In the Friday, August 13th edition of the Philadelphia Inquirer, I read an interesting article on the challenges hospitals are faced with in collecting from patients.
With the increases in deductibles and coinsurance, hospitals are chasing more dollars from consumers, whereas in the past they spent most of their time trying to collect the correct payments from the insurance companies. When deductibles go from $200 to $1,000 and above, patients have more skin in the game and hospitals are trying to collect from them. Today, consumers will need to ask questions they have never asked their physicians or hospitals in the past and that is, “What will you be charging me for this procedure?” In the past, a patient would walk in, show his or her insurance card and plop down the $10 copay, sign a few forms (well maybe a lot of forms) and that was the last the patient was involved in the financing of his or her health. Now with the high deductible plans in place, the patients will need to now be in financing end of the discussion.
As they say, this is the new normal. With that said the issue of pricing transparency is front and center. Consumers will need to shop around and ask for pricing. We know this is not always possible but in a substantial number of cases it is possible. The limitation is not having the necessary tools to research pricing. At NCN we have develop our consumer tool called Consumer Scope and also developed an iPhone app called Consumer Scope (please download it if you have an iPhone). We believe that a key component of driving down the cost of healthcare is to shop around and compare pricing and quality.
Ten years ago this idea would have been laughed out of the room, but look what has happened in the last few years. Retail clinics such as Minute Clinic have exploded onto the scene. Simple, straight forward pricing clearly marked is available for the consumer to see. Websites such as ours are beginning to draw consumers and research charges. Hospitals should encourage the use of these tools since it helps prevent surprises after the procedure is performed. Being hit with a medical bill and not realizing what the charges would be is no long acceptable. An educated consumer is the best customer.
Today is Friday, and for a number of weeks I have been blogging about the many changes occurring within healthcare and the impact this will have in our current delivery system. With all that going on sometimes you just need to step back and take a deep breath and exhale and find some laughter in the world. My 16 year-old-son shared this video and every time I watch this I think about how we all desire to be unique and passionate about our jobs and careers. In this month’s FORTUNE issue, there was an article entitled “Building your brand and keeping your job.” It talks about ways you should differentiate yourself from your coworkers and how to stand out, i.e. like a brand. Well the video below certainly shows and individual who is passionate and unique. Pay attention to the drummer; this guy takes passion for his work to a whole new level.
Have a great weekend. Breathe in…breathe out…enjoy!
I recently came across an interview with James Cleverley, consultant for Cleverley & Associates group. This interview appeared in the July 21st, 2010 Healthcare Fianancial Management Association newsletter called Leadership. In the article they were asking him about the recent 2010 Community Value Leadership Award. What I found interesting were his comments around cost vs. quality vs. operating margin. In today’s healthcare debate, we continually hear of the need for providers to increase their charges.
The real question we should be asking is if there is a focus on quality, shouldn’t your cost structure reduce and thus improve operating margins? We see this in any basic business model. I continue to hear arguments from the healthcare delivery side that says “well that might be true for them, but this is a hospital and we must continually increase our fees. When you read this interview, you see there are innovative healthcare systems that are focused on quality and as such, their costs go down and margin improves, so the need to increase prices to make up for their inefficiencies is null and void.
We believe in order to change the healthcare system from the facility side of the equation you must start with what it is “costing” to deliver services and from that develop a margin on top of the cost. Unless we do this, we are just rewarding inefficiencies and the consumer ends up paying for this. Congratulations to those hospitals committed to quality. You are making a difference in “bending the cost curve” and more importantly delivering superior health outcomes.
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The following is an excerpt from the July 21, 2010 HFMA newsletter called Leadership:
Leadership talked with James O. Cleverley, consultant, Cleverley & Associates, Inc., to learn more about hospital performance on the cost and quality dimensions of the index.
How did top performers on the 2010 Community Value Index achieve this ranking? What are they doing right?
Cleverley: The top-performing hospitals tend to have higher margins, lower debt, and greater levels of reinvestment. So they are very strong financial performers.
On the pricing side, these top performers tend to have lower inpatient and outpatient charge structures. Even top-performing hospitals with less favorable payer mixes (i.e., a higher number of Medicaid patients) are able to maintain reasonable charges, which I think is remarkable.
They achieve this primarily by keeping costs low. These organizations are so efficient on cost side that they are able to maintain lower charges and still generate a reasonable margin.
Have you dug deeper into the cost data to see where these top performers are saving dollars? For instance, are they keeping labor costs low?
Cleverley: We essentially look at the total cost per patient encounter. We use two measures to assess cost structure: Medicare cost per discharge (adjusted for case mix and wage index) and Medicare cost per visit (adjusted for relative weight and wage index).
However, if you drill into any top performing hospital’s detailed cost data, you will likely find variation. For instance, one hospital may have higher nursing salaries, which contributes to a high cost per nursing day. But that same hospital might be very good at managing patients, which contributes to a low length of stay and a low overall cost structure.
So there are variances. Hospitals can achieve lower costs in different ways, whether it’s a lower cost per unit, a lower utilization, or both.
But there is still room for improvement in terms of quality?
Cleverley: Yes, there are outliers. In many cases, hospitals are not necessarily performing poorly, but their scores are lower than the U.S. average for many of these metrics. Some hospital leaders are surprised to learn this. They’ll look at the data and say, “We didn’t realize we were below the national average. We thought we were in a good place. But now we know we need to do better.”
So examining how you compare on these quality metrics can give you some tangible areas for improvement. (The quality data, including U.S. averages, is publicly available on the Hospital Compare web site.)
Yet, you did find greater variation on the cost and price metrics in the Community Value Index.
Cleverley: Yes, we saw much wider variation in hospital cost and charge structures. Everyone is driving at very consistent quality scores. But some hospitals are able to provide that care much more efficiently. At the end of the day, a hospital may have the same quality scores as another hospital. But that hospital will be better positioned for success if it can provide that level of care more efficiently.
Last Thursday, NCN co-sponsored a luncheon featuring Dr. Ron Anderson, who heads the Parkland Hospital System in Dallas and John Goodman, PhD, President and CEO of the National Center for Policy Analysis. The discussion centered on the recently passed health reform law (PPACA) and how this legislation will impact the nation’s health care delivery system.
It was interesting to hear how similar their take was on where healthcare is headed. In particular both believe that:
- Emergency room traffic will increase;
- Access to care for seniors and the disabled will be so impaired, that they are at risk of becoming like Medicaid enrollees who are forced to seek care at community health centers and safety-net hospitals; and
- Unparalleled/unprecedented discretionary power is being given to one federal agency (Health and Human Services) to make decisions that will affect everyone.
NCN will continue to focus on ways to develop a rational and transparent payment system allowing affordability and sustainability for all.
Watch the embedded video above; it'll be worth your time. Will you comment and let me know your thoughts?
Sometimes the grass is not always greener on the other side of the fence (in this case, the other side of the pond)
The reality of sweeping changes made with the passage of PPACA is now happening. Some will argue it’s for the better and others view the passage of PPACA as the beginning of the end to healthcare as we have known it in the USA. I personally believe the delivery system and the payment structure to support the healthcare system needed to change, however with the passage of PPACA, be careful what you wish for.
Covering 30 plus million additional people without the means to increase the structure of primary provider care, absolutely no effective rational payment methods to balance what a provider charges, and the fiduciary responsibility of the employers to manage assets of the healthcare plan … and now the added bureaucracy to implement all the provisions of PPACA as they exist today, with more bureaucracy to follow.
So what have we done? We looked at our neighbors in Canada and across the pond to the UK and said, “We should do what they do.” The grass sure seems greener over there. Is it?
I find it interesting that as the debate around healthcare reform occurred last year, many looked to the Canadian system and UK system as success on how to provide access to all and still deliver care in a cost effective way. As one of my mentors once said, “Truth over time prevails.” Just this week in a July 25th New York Times article, the headline read, “Leaders plan to turn healthcare upside down.” At first, I thought this article was another long list of articles detailing the new PPACA plan. On further review, the article announced that Britain’s healthcare system would need to be totally revamped or it would go bankrupt. Yes that’s right…bankrupt.
The British socialized program is in for major changes. The new coalition government has enacted substantial cuts in health spending. Although not all the details have been made public, what we do know there is a new focus on switching from a highly centralized control of their health system to allow the care and decisions to be made at a local level.
As mentioned in the New York Times article a document produced by the National Health Service (NHS) of the UK states, “The current architecture of the health system has developed piecemeal, involves duplication and is unwieldy. Liberating the NHS and putting power in the hands of patients and clinicians means we will be able to effect a radical simplification, and remove layers of management.” As the article goes on to say, “Currently, how and where patients are treated, and by whom, is largely determined by decisions made by 150 entities known as primary care trust – all of which would be abolished under the plan.”
It seems as we are heading (at least in my opinion) from a highly decentralized system to one that is highly controlled at a national level. While we are moving in this direction, the British system is moving away from a highly centralize to a decentralized system.
Sometimes the grass is not always greener on the other side of the fence…in this case, the other side of the pond.
For years we have pumped a tremendous amount of money into research and design to develop innovative drugs or diagnostic equipment to identify and cure diseases. I’m not opposed to the amount of dollars invested in research and design but sometimes you wonder with all the money being invested, could simpler and less costly ideas be implemented that could be deployed to third world countries and not just developed countries?
I came across this story of two innovative Rice University undergraduate students, Lauren Theis and Lila Kerr, who were given an assignment to solve a problem. As Theis explains, “We were essentially told we need to find a way to diagnose anemia without power, without it being very costly and with a portable device."
With this in mind the two set out to find a low cost solution. They took a basic salad spinner and modified it to be able to transport centrifuge that is able separate blood and allow the accurate diagnosis of anemia. This is done without using any electricity.
As shared in the news article, "In rural, under-served and impoverished parts of the world, a positive diagnosis for anemia is a critically important clue when looking for other health problems such as malnutrition, or serious chronic infectious diseases such as malaria and HIV/AIDS. Until now, blood samples taken in the field would have to be sent to a distant location complete with expensive laboratory centrifuges and electricity, while patients would be left waiting for the results — a lapse in time that can be deadly. Being able to diagnose the condition in real time with "Sally Centrifuge" would allow appropriate treatment to begin before an illness progresses and a patient's condition deteriorates too drastically”
What can a salad spinner teach us about healthcare costs? Sometimes the most effective and easily affordable solution has already been developed … just not for healthcare per se.
Photo Credit: Jeff Fitlow/Rice University
I have written the past about the slow adoption rate for innovative technology and solutions in the healthcare payer space. Not much has changed in the way healthcare payers interact with healthcare providers. This will change and it must change. We are starting to see some signs of the “paralysis by analysis” walls are starting to crumble in healthcare. It is an evolutionary process and yet outside the healthcare payer space we see a technology revolution occurring.
For example, today I read in the Wall Street Journal that Amazon announced E-book sales outpaced hardcover sales. A few years ago no one thought it possible and yet it just happened. The ease and convenience of reading a book just got easier. Oh I forgot to mention that Amazon reduced their rate of the Kindle device and of course e-books are cheaper. We don’t see a reduction in healthcare charges whenever new technology is applied. In fact, prices traditionally go up.
If healthcare payers and providers are going to remain an integral part of the future landscape of healthcare delivery they must adopt technology that will continually improve outcomes while reducing the charges for services. Today the providers are still asking for things to be faxed, forms filled out on paper and photocopied, doctors who still handwrite prescriptions that nobody can read.
iphone, ipad, Kindle, Fax…(oops). So long fax. The “paralysis from analysis” wall is about to tumble.
In the July issue of Managed Healthcare Executive there was an interview with Karen Davis, President of the Commonwealth Fund, a private foundation based in New York that supports research on improvements in healthcare. In this interview I was struck by her comments relating to payment innovations. She is quoted in this article “But the bigger issue is whether the public and private sector can work together on payment…Some states may be willing to use their convening skills to bring different parties together to identify a payment model that is more rational instead of having so many different ways of paying. It’s consuming so much in administrative costs.”
I wholeheartedly agree with her assessment. With the recent passage of PPACA all eyes are focused on providing access to 32 million uninsured/underinsured people. However, there has been no attention to developing a rational payment approach to support this added burden on states and individual employers. For years, we have operated on a payment methodology created by Medicare which today is broken, or a system based on contracts based on discounts in return for volume that is no longer advantageous to employers. What do we do? Our current system is not sustainable. Anyone in the business realizes this and we need to change this quickly.
A rational payment process is needed and will be central to the success of a sustainable healthcare system. Since 2001 we have worked on ways to bring rationality to an irrational payment world. The spotlight of the sustainability of healthcare will be squarely on this word “rational reimbursement.”
Recently the President convened a group of insurance executives and business owners to the White House to discuss the current state of healthcare and to reinforce his desire to provide healthcare to more Americans. In a recent post on June 22
nd by Inside Health Reform stated:
"All sides in Monday's meeting involving President Barack Obama, health insurance executives and state regulators agreed that more needs to be done to confront rising health care costs, including addressing pharmaceutical costs, but the conversation did not produce concrete plans, participants said. One participant said the president balanced promises to hold insurers accountable for their rates with acknowledgments that some cost drivers are outside of their control."
Now reality is starting to hit. Renewal rates for 2010 are starting to surface, and again we will be facing double-digit increases. We can yell and scream at the insurance companies for increasing their rates but if we step back and see the big picture the insurance companies are in a no win situation. If providers continue to increase their billing rates the insurance companies have to increase rates to cover the increase in billing costs. When this happens guess who gets the blame - the insurance company, not the healthcare provider.
If we are going to truly have health reform we need to have the employer, payer AND provider at the table to discuss what a RATIONAL reimbursement should look like. Until we establish a rational reimbursement approach, we will never "bend the curve" in healthcare. We will continue to view insurance companies as the evil empire while increases in healthcare charges go unchecked.
As NCN we believe you must have a rational reimbursement that is fully transparent to the provider, patient and payer. Until this is fully adopted there will be more meetings with the president at the White House scolding the insurance carriers who have little control on cost drivers.
Over the last few days as I have been glued to the TV or my Blackberry watching the news reports on whether BP will be able to cap the flow of oil pouring into the Gulf. While observing these events unfold, I started to ask myself, how will our government respond to this crisis? I asked the same question when Katrina hit, and most recently that question has been asked on how the government will respond to the healthcare crisis.
If history serves as any guide, there are certainly areas where the government does extremely well and I am grateful for that, but in other areas it shows it can be a difficult process to respond. We see this with the recent BP oil spill and we have seen this with the response to Katrina. How will the government respond should we have a healthcare crisis? Oh wait we already do have a crisis.
A quick response, or lack thereof, ultimately comes down to bureaucracy. Not knowing how to coordinate all the multiple agencies that government creates over time is a huge barrier. Whether it be the BP oil spill or Katrina, as the old saying goes, it is difficult to turn a ship around quickly.
With the recent healthcare bill passed we are already seeing warning signals of big bureaucracies being created which will inevitably slow down responses to crises. With healthcare premiums for employer plans on target for another double-digit rate increases, Social Security solvency in question and the ongoing instability of Medicare and Medicaid systems, we need to start thinking about this reality.
I recently came across this website by Congressman Lee Terry of Nebraska. In his site he listed all the newly-created agencies that the Federal government will need in order to support the recently passed healthcare reform bill, PPACA (see below). He has identified over 145 new agencies that would need to be created. I'm not here to argue whether his assessment is correct on the number of new agencies that will be created but I do know more government will be needed to support this bill.
Question: If we have a healthcare crisis (some would say it's going on now), will we see the response like Katrina or the Swine flu vaccine distribution or as the BP oil spill? It's a question I am asking and trying to sort out possible answers to as I watch the oil continue to spill from the below the Gulf, and I get email updates on ongoing clarifications on how the healthcare bill should be rolled out over the next four years (through additional agencies). Hmm....
Republican Congressman Lee Terry of Nebraska has what we passed: 145 bureaucracies.
1. Grant program for consumer assistance offices (Section 1002, p. 37)
2. Grant program for states to monitor premium increases (Section 1003, p. 42)
3. Committee to review administrative simplification standards (Section 1104, p. 71)
4. Demonstration program for state wellness programs (Section 1201, p. 93)
5. Grant program to establish state Exchanges (Section 1311(a), p. 130)
6. State American Health Benefit Exchanges (Section 1311(b), p. 131)
7. Exchange grants to establish consumer navigator programs (Section 1311(i), p. 150)
8. Grant program for state cooperatives (Section 1322, p. 169)
9. Advisory board for state cooperatives (Section 1322(b)(3), p. 173)
10. Private purchasing council for state cooperatives (Section 1322(d), p. 177)
11. State basic health plan programs (Section 1331, p. 201)
12. State-based reinsurance program (Section 1341, p. 226)
13. Program of risk corridors for individual and small group markets (Section 1342, p. 233)
14. Program to determine eligibility for Exchange participation (Section 1411, p. 267)
15. Program for advance determination of tax credit eligibility (Section 1412, p. 288)
16. Grant program to implement health IT enrollment standards (Section 1561, p. 370)
17. Federal Coordinated Health Care Office for dual eligible beneficiaries (Section 2602, p. 512)
18. Medicaid quality measurement program (Section 2701, p. 518)
19. Medicaid health home program for people with chronic conditions, and grants for planning same (Section 2703, p. 524)
20. Medicaid demonstration project to evaluate bundled payments (Section 2704, p. 532)
21. Medicaid demonstration project for global payment system (Section 2705, p. 536)
22. Medicaid demonstration project for accountable care organizations (Section 2706, p. 538)
23. Medicaid demonstration project for emergency psychiatric care (Section 2707, p. 540)
24. Grant program for delivery of services to individuals with postpartum depression (Section 2952(b), p. 591)
25. State allotments for grants to promote personal responsibility education programs (Section 2953, p. 596)
26. Medicare value-based purchasing program (Section 3001(a), p. 613)
27. Medicare value-based purchasing demonstration program for critical access hospitals (Section 3001(b), p. 637)
28. Medicare value-based purchasing program for skilled nursing facilities (Section 3006(a), p. 666)
29. Medicare value-based purchasing program for home health agencies (Section 3006(b), p. 668)
30. Interagency Working Group on Health Care Quality (Section 3012, p. 688)
31. Grant program to develop health care quality measures (Section 3013, p. 693)
32. Center for Medicare and Medicaid Innovation (Section 3021, p. 712)
33. Medicare shared savings program (Section 3022, p. 728)
34. Medicare pilot program on payment bundling (Section 3023, p. 739)
35. Independence at home medical practice demonstration program (Section 3024, p. 752)
36. Program for use of patient safety organizations to reduce hospital readmission rates (Section 3025(b), p. 775)
37. Community-based care transitions program (Section 3026, p. 776)
38. Demonstration project for payment of complex diagnostic laboratory tests (Section 3113, p. 800)
39. Medicare hospice concurrent care demonstration project (Section 3140, p. 850)
40. Independent Payment Advisory Board (Section 3403, p. 982)
41. Consumer Advisory Council for Independent Payment Advisory Board (Section 3403, p. 1027)
42. Grant program for technical assistance to providers implementing health quality practices (Section 3501, p. 1043)
43. Grant program to establish interdisciplinary health teams (Section 3502, p. 1048)
44. Grant program to implement medication therapy management (Section 3503, p. 1055)
45. Grant program to support emergency care pilot programs (Section 3504, p. 1061)
46. Grant program to promote universal access to trauma services (Section 3505(b), p. 1081)
47. Grant program to develop and promote shared decision-making aids (Section 3506, p. 1088)
48. Grant program to support implementation of shared decision-making (Section 3506, p. 1091)
49. Grant program to integrate quality improvement in clinical education (Section 3508, p. 1095)
50. Health and Human Services Coordinating Committee on Women's Health (Section 3509(a), p. 1098)
51. Centers for Disease Control Office of Women's Health (Section 3509(b), p. 1102)
52. Agency for Healthcare Research and Quality Office of Women's Health (Section 3509(e), p. 1105)
53. Health Resources and Services Administration Office of Women's Health (Section 3509(f), p. 1106)
54. Food and Drug Administration Office of Women's Health (Section 3509(g), p. 1109)
55. National Prevention, Health Promotion, and Public Health Council (Section 4001, p. 1114)
56. Advisory Group on Prevention, Health Promotion, and Integrative and Public Health (Section 4001(f), p. 1117)
57. Prevention and Public Health Fund (Section 4002, p. 1121)
58. Community Preventive Services Task Force (Section 4003(b), p. 1126)
59. Grant program to support school-based health centers (Section 4101, p. 1135)
60. Grant program to promote research-based dental caries disease management (Section 4102, p. 1147)
61. Grant program for States to prevent chronic disease in Medicaid beneficiaries (Section 4108, p. 1174)
62. Community transformation grants (Section 4201, p. 1182)
63. Grant program to provide public health interventions (Section 4202, p. 1188)
64. Demonstration program of grants to improve child immunization rates (Section 4204(b), p. 1200)
65. Pilot program for risk-factor assessments provided through community health centers (Section 4206, p. 1215)
66. Grant program to increase epidemiology and laboratory capacity (Section 4304, p. 1233)
67. Interagency Pain Research Coordinating Committee (Section 4305, p. 1238)
68. National Health Care Workforce Commission (Section 5101, p. 1256)
69. Grant program to plan health care workforce development activities (Section 5102(c), p. 1275)
70. Grant program to implement health care workforce development activities (Section 5102(d), p. 1279)
71. Pediatric specialty loan repayment program (Section 5203, p. 1295)
72. Public Health Workforce Loan Repayment Program (Section 5204, p. 1300)
73. Allied Health Loan Forgiveness Program (Section 5205, p. 1305)
74. Grant program to provide mid-career training for health professionals (Section 5206, p. 1307)
75. Grant program to fund nurse-managed health clinics (Section 5208, p. 1310)
76. Grant program to support primary care training programs (Section 5301, p. 1315)
77. Grant program to fund training for direct care workers (Section 5302, p. 1322)
78. Grant program to develop dental training programs (Section 5303, p. 1325)
79. Demonstration program to increase access to dental health care in underserved communities (Section 5304, p. 1331)
80. Grant program to promote geriatric education centers (Section 5305, p. 1334)
81. Grant program to promote health professionals entering geriatrics (Section 5305, p. 1339)
82. Grant program to promote training in mental and behavioral health (Section 5306, p. 1344)
83. Grant program to promote nurse retention programs (Section 5309, p. 1354)
84. Student loan forgiveness for nursing school faculty (Section 5311(b), p. 1360)
85. Grant program to promote positive health behaviors and outcomes (Section 5313, p. 1364)
86. Public Health Sciences Track for medical students (Section 5315, p. 1372)
87. Primary Care Extension Program to educate providers (Section 5405, p. 1404)
88. Grant program for demonstration projects to address health workforce shortage needs (Section 5507, p. 1442)
89. Grant program for demonstration projects to develop training programs for home health aides (Section 5507, p. 1447)
90. Grant program to establish new primary care residency programs (Section 5508(a), p. 1458)
91. Program of payments to teaching health centers that sponsor medical residency training (Section 5508(c), p. 1462)
92. Graduate nurse education demonstration program (Section 5509, p. 1472)
93. Grant program to establish demonstration projects for community-based mental health settings (Section 5604, p. 1486)
94. Commission on Key National Indicators (Section 5605, p. 1489)
95. Quality assurance and performance improvement program for skilled nursing facilities (Section 6102, p. 1554)
96. Special focus facility program for skilled nursing facilities (Section 6103(a)(3), p. 1561)
97. Special focus facility program for nursing facilities (Section 6103(b)(3), p. 1568)
98. National independent monitor pilot program for skilled nursing facilities and nursing facilities (Section 6112, p. 1589)
99. Demonstration projects for nursing facilities involved in the culture change movement (Section 6114, p. 1597)
100. Patient-Centered Outcomes Research Institute (Section 6301, p. 1619)
101. Standing methodology committee for Patient-Centered Outcomes Research Institute (Section 6301, p. 1629)
102. Board of Governors for Patient-Centered Outcomes Research Institute (Section 6301, p. 1638)
103. Patient-Centered Outcomes Research Trust Fund (Section 6301(e), p. 1656)
104. Elder Justice Coordinating Council (Section 6703, p. 1773)
105. Advisory Board on Elder Abuse, Neglect, and Exploitation (Section 6703, p. 1776)
106. Grant program to create elder abuse forensic centers (Section 6703, p. 1783)
107. Grant program to promote continuing education for long-term care staffers (Section 6703, p. 1787)
108. Grant program to improve management practices and training (Section 6703, p. 1788)
109. Grant program to subsidize costs of electronic health records (Section 6703, p. 1791)
110. Grant program to promote adult protective services (Section 6703, p. 1796)
111. Grant program to conduct elder abuse detection and prevention (Section 6703, p. 1798)
112. Grant program to support long-term care ombudsmen (Section 6703, p. 1800)
113. National Training Institute for long-term care surveyors (Section 6703, p. 1806)
114. Grant program to fund State surveys of long-term care residences (Section 6703, p. 1809)
115. CLASS Independence Fund (Section 8002, p. 1926)
116. CLASS Independence Fund Board of Trustees (Section 8002, p. 1927)
117. CLASS Independence Advisory Council (Section 8002, p. 1931)
118. Personal Care Attendants Workforce Advisory Panel (Section 8002(c), p. 1938)
119. Multi-state health plans offered by Office of Personnel Management (Section 10104(p), p. 2086)
120. Advisory board for multi-state health plans (Section 10104(p), p. 2094)
121. Pregnancy Assistance Fund (Section 10212, p. 2164)
122. Value-based purchasing program for ambulatory surgical centers (Section 10301, p. 2176)
123. Demonstration project for payment adjustments to home health services (Section 10315, p. 2200)
124. Pilot program for care of individuals in environmental emergency declaration areas (Section 10323, p. 2223)
125. Grant program to screen at-risk individuals for environmental health conditions (Section 10323(b), p. 2231)
126. Pilot programs to implement value-based purchasing (Section 10326, p. 2242)
127. Grant program to support community-based collaborative care networks (Section 10333, p. 2265)
128. Centers for Disease Control Office of Minority Health (Section 10334, p. 2272)
129. Health Resources and Services Administration Office of Minority Health (Section 10334, p. 2272)
130. Substance Abuse and Mental Health Services Administration Office of Minority Health (Section 10334, p. 2272)
131. Agency for Healthcare Research and Quality Office of Minority Health (Section 10334, p. 2272)
132. Food and Drug Administration Office of Minority Health (Section 10334, p. 2272)
133. Centers for Medicare and Medicaid Services Office of Minority Health (Section 10334, p. 2272)
134. Grant program to promote small business wellness programs (Section 10408, p. 2285)
135. Cures Acceleration Network (Section 10409, p. 2289)
136. Cures Acceleration Network Review Board (Section 10409, p. 2291)
137. Grant program for Cures Acceleration Network (Section 10409, p. 2297)
138. Grant program to promote centers of excellence for depression (Section 10410, p. 2304)
139. Advisory committee for young women's breast health awareness education campaign (Section 10413, p. 2322)
140. Grant program to provide assistance to provide information to young women with breast cancer (Section 10413, p. 2326)
141. Interagency Access to Health Care in Alaska Task Force (Section 10501, p. 2329)
142. Grant program to train nurse practitioners as primary care providers (Section 10501(e), p. 2332)
143. Grant program for community-based diabetes prevention (Section 10501(g), p. 2337)
144. Grant program for providers who treat a high percentage of medically underserved populations (Section 10501(k), p. 2343)
145. Grant program to recruit students to practice in underserved communities (Section 10501(l), p. 2344)
146. Community Health Center Fund (Section 10503, p. 2355)
147. Demonstration project to provide access to health care for the uninsured at reduced fees (Section 10504, p. 2357)
148. Demonstration program to explore alternatives to tort litigation (Section 10607, p. 2369)
149. Indian Health demonstration program for chronic shortages of health professionals (S. 1790, Section 112, p. 24)*
150. Office of Indian Men's Health (S. 1790, Section 136, p. 71)*
151. Indian Country modular component facilities demonstration program (S. 1790, Section 146, p. 108)*
152. Indian mobile health stations demonstration program (S. 1790, Section 147, p. 111)*
153. Office of Direct Service Tribes (S. 1790, Section 172, p. 151)*
154. Indian Health Service mental health technician training program (S. 1790, Section 181, p. 173)*
155. Indian Health Service program for treatment of child sexual abuse victims (S. 1790, Section 181, p. 192)*
156. Indian Health Service program for treatment of domestic violence and sexual abuse (S. 1790, Section 181, p. 194)*
157. Indian youth telemental health demonstration project (S. 1790, Section 181, p. 204)*
158. Indian youth life skills demonstration project (S. 1790, Section 181, p. 220)*
159. Indian Health Service Director of HIV/AIDS Prevention and Treatment (S. 1790, Section 199B, p. 258)*