereadmissions;imposes monetarypenaltyonhospitalswiththeworstrates ofhospitalacquiredconditions.

ACAPROVISIONRELATINGTOCARE

CreatesMedicaidHealthQualityMeasures
EstablishesMedicaidQualityMeasurementProgram, requiringstateMedicaidplanstoreportonstate specifichealthqualitymeasures,asdeterminedbythe HHSSecretary;requiresHHSSecretarytotest, validate,anddevelopthequalitymeasures.

ACAPROVISIONRELATINGTOCARE

CreatesQualityMeasuresforLongTerm Care,RehabandHospice
Createsaqualitymeasuresreportingsystemfor longtermcarehospitals,inpatientrehabilitation facilities,cancerhospitals,andhospiceprograms.

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ACAPROVISIONRELATINGTOCARE

CoordinatesQualityWorkfor23Federal Departments
CreatesanInteragencyWorkingGroup onHealth CareQualitytocoordinatequalityactivitiesacross 23federaldepartments.

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PaysHospitalsforPerformanceLevelsfor MultipleConditions
PromotesvaluebasedpurchasinginMedicareby payinghospitalsbasedonperformanceonquality measures forcommonandhighcostconditions, includingacutemyocardialinfarction,heartfailure, pneumonia,surgeries,andhealthcareassociated infections.(OnorafterOctober1,2012.)

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ACAPROVISIONRELATINGTOCARE

VariesPhysicianPaymentsBasedonthe QualityofCare
ModifiestheMedicarephysicianfeescheduleto incorporatepaymentsthatvarybasedonthequality ofcareprovided. Themodifierwillbeapplicableto specificphysiciansandphysiciangroups,as determinedbyHHS,beginningJanuary1,2015,and willapplytoallphysiciansandphysiciangroups startingJanuary1,2017.

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ACAPROVISIONRELATINGTOCARE

BestPracticeDisseminationandUse
Developsacollaborativeofhealthcareinstitutions responsiblefordeveloping,documentingand disseminatingbestpractices;implementingbest practiceswithininstitutionstodemonstrate improvedquality,efficiency;andproviding assistancetootherhealthcareinstitutionsonhow toemploybestpracticesandprovencaremethods.

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ACAPROVISIONRELATINGTOCARE

NewModelsforBetterEmergencyCare
DirectstheHHSAssistantSecretaryfor PreparednessandResponsetoawardgrantstopilot projectsthatdesign,implement,andevaluatenew modelsforemergencycare.Fundsemergency medicineresearch,pediatricemergencymedicine researchtoimprovetraumacentercapacity.

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ACAPROVISIONRELATINGTOCARE

ConsumerPortalWebsite
Createsawebsite,HealthCare.gov,toeducate consumersabouttheAffordableCareAct includinginsurancecoverageoptionsand informationonhealthcarequalityandpreventive care.

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ExtendsPhysicianQualityIncentives
ExtendsthePhysicianQualityReportingInitiative, aprogramthatmakesincentivepaymentsto physicianswhoreportqualitymeasuresdatato Medicare.

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CreatesClinicalEffectivenessInstitute
EstablishesthePatientCenteredOutcomes ResearchInstitute thatwillconductresearch comparingclinicaleffectiveness,appropriateness, andprocesses usedformedicaltreatmentsand procedures.TheInstitutesresearchwillassist patients,providers,purchasers,andpolicymakers inmakinginformedhealthdecisionsbasedon continuouslyimprovingthedeliveryofhealthcare, fullyinformedbydataabouttheeffectivenessof variousapproachestocare.
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ACAPROVISIONRELATINGTOCARE

UsesMedicareDatabaseForQuality Measurements
DirectstheHHSSecretarytomakestandardized extractsofMedicareclaimsdataavailable to qualifiedentitiesforanalysisofproviderand supplierperformanceonquality,efficiency,and effectiveness.

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ImprovesHomeBasedCarefor PatientswithMultipleConditions
EstablishestheCommunityBasedCare TransitionsProgram toimprovehomebased chroniccaremanagementforMedicare beneficiarieswithmultiplechronicconditions.

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CreatesHomeCareServicesforCertain MedicaidPatients
CreatestheCommunityFirstChoiceOption,which givesstatestheabilitytoofferhomeand communitybasedattendantservices tocertain Medicaidbeneficiaries.

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CreatesCollaborativeCareNetwork
EstablishestheCommunityBasedCollaborative CareNetwork Programtosupportproviders thatworkcollaborativelytocoordinatecarefor lowincomeandunderinsuredpopulations.

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CreatesInterdisciplinaryCareTeams
Establishesinterdisciplinarycommunityhealth teams,createdbygrantsandcontractstoeligible organizationsfromtheHHSSecretary,tofacilitate collaborationbetweenprimarycareprovidersand communitybasedprevention,patienteducation, andotherresources.

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ACAPROVISIONRELATINGTOCARE

CoordinatesCareforDualEligibles
CreatestheFederalCoordinatedHealthCare Office,anewofficewithintheCentersfor MedicareandMedicaidServicestoimprove coordinationofcarefordualeligibles individualswhoqualifyforbothMedicareand Medicaidcoverage.

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ACAPROVISIONRELATINGTOCARE

CreatesNationalCongenitalHeartCare TrackingProgram
CreatesaNationalCongenitalHeartDisease SurveillanceSystem totrackepidemiological dataonheartdiseaseandidentifyareasfor preventionandoutreach.

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EstablishesCentersofExcellenceFor Depression
EstablishesCentersofExcellenceforDepression anetworkoforganizationsdevelopingand implementingevidencebasedtreatmentand preventionstandards;fosteringcommunication withstakeholders;leveragingcommunity resources;andpromotinguseofelectronichealth recordstocoordinateandmanagetreatmentof depressivedisorders.
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ACAPROVISIONRELATINGTOCARE

CreatesNationalDiabetesReportCard
CreatesaNationalDiabetesReportCard: biennial,publiclyavailablereportofaggregate prevention,qualityofcare,riskfactors,and outcomesdatafordiabeticpatients.

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EstablishesBundlingorEpisodeof Care PaymentDemonstrationProjects

Establishesanationalpilotprogramby2013to improvepatientcareandreduceMedicarecosts bybundlingpaymentsforepisodesofcare.

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FocusesonImprovingHospital UtilizationforMedicare
ExtendstheMedicareHospitalGainsharing Demonstration,whichevaluatesarrangements betweenhospitalsandprovidersaimedat improvingutilizationofinpatienthospital resources.

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EstablishesAccountableCare Organizations(ACOs)forMedicare Beneficiaries

AllowsforthecreationofAccountableCare Organizations(ACOs),briningtogethergroupsof Medicareprovidersthatvoluntarilymeetquality thresholdsandstandardsandallowingtheACO providerstoshareincollectivecostsavingsfor thepatientstheyserve.

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EstablishesPediatricAccountableCare Organizations
Establishesademonstrationprojectforpediatric ACOs.

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ProvidesInHomeCareforHighNeed MedicarePatients
CreatesanIndependenceatHomedemonstration program toprovideinhomeprimarycare servicesforhighneedMedicarepatients.Allows providerstoshareincostsavings.

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CreatesNationalPrevention,Health ImprovementandPublicHealth Councils

EstablishesNationalPrevention,HealthPromotion andPublicHealthCouncilstocoordinatefederal publichealthactivities;fundpreventionandpublic healthprograms;anddevelopevidencebased recommendationsontheuseofclinicaland communitypreventiveservices.
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CreatesOfficeofWomensHealth
EstablishesanOfficeofWomensHealthwitha mandateforhelpingimprovehealthcarein Americaforwomen.

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CreatesOfficeofMinorityHealth
Establishesprogramstoimprovehealthand careforminoritypopulations.

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CreatesNationalEmergencyCareCorps
EstablishesaRegularCorpsandaReady ReserveCorpsoftrainedcaregiversavailable andreadytoserveinnationalemergencies.

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CreatesFundToInvestInPublicHealth ImprovementPrograms
EstablishesaPreventionandPublicHealthFund(PPHF) toinvestinpreventionandpublichealthprograms with thegoalofimprovinghealthandslowingtherateof growthinhealthcarecosts.

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EliminatesCostSharingforPreventive Services
Eliminatescostsharingforadefinedlistof medicallyappropriatepreventiveservices.

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ProvidesWellnessVisits,RiskAssessments andPreventionPlansforMedicare Beneficiaries

Providesaccesstoannualwellnessvisits, comprehensiveriskassessments,andpersonalized preventionplans forMedicarebeneficiaries.

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ACAPROVISIONRELATINGTOCARE

ProvidesGrantsforTobaccoCessation, WeightControl,HealthParticipation
Awardsgrantstostatesforprogramsthat incentivizeMedicaidbeneficiaryparticipationin tobaccocessation,weightcontrol,andother healthpromotionprograms tohelppreventor managechronicdisease.

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ACAPROVISIONRELATINGTOCARE

CreatesaProgramtoStabilizePatients withEmergencyPsychiatricConditions
CreatesaMedicaiddemonstrationprogram requiringstatestoreimbursequalifiedmental healthcareinstitutionsforservicestostabilize Medicaidbeneficiariesexperiencingan emergencypsychiatriccondition.

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ACAPROVISIONRELATINGTOCARE

RequiresHospitalCommunityNeeds Assessments
Requiresnonprofithospitalstoconduct communityneedsassessments,takinginto accountinputfromthecommunityservedbythe hospital,andadoptimplementationstrategiesto meetidentifiedneeds.

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ACAPROVISIONRELATINGTOCARE

PromotesEmployerBasedWellness Programs
Promotesemployerbasedwellness programs byprovidingtechnicalassistance, implementationsupport,andgrantstosmall employers.

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ACAPROVISIONRELATINGTOCARE

IncreasesFundingforCommunity HealthCenters,SchoolHealthCosts
Increasesfundingandprovidesdirectionto theNationalHealthServiceCorps,community healthcenters,schoolbasedhealthcenters, andnursemanagedclinics.

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StreamlinesAccesstoLongTermCarefor ElderlywithDisabilities
SupportsAgingandDisabilityResourceCenters aimedatstreamliningaccesstolongtermcare fortheelderlyandpeoplewithphysical,mental, ordevelopmentaldisabilities.

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ACAPROVISIONRELATINGTOCARE

EvidenceBasedCancerProgram
Createsanevidencebasednationaleducation campaigntoincreaseawarenessaboutbreast cancerpreventionandtreatment.

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CreatesDeliveryModelInnovations
CreatesanewCenterforMedicareandMedicaid Innovation(CMMI)withinCMStotestand evaluatepaymentandservicedeliverymodels that reducecostsandmaintainorimprovequalityof care.

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PromotesandEvaluatesMedicalHomes
Patientcenteredmedicalhomes willbeevaluatedin primarycaresettingswiththegoalofproviding coordinatedteamcaretopatientswithmultiple healthconditions.

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CreatesDirectContractingPilots
Createspilotprogramstotestdirectcontracting modelswithproviders,services andsuppliers to reducethecostsofcareandmaketheunitcosts ofcaremoreaffordable.

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TestsComprehensiveCarePlansand GeriatricAssessmentTools
Createspilotprogramstotesttheeffectiveness ofutilizinggeriatricassessmentsand comprehensivecareplanstocoordinatecarefor patientswithmultiplechronicconditions.

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SalaryBasedCareGiverPilotPrograms
Promotingcarecoordinationbetweenproviders andsupplierstofacilitatethetransitionaway frompurefeeforservicereimbursementand towardsalarybasedpaymentapproachesfor keycaregivers.

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CreatesCareSupportToolsBuiltOn HealthCareITCapabilities
Pilotwilltestsupportingcarecoordinationfor chronicallyillpatientsthroughtheuseofhealth ITenabledprovidernetworks,includingcare coordinators,achronicdiseaseregistry,layersof caregiver/patientconnectivityandhome telehealthtechnology.

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TestsPaymentModelsBasedon AppropriatenessofService
Adjustspaymentmethodologiesto physiciansorderingdiagnosticimaging servicesbasedonthemedical appropriatenessoftheserviceordered.

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EvaluatesTherapyManagementApproaches
Establishesprogramstoevaluate medicationtherapy managementservicesintended toimprovepatient useofmedication.

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AssistingPrimaryCareDoctorswith ChronicCareManagement
Establishingcommunitybasedhealthteams that functiontoassistprimarycareprovidersin chroniccaremanagementforpatientswhose medicalconditionsrequireteamcare.

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FacilitatesBetterInformedPatient Choices
Establishespilotprogramstoassistpatientsin makinginformedhealthcarechoices bypaying providersforusingpatientdecisionsupporttools.

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AllowsStateInnovationforDual EligiblePrograms
Allowsstatestotestandevaluatemodelsforthe integrationofcare fordualeligibles.

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TestsAllPayerFeeApproaches
ACAallowingstatestotestandevaluatesystems ofallpayerpaymentreform.

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PromotesEvidenceBasedCancerCare Approaches
Promotesthealignmentofevidencebased guidelinesofcancercare withpaymentincentives forprofessionaltreatmentplanningandoptimal followupcare.

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CoordinatesPostAcuteCare
Establishespilotstoimprovepostacutecare throughcontinuingcarehospitals,longterm carehospitals,homehealth,andskillednursing care toimprovepatienthealthstatusaftera hospitaldischarge.

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HomeHealthforChronicCare
Setsuppilotstofundhomehealthprovidersof chroniccaremanagementservicestohelp improveteamcareforchroniccarepatients.

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SupportsElectronicMonitoringby Specialists
Supportsimprovementsin inpatientcare through theuseofmodern,patientfocusedelectronic monitoringbyspecialists.

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SupportsDirectReferralsforOutpatient Services
Pilotwilltestefficiencyandaccesstooutpatient servicesthoughmodelsthatdonotrequirea providersreferralfortheservice.

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TestsHealthcareInnovationZone PaymentApproaches
EstablishesHealthcareInnovationZonepayment pilots teachinghospitals,groupsofproviders,and otherclinicalentitiesthat,throughtheirstructure, deliverintegratedandcomprehensivehealth services whileincorporatinginnovativemethodsfor theclinicaltrainingoffuturehealthcare professionals.

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EstablishesNewTherapiesTaxCredit
ProvidesanEncouragingInvestmentinNew Therapiestaxcredit toencourageinvestmentsin newtherapiestopreventanddiagnoseacute andchronicdiseases.

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CreatesCuresAccelerationNetwork
EstablishestheCuresAccelerationNetworkin theOfficeoftheDirectorofNIHthatwillaward grantsandcontractstoacceleratethe developmentofproductsandtherapiestocure certainhighneedconditions.

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FostersTeamManagementofMedications
Awardgrantsandcontractstoimplement collaborativemedicationmanagementservices, wherepharmacistsandotherproviderswould formulatetreatmentplans,preventadversedrug interactions,andeducatepatientsandcaregivers onthemanagementofchronicdiseases.

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CreatesBiosimilarLicensing
Establishesaformallicensingprocessfor approvingbiosimilartherapeutics,withdata exclusivityperiods.

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EncouragesMalpracticeLitigation Alternatives
Awardsfiveyeardemonstrationgrantstostates todevelop,evaluate,andimplementalternatives tocurrentmedicalmalpracticelitigation.

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CreatesComparativeDatabasefor PhysicianPerformance
CreatesPhysicianCompare,awebaccessible databaseofperformance,effectiveness,safetyand otherassessmentsofproviders whoparticipatein MedicarePhysicianQualityReportingInitiative.

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RequiresFinancialDisclosureswith ProvidersandSuppliers
Requiresopendisclosureoffinancial relationshipsbetweenhospitals,providers,and manufacturersanddistributorsofdrugsand medicaldevices.

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CreatesOwnershipTransparency Requirements
RequiresMedicareandMedicaidnursing facilitiestodiscloseownership,expenditureand certificationinformation.

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CreatesEnhancedDatabaseonPatient Populations
Requiresenhancedcollectionandreportingof patientpopulationdataonrace,ethnicity,sex, primarylanguageanddisabilitystatus inall federallyconductedorsupportedhealthcareor publichealthprograms.

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CreatesNationalOfficeofHealth InformationTechnology
FormallyestablishestheOfficeoftheNational CoordinatorforHealthInformationTechnology tooverseedevelopmentandsupportfora nationalhealthinformationnetwork.

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StrengthensDataPrivacy
Strengthenshealthinformationprivacyand securitystandards.

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ProvidesFinancialSupportforHealth CareITAdoption
Authorizesgrantstoassiststateandlocal governmentsandhealthcareprovidersin adoptingandusinghealthIT.

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CreatesMeaningfulUse Requirements forHealthCareIT

ProvidesfinancialincentivesunderMedicareand Medicaidtoencouragehospitals,physiciansand healthprofessionalstobecomemeaningfulusers ofhealthITbyusingcertifiedelectronichealth recordtechnology inwaysthatallowthe electronicexchangeofinformationtoimprove healthcaredeliverycompetencyandquality.

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CreatesHealthCareWorkforceCommission
EstablishesanationalHealthCareWorkforce Commissionof15members,appointedbytheU.S. GovernmentAccountabilityOffice,todevelopa nationalhealthcareworkforcestrategy.

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IncreasestheNumberofNurses
Increasesthenurseworkforcethoughtraining programs,loanrepaymentandretentiongrants.

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RefocusesGraduateMedicalEducation Priorities
RedistributesunusedGraduateMedical Educationtrainingpositionstowardprimary care,generalsurgery,andmedically underservedgeographicareas.

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SupportsRecruitmentofProvidersto RuralAreas
Providesbonuspaymentsandgrantsfor recruitmentandtrainingofproviders toservein ruralandunderservedareas.

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SupportsDeliveryReformInitiatives
Supportsdevelopmentoftrainingprograms focusedonprevention,publichealth,primary care,medicalhomes,teammanagementof disease,andintegrationofmentalandphysical healthservices.

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StageOneGuaranteedIssue
BillCreatesImmediateAccessto GuaranteedCoverageforHighRiskPatients inEveryState
Guaranteedcoveragecanbeaqualityofcare issue.EverystatenowhasinplaceaPCIP(pre existingconditioninsuranceprogram)runbythe stateorthefederalgovernment.Noonein Americaisuninsurablerightnow.Highrisk patientscannowgetcoverage thereby improvingthelikelihoodthathighriskpatients willreceivebettercare.
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StageTwoGuaranteedIssue StageTwoforinsuranceaccesswill happenin2014whenallhealthplans whosellindividualcoveragewillbe opentoallapplicants.

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MostoftheprovisionsoftheAffordable CareActdealwiththeprovisionofcare. Lessthan25percentoftheprovisionsdeal withtheroleandfunctionofinsurance. Thetwosetsofprovisionsarerelated becausecarewillnotbeaffordableuntilit isimproved,andpeoplewithoutcoverage cannotgetaccesstoqualitycare.

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