entering the new normal with the wind at your back leadingage … the new... · 2013. 5. 7. · a...
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© 2013 Health Dimensions Group Page 1
March 4, 2013
© HDG 2013
Presentation TitleEntering the New Normal with theWind at Your Back
LeadingAge New York
May 22, 2013
© HDG 2013
Entering the New Normal with the Wind at Your Back
Kathleen M. Griffin, PhDNational Director, Post-Acute and Senior [email protected]
May 22, 2013
© HDG 2013
Payment Driving Care Continuum Transformation
May 22, 2013 2
Risk Shifts from Government to ProvidersFee-for-Service Becomes Fee-for-Value
© HDG 2013
2013 - Majority Fee-for-Service. Early P4P, Shared Savings, Bundled Payment. Limited Capitation
2020 - Majority Fee-for-Value. Significant Capitation. Minority Fee-For-Service
2020: Majority Payment will be Fee-For-Value, Not Fee-For-Service
Why? What? How?And what can you do about it?
May 22, 2013 3
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© HDG 2013
Why Payment Reform: P4P, ACOs, Managed Care, Bundled Payment
May 22, 2013 4
TechnologyPoor
Population Health
More Aged Unsustainable Costs
© HDG 2013Source: JAMA Internal Medicine, Volume 173, No. 2 – January 2013
May 22, 2013 5
© HDG 2013
Shrinking Payments Make Current Business Model Unsustainable
• Hospitals lose 5% on Medicare; insurance payments and overall occupancy down and going lower
• FY 2013–2015, many hospitals will have penalties (Medicare takeaways) for excessive 30-day readmissions for 3-5 conditions and downward adjustments for value-based payment
• More Medicare and Medicaid managed care = rate declines, reduced ability to cost shift (SNF
= $30-$90)
• By 2015, hospital Medicare payments could be reduced by >7.5%
May 22, 2013 6 © HDG 2013
SNFs Proposal/LawNo MB increase in 2014; rebase payments by -4%/year MedPAC
Equalize payments (joints, pulmonary, other) for SNFs & IRFs President 2014
In 2017, reduce payments by 3% to SNFs with excessive hospital readmissions
President 2014
HHAs Proposal/LawRebase HHA payment in 2014, 4 years, max reduction = 3.5%/year-2 years, no MB increase, remove therapy visits as payment driver
ACA
$100 co-pay/non-post-acute HH episode for new beneficiaries, 2017President 2014 &MedPAC
Reduce MB increase by 1.1%, 2014-2023, for HHANo MB increase for HHA
President 2014 MedPAC
Bundle > ½ post-acute payments = -2.85 by 2020 President 2014(MedPAC-April)
ACA, Budget Proposals, MedPAC Squeeze Medicare SNF/HHA Payments
May 22, 2013 7
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Lower Payments = Providers Must Accept Risk to Survive
May 22, 2013 8
FFS Payment Reductions Readmission Penalties
Value-Based PurchasingPay-for-Outcomes
ACOs: Shared SavingsAcute/Post-Acute Bundling
Capitation (Population Health)/Managed Care
© HDG 2013
National Quality-Based Incentive Program for SNFs
• Contracting with 3 national SNF chains
• Convert payment system from per day/per bed level to quality incentive-based with shared savings– Blended rate for all beds instead of tiers, frees Aetna nurses
from arbitrating bed levels
• Contracting arrangement to share savings– Infrastructure requirements, clinical measures
• Financial incentive program – shared savings to be used to offset costs of additional SNF resources and infrastructure investments
Pay-for-Outcomes: Aetna’s Program for SNFs
May 22, 2013 9
© HDG 2013
Infrastructure Requirements
Physician and/or Nurse Practitioner coverage 40 hours per week
Rehabilitation services available at least 6 days per week
Direct admits from emergency room, 24 hours, 7 days per week
Aetna Quality Payment Incentive Program for SNFs
Clinical Measures
Patient and family meeting within one week of SNF admission
Enhanced discharge planning and member education program
Member’s PCP appointment scheduled prior to SNF discharge
Enhanced discharge information to Aetna with 48 hours of SNF discharge
Patient falls and pressure ulcer prevention program at SNF
SNF needs to meet infrastructure and clinical measures to be eligible for shared savings model
May 22, 2013 10
Shared Savings
SNFs receive blended per diem payment plus quarterly share of Aetna savings when payments below targets
© HDG 2013
A group of physicians and hospitals working together to manage and coordinate care for a defined population, that share in the risk and reward relative to the total cost of care and patient outcomes
Accountable Care Organization
ACOs and Shared Savings: Definition
May 22, 2013 11
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• Share in savings lower than target based on previous 3 years per capita Medicare payments, if quality measures also achieved
How Shared Savings Works (But Not Sharing with SNFs Yet)
May 22, 2013 12
ActualShared savings
ACO Launched
ProjectedTarget
Adapted from Brookings Institute
…to be distributed
among ACO participants
(docs, hospitals)
© HDG 2013
252 Medicare ACOs and More to Come
May 22, 2013 13Source: Avalere, April 2013
© HDG 2013
Not Just Medicare: Equal Number of Commercial ACOs (>20 in NY)
May 22, 2013 14
Source: Muhlestein, David, Continued Growth Of Public And Private Accountable Care Organizations, Health Affairs Blog, February 19, 2013, http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations/
Copyright ©2013 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.© HDG 2013
1• Attribution Risk Stratification: sorting out which
beneficiaries require intensive management and monitoring
2• Longitudinal Care Management
Implementation: developing model by which these beneficiaries will be managed (at home)
3• Developing Network of Post-Acute Providers:
attention now turning to continuing care networks
What are the ACOs Doing NOW?
May 22, 2013 15
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ACO’s Selection Criteria for SNFs (Getting into the Network)
A Pioneer ACO’s Criteria for Selection of SNFs
Patient Experience
Case Managers/Physicians’ Experience
Hospital Readmissions
SNF Length of Stay, Cost
High Volume Discharges
ACO Network Physician/NP in SNF
May 22, 2013 16 © HDG 2013
Metrics for SNFs ExpectationACO patients who 'probably' or 'definitely' would recommend SNF to others > 90%
Patients readmitted for all cause, all diagnoses from SNF to acute care setting in 30 days or less from discharge from acute care setting
< 10%
Within 72 hours of SNF admission, number of patients referred to Emergency Department (ED)
< 10%
Patients discharged from SNF to home with home health safety evaluation
> 80%
Patients discharged from SNF to home with evaluation for home health agency (HHA) services > 80%
SNF ALOS ≤ 27.2 days > 80%
Patients who die receiving hospice care > 80%
A Pioneer ACO’s Selected Metrics for SNFs (Staying in the Network)
May 22, 2013 17
© HDG 2013
“These transformational models are no longer isolated pilots. They [ACOs and Bundled Payment Initiatives] are becoming the face of American medicine.”
May 22, 2013 18
Kathleen Sebelius, HHS Secretary to the American Medical Association, February 12, 2013
© HDG 2013
Medicare Bundled Payment Initiatives and Future Pilot, 2013
Providers at risk for all episode costsManage the bundle:
– Reduce hospital LOS
– Use lower cost settings
– Reduce rehospitalizations and ED visits
– Use care transitions and care management after post-acute
Source: Avalere, April 2013 May 22, 2013 19
Other, Part B5%
Acute Inpatient
30%
Readmission15%
Post-Acute Care30%
Hospital Outpatient
5%
Physician Services
15%
Average Episode Cost: $30,000(Hypothetical)
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Post-Acute Providers Likely to Feel Impact of Bundling Before ACOs
May 22, 2013 20
First Setting Avg. Medicare Episode PaymentHHA $20,345SNF $29,218IRF $44,193
LTCH $89,869STACH $29,713
Source: Dobson/DaVanzo analysis, 2007-2009. Clinically Appropriate and Cost-Effective Placement Project,Alliance for Home Health Quality and Innovation, www.ahhqi.org, 2013
HHAs and SNFs Win in Post-Acute Episode Costs – All Diagnoses
© HDG 2013
Heart Failure: Home Health Wins
May 22, 2013 21Source: Dobson/DaVanzo Analysis of 2008 Medicare Claims, 2012
Home health best, SNFs second in episode cost that includes post-acute (unless readmissions)
© HDG 2013
Before Leaping Into Bundling, Know Costs by Condition, Co-Morbidities
• Age 70+
• Lives alone
• Cognitive impairment
• 6+ medications
• 2+ chronic conditions
• Multiple ADL impairments
• Multiple hospital readmissions –6 months
• Suspected non-adherence to diet or medication
Poor Discharge Outcomes
Adverse selection will kill your bundle: know your
average costs and standard deviations for
highest risk patients
Source: Bowles, et al. Patient Characteristics at Hospital Discharge and a Comparison of Home Care Referral Decisions. JAGS 50:336-342, 2002 May 22, 2013 22 © HDG 2013 Source: DataBrief (2011)
Managed Care (Population Health) Pushes Risk to Providers
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCOUT
TX
NMSC
FL
GAALMS
LA
AR
MO
IA
VA
NCTN
IN
KY
IL
MIWI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
D.C.
20% to <25%25%+
15% to <20% 10% to <15%
NY Has High Volume Dual Eligiblesas Percent of Total Medicare Population
May 22, 2013 23
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NY’s Movement of 123,000 Duals to Fully Integrated Care
May 22, 2013 24
July 2012
• Start with Medicaid MLTC enrollment for dual eligibles needing LTSS
April 2014
• Mandatory dual eligible enrollment in integrated Medicare and Medicaid plan
Certain NY providers preparing with MLTC PlansVolume essential for margin and big plans are lying in wait
© HDG 2013
• Health plans will receive capitated paymentsand have quality incentives
• In turn, payment to contracted providerswill be based on outcomes, not volumes– Responsible for total costs of population,
regardless of care setting
– Strong incentives to prevent utilization of costly, facility-based care and substitute HCBS care
– Payments based upon assumed savings
– Payments will have overall reduction in payment that can then be earned back through high-quality performance
Duals’ Health Plan Incentives
May 22, 2013 25
© HDG 2013
Hospital Acute Care
Subacute Skilled Nursing Facility
Traditional Long-term Care
Assisted Living
Supportive Housing
Skilled Home Care
Home- and Community-BasedServices
P4P, ACOs, Bundled Payment, Managed Care/Capitation
Payment Changes’ Impact on Your Business
May 22, 2013 26 © HDG 2013
Acute hospital use will decline dramatically
More care shifts to subacute SNF/home care
Referrals to SNFs/HHAs no longer sent to any willing
provider
SNFs/HHAs must develop clinically integrated care from acute to
post-acute to community
Bundled payment and managed care will change models of care and increase integration of care
Capacity to manage risk in future key to bundled and capitated payment
Traditional nursing home use will drop
Volume of care provided in AL and IL increases
Care will be provided in least costly and most effective setting
Palliative care emerges as covered service; hospice and home care use
increases
What Does This Mean for You?
May 22, 2013 27
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• Providers willing to take payment risk (e.g., MLTCs)
• Bundlers
• Care Management
• Providers that fill need for managed care organizations and ACOs
Road Map Being Developed by Aging Services Providers Willing to Take Risk
© HDG 2013 May 22, 2013 28 © HDG 2013
ACO’s Population Health ConundrumPopulations are not homogenous, especially seniors
Each cohort requires a different care management strategy
May 22, 2013 29
Healthy Seniors Chronic Disease Frail, At-Risk
ApproachAnnual phone contact
Non-clinical staff – 1:1000
ApproachNavigators, Health
Coaches, CCW/LSW/RN – 1:100
ApproachHigh Intensity MedicallyComplex Management
RN/LPN – 1:35
© HDG 2013
Care Management Challenges ACOs
May 22, 2013 30
Longitudinal care management is not core skill for most acute health systems…or primary care physicians.
Home PCP Hospital PostAcute
Home
Care Continuum
Hospital’s HistoricalAttention Span
© HDG 2013
No Shared Savings for ACOs if Cannot Manage Chronic Diseases
May 22, 2013 31
¼ of seniors with 4+ chronic conditions = 80% of health care dollars
01%
13%
26% 3
10%
412%
5+68%
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© HDG 2013
One ACO’s Solution to Managing Beneficiaries with Chronic Diseases
•Personal care coordinator added to primary care team (physician’s office/health home) to act as “air traffic controller”
•Connects care team around beneficiary with chronic diseases, augments work of physicians, nurses, social workers, case managers
Allina, Pioneer ACO Imperative: Provide integrating care management across the continuum
May 22, 2013 32 © HDG 2013
• KY ACO – Pays private duty agency for 3 home visits after discharge– Tasks: medication reminders, clean house, help with
meal prep, reminders about physician appointments or exercises, hygiene assistance, simple transfers
– Report back to ACO case manager
– Payment: $30/visit for three visits
– Focus on patientsidentified as high riskfor re-admission(20+% of discharges)
Another ACO’s Solution to Managing Readmissions
May 22, 2013 33
© HDG 2013
• Risk-based Care Management– Permanent supportive housing
stabilizes lives, supports better self-management
– Affordable housing with services can coordinate care for residents through social-medical model of care
– Total lower costs of care achieved through reduced ER and hospital costs
Housing as Care Management Intervention
May 22, 2013 34 © HDG 2013
• NCR will partner with Aetna and receive payment for providing certain services that achieve quality outcomes and pay for cost of NPs on site
• NCR will partner with CareSource to develop and operate affordable housing units for disabled and mentally ill members who would otherwise go to nursing home; medical care would be provided on site
Care Management Risk-Based Payment: NCR and Ohio Duals Plans
May 22, 2013 35
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Fee-for-value: What Can You DoAbout It?
May 22, 2013 36
Be financially stable now
Manage medically complex
patients very well
Partner with physicians,
hospitals and payors
Excel at cross continuum
chronic care management so you can
take payment risk
© HDG 2013
If you think you can run your company the next ten years the way you ran it the last ten years,
you are out of your mind…”
CEO Coca-Cola
If you think you can run your company the next
ten years the way you ran it the last ten years, you are out of your mind…”
CEO, Coca-Cola
© HDG 2013
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