Optimizing Post-Acute Care Services in Population …...facilitates the flow and analysis of...

Optimizing Post-Acute Care Services in Population Health April 3, 2013

2

PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC.

Key objectives !  Provide background on population health and its impact

on PAC providers !  Discuss capabilities required / associated with post-acute

care coordination !  Share case studies and examples

Contents !  Background !  Post acute care (PAC) costs and utilization !  Strategic considerations !  PAC assessment tool

Table of contents

Population Health Background

4


“Americans always do the right thing, after they have tried everything else”

– Winston Churchill

5


Integration & new payment models Deliver continuous improvement in clinical cost and quality

Population Management •  Population analytics •  Care management •  Financial modeling and

management •  Legal •  Physician integration

and leadership •  Covered lives

High Value Episodes •  DRG and episode

targeting •  Care models •  Gainsharing •  Data analytics •  Cost management •  Physician integration

High Performing Hospitals •  Cost management •  Waste elimination •  Best outcomes in quality,

safety •  Satisfied patients •  Physician alignment •  Growth strategies

Proliferation of solutions and uncertainty around successful models of the future heightens risk; Replicate those strategies and operations that are already successful.

MOVEMENT TO INTEGRATED CARE, NEW PAYMENT MODELS & RISK

Bundled payment

Shared savings

Value-based purchasing: HACs, quality, efficiency Global payments

Reimbursement cuts Medical home

6


Medicare Bundled Payment Initiative Over 500

7


!  CMS has begun it’s “no risk” period and preparing agreements for this initiative

!  Model 1, a retrospective model across all MS-DRGs, is expected to begin in April

!  Models 2 – 4 are expected to begin operating in July • Model 2 – acute care hospital stay plus 30+ days post acute care

with retrospective reconciliation • Model 3 – post acute care only with retrospective reconciliation • Model 4 – acute care hospital stay only with prospective payment

CMMI’s Bundled Payments for Care Improvement Initiative

8


Medicare ACOs across the country

8

NJ

DE MD

WA

IL

LA

AR

MO

IA

MN

KS

NE

SD

ND MT

WY

CO

NM

ID

UT

AZ

NV

CA

OR

MA

RI CT

SC

NC

VA WV

PA

VT

NH

ME

FL

GA AL MS

TN

KY

MI

OH IN

DC

MO

NY

TX

OK

NATIONWIDE GROWTH

WI

Medicare ACO’s 20+ 10-19 5-10 2-4 1 0

HI

AK

9


!  254 Medicare ACO’s in 43 states • First ACOs (10 organizations) part of the PGP demonstration

project beginning in 2006 (sunset 12/31/12)

!  32 CMMI “Pioneer” participants, program began 1/1/2012 • Roughly 30% physician organization-led

!  Medicare Shared Savings Program •  4/1/2012: 27 ACOs selected to participate

» Majority of organizations physician-led •  7/01/2012: 89 ACOs selected to participate •  1/1/2013: 106 ACOs selected to participate

Growing number of Medicare ACOs

10


Complete view of accountable care

ACO CEO

COO CFO CMO CNO CQO

Payer Partners

People Centered Foundation will ensure that the first principle for

accountable care design and ongoing operations is to enable all people within the AC community to meet their needs and desires for

good health.

Health Home redesigns primary care to create a new PCP model

that provides people centric care as well as care guidance to the

practice population.

Payer Partnerships - focused on the framework necessary for the network

to develop and maintain mutually advantageous relationships with AC

payer partners (plans and employers).

AC Leadership addresses the strategic leadership and operational infrastructure

necessary to support a successful network that is organized around

Triple Aim goals.

Population Health Data Management facilitates the flow and analysis of

clinical, financial, and patient related data and information across all components of

accountable care delivery system.

High Value Network delivers provider networks that will

optimize care delivery within and across the continuum and

ensure that care is coordinated.

11


The High Value Network will deliver provider networks that will optimize care delivery within and across the continuum and ensure that care is coordinated.

High Value Network

Key Attributes: •  There is a wide range of clinical providers and

facilities supporting primary care practices •  Care models across the health system define how

care is consistently delivered to patients •  How and when patients move between sites of

care is actively managed and supported •  The entire health system is focused on improving

the health and costs of the population it serves

12


Post Acute Spectrum

Key ACO Attributes: •  Person-Centered Foundation •  High-Value PAC Network •  Payer Partnerships •  Leadership •  Post-Acute Care Coordination •  Population Health Data Management

The Post Acute Spectrum serves as a step down from the intense acute hospital services and a partner in management of chronic conditions.

13


!  Has your organization identified your accountable care partner(s)?

!  Have you assessed your capabilities relative to managing a population?

!  For those that have, have you taken those results to accountable care networks?

Context setting questions

PAC costs and utilization

15


Payment Models

Physician Outpatient Hospital and

ASCs

Inpatient Acute Care

Long Term Acute Care

Inpatient Rehab

SNFs Home Health Care

RBRVS APC MS-‐DRG MS-‐DRG RICs RUGs HHRGs

VBP modifier plan published on 11/1/11

Implement in FY2013 PFS

P4R in FY2013; VBP

implementaJon plan submiKed to

Congress on 4/18/11

VBP commenced 10/1/12

P4R in FY14: VBP test pilot by 1/1/16

VBP test pilot by 1/1/2016

VBP impl. plan sent to Congress 6/15/13

VBP impl. plan to Congress overdue (10/1/11 deadline)

Accountable Care Organizations

Trac

k Tw

o Tr

ack

One

Value Based Purchasing across payment silos

Post-Acute Care Episode Bundling

Acute Care Bundling

Medical Home

Acute and Post-Acute Care Episode Bundling

Will Congress speed up VBP and create national Bundling Program in CY 2013?

16


Medicare spend on post acute care

Managed care spending is not included in this chart. Source: CMS, Office of the Actuary (Healthcare Spending and the Medicare Program MEDPAC, June, 2012)

26.6

32.6 34.337.5

42.1 43.5

48.651.9

55.758.0

63.5

12.114.8 15.0 16.7

18.6 19.622.4 24.2 25.8 27.0

31.8

8.09.6 10.1 10.8 12.6 13.0 15.4 16.9 18.8 19.4 19.6

4.5 5.7 6.2 6.4 6.5 6.3 6.1 6.0 6.0 6.3 6.7

2.0 2.5 3.0 3.6 4.4 4.6 4.7 4.8 5.1 5.3 5.40.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

$ in billions

Medicare Spending on FFS Post-‐Acute Care 2001-‐2011All post-‐acute care

Skilled nursing facilities

Home health agencies

Inpatient rehabilitation hospitals

Long-‐term care hospitals

17


Summary of ACO expenditures

Home health alone could generate over 3x the savings as inpatient expenses

NOTE: Client example; costs not severity adjusted

Expense for ACO Assigned Beneficiaries

All MSSP ACOs

Impact of 5% Cost

Reduction

Impact of Reaching

MSSP Average

Total $11,494 $9,824 $7,308,138 $21,236,584

ERSD $69,541 $65,029 $740,612 $961,103 Inpatient $3,550 $3,200 $2,257,328 $4,458,411

Skilled Nursing $1,088 $891 $692,058 $2,609,422

Home Health $1,664 $527 $1,012,427 $14,462,779

18


MSSP results of first year # of beneficiaries

1st 27 375,000Next 88 1,200,000Total 1,575,000

1/1/2011 -‐ 12/31/2011 1/1/2012 -‐ 12/31/2012 ∆All ACOs All ACOs % Improvement

Total Expenditures per Assigned Beneficiary Status2, 4

Total 9,832 9,895 -‐0.64%

Component Expenditures per Assigned Beneficiary3

Inpatient4 3,305 3,236 2.08% Indirect Medical Education (IME)4 135 131 3.52% Disproportionate Share Hospital (DSH)4 310 315 -‐1.69%Skilled Nursing Facility 867 732 15.61%Institutional (Hospital) Outpatient 1,449 1,597 -‐10.21%Part B Physician/Supplier 3,454 3,253 5.82%Home Health 484 538 -‐11.11%Durable Medical Equipment 317 309 2.53%Hospice 196 228 -‐16.33%

Transition of Care/Care Coordination Utilization30-‐Day All-‐Cause Readmissions Per 1,000 Discharges5 158 147 6.96%30-‐Day Post-‐Discharge Provider Visits Per 1,000 Discharges 785 780 0.64%

Additional Utilization Rates (Per 1,000 Person Years)Hospitalizations6 378 340 10.15%Emergency Department Visits 672 662 1.44% Emergency Department Visits That Lead To Hospitalizations 250 226 9.70%Computed Tomography (CT) Events 639 643 -‐0.67%Magnetic Resonance Imaging (MRI) Events 303 259 14.67%Primary Care Service Visits7 With a Primary Care Physician8 4,609 4,144 10.09%With a Specialist Physician9 4,766 4,222 11.42%With a Nurse Practitioner/Physician's Assistant/Clinical Nurse Specialist10 553 648 -‐17.11%With a FQHC / RHC11 47 36 24.10%

Ambulance Events 855 694 18.81%

Medicare Shared Savings ProgramBenchmark Period Aggregate Expenditure/Utilization Trend Report

All ACO -‐ comparison of 2011 and 2012 expenditures and utilization statistics

19


Post Acute Care -‐ 1-‐30 Days after Discharge

Cost Categories Hospital Total HRC Hospital Total HRCNationwide Average

Well-‐Managed Benchmark Hospital Total HRC

Part AInpatient Readmissions -‐ Facil ity *** $796 $1,110 8.3% 11.9% 9.5% 6.2% $9,590 $9,330Acute Inpatient Rehab -‐ Facil ity $634 $308 4.2% 1.8% 2.0% 1.1% $15,089 $17,087Long Term Acute Care (LTAC) -‐ Facil ity $0 $57 0.0% 0.2% 1.1% 0.9% $0 $28,400Skilled Nursing Facil ity -‐ Facil ity $3,201 $3,120 25.0% 26.8% 18.6% 10.8% $12,802 $11,641Home care ** $1,278 $1,034 62.5% 45.7% 34.5% 30.2% $2,044 $2,263

Part BInpatient Readmissions -‐ Professional $110 $130 8.3% 11.9% 9.5% 6.2% $1,325 $1,094Acute Inpatient Rehab -‐ Professional $3 $7 4.2% 1.8% 2.0% 1.1% $68 $369Long Term Acute Care (LTAC) -‐ Professional $0 $2 0.0% 0.2% 1.1% 0.9% $0 $1,035Skilled Nursing Facil ity -‐ Professional $16 $44 25.0% 26.8% 18.6% 10.8% $62 $164OP rehab $0 $0 0.0% 0.2% -‐ -‐ $0 $130Part B drugs $0 $3 0.0% 2.0% -‐ -‐ $0 $172Other outpatient facil ity (lab, radiology, etc) $6 $27 8.3% 12.3% -‐ -‐ $77 $220Other outpatient professional $8 $29 12.5% 20.3% -‐ -‐ $63 $142Other outpatient (including DME) $7 $33 4.2% 5.2% -‐ -‐ $159 $643

Total Post Acute Care -‐ Part A and B $6,057 $5,904

Average Allowed Cost per Patient*

% of Anchor DRG Admissions with Some Util ization in Category

Average Allowed Cost per Service for those

with a Claim for Service

Episode of care utilization of post acute services MS-DRG 330 - Major small & large bowel procedures w CC

Strategic considerations

21


!   Conduct an inventory of PAC providers in the community and assess their performance?

•  How to assess performance? The most appropriate site for info is www.medicaregov.org - nursing home compare. Includes staffing, 3 years of regulatory results, quality measures, bed size, ownership, LOS, historical RUGS data.

•  PAC capabilities assessment tool

!   Narrow the list to high performers to approach

!   Decide how to partner with PAC providers going forward •  Hospitals and health systems that are developing bundled payments,

accountable care and other population health management strategies will have to determine how to align with PAC providers.

•  Three choices that are currently available include owning, outsourcing or joint venturing.

Strategic considerations – from the ACO perspective

22


!   Knowledge and understanding of industry trends •  What do we need to learn and how will we learn it?

!   Knowledge of the market(s) / environmental scan (external) •  Referral patterns and utilization of post-acute care •  Market data Review •  Physician practice strategies/ hospital & physician alignment •  Payer strategies •  How fast is the market moving towards integrated care •  Continuum strategies •  Competitor intelligence •  What are potential collaborators in the market doing

!   Internal assessment •  PAC assessment Tool •  Culture •  Fluidity / ability to change •  Capacity for new service development / innovative care delivery

approaches

Strategic considerations – from the PAC perspective

PAC assessment tool

24


Attributes of a post acute partner (1)

Minimum Requirements Ideal Requirements Post Acute Continuum

Single service Source for full continuum, from skilled nursing to palliative care

Access for Qualified Patients

Admits <10% of a hospital’s post acute patients

Guarantees for access & placement of 100% of patients in need

Location Within the hospital’s service area Locations close to population clusters

Clinical Quality Scores

Quality scores similar to local averages

Better scores than other local providers and in the top quartile nationally

Service Quality

Similar to other local providers Demonstrably better than local providers

Patient Satisfaction

Scores close to local average scores

Better than acute provider’s satisfaction scores

25


Attributes of a post acute partner (2)

Minimum Requirements Ideal Requirements Case Management

Manages cost and quality control for services offered

Participates in management across episode of care

Patient Compliance

None Innovative systems to help track and manage compliance

EHR Ability to receive and transmit basic patient information

Provides cost and care information in a manner that allows for analysis

Medical Champions

Passive Medical Directors Physicians helping to drive improvement

Vision Targets for the cost and quality of service provided

Concept of the future and action to plan to achieve it with the help of its partners

Leadership Can competently manage the services being provided

Can help anticipate future needs and respond in an appropriate manner

Cost Proportionate to above measures

Value added

26


Post acute care coordination models

27


!   Population health management, whether it be through an ACO or an episode of care, is expected to connect groups of providers across the care continuum that are willing and able to take responsibility for improving the health status, efficiency and experience of care for a defined population.

!   The Post-Acute Care (PAC) Capabilities Framework is intended to provide organizations with a tool to assess a PAC provider’s current level of performance and readiness as it relates to the implementation of population health management principles.

!   It can be used to inform acute care providers who are developing ACOs or bundled payments with information regarding which PAC providers should be considered for partnerships and/or preferred provider status.

PAC Capabilities Framework: Overview

28


!   The assessment is meant to be used by a number of different audiences.

•  Provider systems that are developing accountable care organizations and the network to serve that population can use this tool to assess potential PAC partners they might want to have as a part of the full continuum of care.

•  PAC providers that are not currently associated with an accountable care network can assess their capabilities and take the results to large provider systems to point out that they would be a good partner in the accountable care network.

•  PAC providers that are part of a PAC system or stand-alone providers.

PAC readiness assessment

29


PAC core capabilities (1)

Core Capabilities Example Capabilities

Example Operating Activities

Person-Centered Foundation Patient and caregivers at the center, honoring preferences, coordination, education, patient satisfaction scores, service, etc.

Involve people in decisions that affect their health care

Individualized Care Plans, Navigation/Coordination, Advanced Care Planning

High-Value PAC Network Source of full PAC continuum, access, coordination, transitions, and partnerships/affiliations

Full PAC continuum, Transitions of Care across care settings

Skilled to Palliative Care, Measurements for readmissions and evaluative improvement systems in place

Payer Partnerships Focused on the framework necessary to develop and maintain mutually beneficial relationships with payers; ability and/or willingness to perform under a variety of reimbursement structures

Value Based Purchasing

Willingness to work with a variety of reimbursement models and takes accountability for outcomes

Leadership Vision and strategy evident; corporate infrastructure, retention, partnerships /alliances, and culture

Vision and Strategic Planning

Evidence that strategic planning occurs; leadership involvement in creating alignment with ACO initiatives

30


PAC core capabilities (2)

Core Capabilities Example Capabilities

Example Operating Activities

Post-Acute Care Coordination Use of evidence based medicine and clinical pathways, care transitions and coordination interventions, ability to accept medically complex patients, guaranteed access, medical champions, and in alignment with 33 quality indicators (Medicare Shared Savings Program)

Delivery of High Quality Post Acute Care

Medication Management, Chronic Disease Management, Use of Care Path Programs

Population Health Data Management Able to analyze clinical, financial and patient information; data exchange among providers

Data Analysis and Exchange

Capture & Analyze data across multiple sources and exchange data across the care continuum

31


Post Acute (Home Health) Capabilities Framework: Sample Subset

POST ACUTE CARE CAPABILITIES FRAMEWORK: Home Health

PAC Component Capability Operating Activity Description of Operating Activity to help score status

High Value PAC Network

II.A. Provides full PAC continuum

II.A.1.System has full PAC continuum, from skilled care to palliative care

Baseline: Single Service Credentialed, Partnerships with other PAC providers. Partner: provides most services Driver: Source for full continuum


II.B.1. Admission Capabilities The HHA has a written process for accepting patients that is based on its ability to provide the care, treatment or services required. Admission capabilities have been assessed, and the organization puts the necessary resources, oversight and staff development processes in place to enable them to receive and care for all levels of acuity appropriate for a home care setting.


II.B.2. Within the hospital’s service area

Locations close to ACO's population and/or related affiliated clinics and service providers. 24/7 coverage


II.C.1. Identifies and partners with ancillary care providers

Outsources/contracts for ancillary services such as lab; x-‐ray; podiatry; rehabilitative therapies. Selection standards for screening and performance of ancillary providers are identified and followed -‐ including but not limited to their involvement in the IDT plan of care. Selection process includes an evaluation of willingness to share efforts and responsibility for reduction of readmissions and quality outcomes for patients.


II.C.2. Identifies partners essential to success in reducing readmission rates/ER visits

HHA initiates/participates in a collaborative effort with hospitals and other PAC providers to reduce hospital readmission rates and ER visits. Metrics and best practices are studied. Shared processes and work flows are analyzed and improved (e.g.. Method with which patient information is shared during transitions in care). The culture established is one of shared responsibility.

II.B. Access

II. C. PAC collaborates to facilitate high-‐

quality partnerships

32


Capabilities Framework: Demonstration of Scoring System

POST ACUTE CARE CAPABILITIES FRAMEWORK: Skilled Nursing Facility (SNF)

PAC Component Capability Operating Activity Score Weight

Total Score Per

"Operational Activity"

Total Score Per Capability

Percent of Implementation per Capability

Total Score per

Component

Percent of Implementation per Component

Post Acute Care Coordination

V.A.9 . Infection Control

0.8 0.0

PHDM VI.A. Support Data Analysis

VI.A.1. Capture and analyze data from multiple sources

0.8 0.0

0.0 0%

PHDM VI.B. Data ExchangeVI.B.1. Data exchange across care continuum

0.8 0.00.0 0%

PHDM VI.C. Support Clinical Practice

VI. C.1. Clinical Record Platform

0.8 0.0

0.0 0%

V.A. Deliver High Quality Post Acute

Care0.0 0% 0.0 0%

0.0 0%

33


34


Brent Hardaway Vice President, Population Health Management

Premier healthcare alliance Telephone: 512-657-2225

Email: [email protected]

Lori Peterson Collaborative Consulting

Telephone: 866.332.3923 Email: [email protected]

Contact information

Appendix

Optimizing Post-Acute Care Services in Population …...facilitates the flow and analysis of...

Documents

Transcript of Optimizing Post-Acute Care Services in Population …...facilitates the flow and analysis of...