Managed Care Trends for Strategic Positioning

NELLIE JOHNSON A U G U S T 2 5 , 2 0 1 6

2012-13 Leading Age Michigan Conferences

Product◦ Medicare Advantage◦ ACOs; bundled payment starting (little

emphasis on SNF)

Pricing (how to contract with health plans)

Performance – readmissions / LOS

Today

Product, Pricing and Performance PLUS

Payors

Partnerships/Preferred Networks

Protocols

Prior Authorizations/Preadmission Screening

Person-Centered Care Coordination

Overview - The “P”s of Managed Care Trends

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Managed Care – Concept is Expanding to All Products with Various Partners

Medicare Medicare Advantage Medicare Fee for Service

◦ Accountable Care ◦ Bundled Payment Initiative ◦ Expanded Mandatory Bundles ◦ SNF Value based Purchasing

Medicaid Under 65 Dual (FIDA – Fully Integrated Dual Eligible Long Term Support and Services (LTSS)

Commercial

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Making the Transition to Risk-Based Medicare PaymentPopulation-Based Payment/ Shared Savings/Total Cost of Care

Fee For Service• No risk payments

• Common payments• Predictable

•New metrics•Best practices

•Performance based•Uncertainty

•Electronic communications

•Risk based•Collaboration

•Predictive modeling•Global budget or sub-

capitation

Significant Change

Significant Change

Bundled Payments•Negotiated Episode Price

•Longitudinal Accountability•Risk based

Significant Change

Value Based Reimbursement

No Shortage of Changes/Experiments

Medicare Advantage | National Enrollment

Medicare Advantage | National Growth –Implications

Managed Care – Implications of Population Shifts between Medicare and Medicare Advantage

50% of seniors turning 65 are selecting Medicare Advantage as insurance carrier

Medicare FFS population is aging and becoming more medically complex/fragile

Impacts availability to achieve savings under Medicare ACO/Bundled Payment Initiatives

Changes in Payer relationships/Need for Preferred Network status with ACOs, Bundled Payment and Hospitals

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Preferred Network• Health Plans • ACOs, bundled payment entities • Health System /hospitals –

referral source /payor• Relationships with physician

groups /Bundled Payment

Health systems• Sending out RFPs to form

SNF network• Building SNFs in

partnership with LTC providers

• Converting hospital space into SNF beds

Implications of Medicare Payment Reform –Preferred Network and Physicians

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More States Moving to Medicaid Managed Care Programs

Traditional Fee-for-Service (FFS)

Low or no care management or

care coordination

Enhanced PCP payment or case

management fees

Enhanced federal funding

for enhanced services

Full Risk-Based Managed Care

Higher level of care management

and care coordination with

P4P elements

Shared savings between MCO or

providers and state/feds

Full risk for savings and

losses (MA-SNPs, FIDE SNPs,

Medicaid only ACOs & MCOs)

Traditional Fee-for-Service

Health Home Model

Provider Sponsored

Organization -Share Savings

(ACO)

Waiver Programs (i.e. HCBS)

Primary Care Case

Management Model

Enhanced Primary Care

Case Management

ModelPartial Risk

MCO

Full Risk MCO &

ACO

Focus on the same -VALUE Readmissions to control overall

costs Readmissions to control

penalties/performance metrics Cost – as monitored by length of

stay Quality of care ◦ Scorecards◦ Nursing Home Compare

Health Plans Specific CMS performance metrics will target

plans who have Dual Eligible because of population differences Partner with them to meet these metrics More integration/consolidation of health

plans Dual Eligible Plans have savings taken off

the top and a quality withhold as an incentive to perform

Implications of Medicare/Medicaid Payment Reform –Performance Data

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CMS Final Comprehensive Care for Joint Replacement (CJR) Model Bundled Payment

CMS’ final rule requires all PPS hospitals in 67 Metropolitan Statistical Areas to participate in a Bundled Payment demo for a Lower Extremity Joint Replacement – MS-DRG 469 -470◦ 90-day episode post-discharge◦ Hospitals in these areas are required to participate unless already in a

BPCI model.

Goal: Reduce current variation in cost and quality of care for hip and knee replacements ($16,500-$33,000)

Annually set prices over 5 performance years

Payment reconciled at the end based on price & quality (Fee for Service with Reconciliation)

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CJR – Key elementsStarts April 1, 2016

67 Metropolitan Statistical Areas

Target price = 2% discount on current bundle cost (risk-adjusted)

Bundle includes all Medicare A & B services related to DRG

Hospitals only eligible to receive “savings” if meet quality

Hospitals permitted to share these savings with other collaborating providers (e.g., PAC)

Bundled Episodes: Comprehensive Joint Replacement(CJR) – Payments

All providers continue to be paid FFS

Hospital reconciles its CJR target price to actual price annually with CMS◦ Year 1: No repayment obligation◦ Year 2: repayment up to stop loss of 5%◦ Year 3: repayment up to stop loss of 10%◦ Years 4 and 5: Repayment up to stop loss of 20 %

Hospital is allowed to share: reconciliation payments, internal cost savings, and the repayments with certain providers and suppliers.

CJR – CMS Waivers for Care Delivery FlexibilityThree-day inpatient hospital stay prior to admission for a covered SNF stay

◦ Begins Year 2 of demo

◦ Only SNFs with 3-Star or higher rating are eligible

Payment for certain “in-home” physician visits to a beneficiary via telehealth

Payment for certain physician-directed home visits for non-homebound beneficiaries

Went from proposal to implementation in 9 months!!!!

CMS Announces Two New Mandatory Bundles on July 25, 2016 – Effective July 2017

1. Expanded CJR to include hip and femur fractures

2. Created new cardiac episodes for health attacks and bypass surgery

Pending- CMS notes round of voluntary bundling (BPCI) will start in Cy 2018

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Bundled Episodes – New Use By Health Plans for Medicare Advantage Members

1. Health Plans are contracting with Health systems/care coordination entity and paying capitated rate for 30 day episode

2. CONTESSA- “Contessa Health creates and manages home hospitalization programs. By partnering with Contessa Health, physicians are able to shift complex surgical procedures and chronically-ill patients to the most clinically appropriate site of care, allowing their patients to enjoy home-based recovery. Contessa Health provides clinical, administrative and technological resources to enable physician partners to deliver the highest quality outcomes in a prospective bundled payment arrangement.”

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What does this mean for PAC Providers?

Shorter lengths of stay –

Must control readmissions - -

No 3-Star or higher rating = no referrals without 3-day hospital stay;

. Hospitals may discharge direct to home with or without home health for these DRGs

Hospitals may discharge to SNFs earlier ( = shorter hospital lengths of stay)

How do you Strategically Partner with Entities

1. Clinical Protocols by diagnosis – develop with speciality groups/medical director

2. Control Length of StayA. monitor by diagnosis

3. Control Readmissions – Best Practices INTERACT Care Transitions (hospital-NH-Home)Person Centered Care Coordination

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How do you Strategically Partner with Entities

4. Need to be able to take hospital/ER admissions 7 days week/24 hours a day;

5. Therapy – Start eval/therapy on day admission;

6. Nursing Home Compare 3 Stars and above to accept admission without three day stay; Tell your story – rolling average of 2 yearsGive them other Nursing Home Compare scores;

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Brief Overview of INTERACT

INTERACT- Interventions to Reduce Acute Care Transfers FREE --Evidenced based clinical system that resulted in 20% reduction in readmissions from nursing homesHas moved from a INTERACT 2 took kit approach to INTERACT 4- QAPI

program LeadingAge Michigan offered two 8 hour workshops in March 2016 Some EMR (PointClick Care)- has integrated INTERACT tools into EMR

system

Website: http://www.interact4.net

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INTERACT Key ToolsQuality Improvement collection of data to complete root cause analsyis

Decision Support Tools Care Paths for six diagnostic Onsite capabilities to assess/treat conditions◦ CHF, Pneumonia, UTI, Acute Mental Status, Fever, Dehydration, lower respiratory,

dementia

Communication tools ◦ SBAR Communication tools◦ Stop/Watch

Nursing Home transfer form/Care transitions to ER

Website: http://www.interact4.net

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Successful Implementation of INTERACT

Research study completed by Dr. Joseph Ouslander, M.D. and published in JAMDA (Journal for American Medical Directors) noted following points to be successful:

Executive Leadership support (Administrator, DON, Medical Director, Clinical Pharm) Creates interdisciplinary team and promotes training Reviews and uses data to improve care

Engagement of Direct Care Staff by INTERACT Champion

Facility Culture dedicated to quality improvement Integrated into new hire orientation Part of QAPI program Training and implementation delivered using a nonpunitive approach When avoidable hospitalizaitons are identified, a spirit of inquiry by the multidisciplinary team seeks

improvement, not blame

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Best Practices: Overview Care Transitions ProcessDefinition of Care Transitions – “The set of actions necessary to ensure coordination and continuity of health care as patients transfer between different health care settings or levels of care.” (Coleman and Berenson. Ann Intern.med. 2004 140: 533-536) Four Critical Components of Safe Transfer * Medication reconciliation Patient Education (Coaching)◦ Resolve confusion over medications ◦ Identifying indicators of worsening conditions (red flags) and knowing who to call Communication between sending and receiving providers◦ Discharge summary /Care transitions plan ◦ Patient ◦ Propriety software ◦ Email and/or phone Timely Physician Follow up

*based on research and PPT presented at American Geriatric Society Convention 11/4/2009; “Safe Care Transitions – Bridging the Silos of Care”

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Care transition planning from hospital◦ Know readmission rate; work on

issues with hospital/pharmacy ◦ Take admits on 24/7 basis

Care planning within PAC Unit/LTC◦ Best practices/INTERACT◦ Root Cause Analysis of readmissions

Care transitioning to home ◦ Start at time of PAC admission◦ Connect to physician appointments ◦ Monitor patient (up to 60-90 days)

upon discharge to determine if plan was successful

Implications of Medicare Payment Reform –Person-Centered Care Coordination

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LeadingAge – Avalere Collaborative Reports- How do you use these reports

LeadingAge members have access to monthly reports from Avalere, however, the data is updated annually. This data is presented by market, by hospital, by PAC site and provider.

Avalere VantageCare Positioning System

Core AnalyticsPost-Acute Scorecard

Other Issues of ImportanceRole of the Medical Director Quality control monitoring/part of QI committee; development of protocols Troubleshooting with physicians TCU-oversight of model Separate medical director?

Control of Pharmacy CostsUse of genericsPharmacy contract

Interoperability- sharing of patient care information across provider groups

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Provider Responses to Trends/Health Care Initiatives Providers- do it alone

Join a Network

Consolidate Business/Sell

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How Did LeadingAge Michigan Respond to These Trends?

Formed SeniorCare Resources, for profit Limited Liability Corporation (LLC) LeadingAge Michigan owns 100% of this subsidiaryMission in Bylaws/Contracts: “Develop and support a clinically and financially integrated network of participants who work together with Network to maximize the health and well-being of seniors through innovative, cost effective care management practices and quality improvement activities with entities involved in managed care.”Structure allows Network to share data; meet antitrust concerns as well

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Network Year Formed

# of NH Homes

# of SNF Beds Member Criteria

CareChoice MN 1996 22 Members/37 NHs

4900 Not for profit with nursing home

Care VenturesMN

1999 18 1200 Not for profit

Florida (FAHA H&S)

2012 30 3125 LeadingAge member

Michigan-SCR 2013 21 2100 LeadingAge member

LeadingChoice/LCN/WI

2016 70 members/87NH’s

8100 LeadingAge member

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Summary -Dynamic and Changing Times 1. Managed care Initiatives are happening across all payor types

2. Requires providers to refine Clinical Practices /Protocols and implement best practices to managed length of stay and costs 3. Informatics/Data will be key to survival

4. Need to proactive – develop and refine scorecard and value proposition based on data

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