Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 1
GROWING PACE WHILE NAVIGATING
COMPETITION
NATIONAL PACE ASSOCIATION ANNUAL MEETING
OCTOBER 24, 2016
PANEL PRESENTATION AND DISCUSSION
2
PACE in the World of Value-
Based Care
Jade Gong, RN, MBA Principal, Jade Gong & Associates
Edo Banach, JDPartner, Gallagher, Evelius & Jones
PACE Innovation With and
Without Innovation
PACE Expansion at Trinity
Health PACE
Anne LewisVP, Trinity Health PACE
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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3
TARGET MARKETSERVING THE 8.2 MILLION DUAL ELIGIBLES WHO
ARE NOT NOW IN ORGANIZED SYSTEMS OF CARE
Source: Bipartisan Policy Center, Delivery System Reform: Improving Care for Individuals Dually
Eligible for Medicare and Medicaid, September 2016, page 18
8.2M
2.1M
Dual Eligibles
Not in System of Care In System of Care
* Includes enrollment in MMP, FIDE and PACE in 2015
4
• Center of gravity for patients,
families: where patients want to be
• Most illness, suffering, coping,
caregiving take place in the home
• Failure of home care environment
leads to hospitalization as care of
last resort
• Less than 3% of total health care
spending, but…
• 50% of total health care effort
- Very little research or medical
education in this setting
- Little-to-no professional medical
attention
PAYOR FOCUS ON CARE @ HOME
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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5
EMERGING RISK-BASED PAYORS NEED
ASSISTANCE WITH LONGITUDINAL CARE
MANAGEMENT @ HOME AND ACROSS SETTINGS
Home PCP SNF HHAOther PAC
Home
Hospital
Current Focus
Lily Tomlin
6
The tipping point is that
magic moment when an idea,
trend, or social behavior
crosses a threshold, tips,
and spreads like wildfire.
Malcolm Gladwell
Author, The Tipping Point
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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SCALING “CLASSIC” PACE AND NEW PACE
Traditional
PACE
Accelerants
• Flexibility with primary care, community-
based physicians and core assessment
team (proposed)
• Telehealth and home-based technologies
• For Profit PACE / Venture Capital
• New populations allowed by Innovation
Act (PD/IDD, under age 55, not yet NH
eligible)
Scaled
PACEFor Traditional and
Expansion Populations
7
• Grow “classic” PACE and consider “new” PACE
• Partner with other plans taking risk for high
cost/high need populations
• Consider other innovative models such as
MediCaring Communities
• You growth plan should assess:
- Where are the emerging opportunities in your
local market?
- Where can PACE infrastructure and expertise
add value and improve care?
8
DEVELOPING YOUR GROWTH PLAN
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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INNOVATION: PACE AS A MEDICARING
COMMUNITY
Source: Gretchen J Lynn, MediCaring Communities: Getting what We Want and Need in
Frail Old Age at an Affordable Cost. Altarum Institute, 2016. Available on Amazon.com
9
VALUE-BASED PAYMENT ACCELERATES
CMS Target 50% of FFS
payment through APMs
by 2018
Health Care Transformation Task Force Target of 75% through
Value-Based Payment by 2020
MACRA Physician Payment Report APM Incentives
begin in 2019
10
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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MEDICARE ALTERNATIVE PAYMENT
MODELS IN 2018 AND BEYOND
Medicare 2016
69 % FFS
34 % Alternative Payment
ACOs Bundled Payment
34% FFS
31 % Medicare
Advantage
CMS has
already
reached its
2016 target of
30%
alternative
payment
11
NEW PHYSICIAN PAYMENT 2019
12
Beginning in 2019, physicians will receive a 5 % bonus if a
significant proportion of revenue from APMs
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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Fully Integrated Dual Eligible Special Needs
Plan (FIDE SNP)
13
COMPETITORS – DUAL ELIGIBLE PLANS
PACE
Medicare and Medicaid Plan (MPP)
Financial Alignment Demonstration
Medicare ACOs
14
COMPETITORS AND COLLABORATORS
Medicare Advantage
Plan
D SNP MLTSS
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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• An ACO should have a financial incentive to reduce the total costs of care for a Medicare beneficiary and manage care across settings
• However, most ACOs have not accepted downside risk(about 5 %)
• Complex care management is not a priority for ACOs that do not have downside risk
• There are more Physician Group Practice sponsored ACOs that hospital sponsored ACOs; more PGP sponsored ACOs achieved shared savings
• Substantial ACO growth in models with downside risk expected due to MACRA incentives on physicians
Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/MSSP-ACO-data.pdf
STATUS OF ACOS TODAY
16
ACOS PAID VIA SHARED SAVINGS:
MEDICARE EXAMPLE• Current average per-capita spending for Medicare patients in
market area determined from claims for past three years
• Spending target is determined by CMS
• If actual spending lower than target, savings are shared IF quality targets are also achieved
16
ActualShared Savings
ACO Launched
TargetProjected
Adapted from Brookings Institute
Today, only 5% of
Medicare ACOs
have downside
risk. Change by
2019.
Growing PACE While Navigating Competition
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October 24, 2016
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Pioneerupside & downside
risk
MSSP
Track 1
upside risk only
MSSPTracks 2 & 3
upside & downside risk
Next Generation
upside & downside risk
17
THREE MEDICARE ACO MODELS WITH
DIFFERENT LEVELS OF RISK BEARING
Only ACOs with downside risk have
strong incentives to manage care
CONTINUED MEDICARE ACO GROWTH *
18
146
243
353
404
460
0
50
100
150
200
250
300
350
400
450
500
2012 2013 2014 2015 2016
Medicare ACOs
66%
45%
14%
14%
* Includes MSSP, Pioneer and Next Generation ACOs
Growing PACE While Navigating Competition
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October 24, 2016
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19
ACO PENETRATION VARIES BY STATE
Source: http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-
private-and-public-sector-growth-and-dispersion/
• There has been a steady growth in MA
enrollment from 19 percent in 2007 to 31
percent in 2016
• 23 states have a MA penetration of at least
30 percent
• D-SNP and MLTSS integration show promise
in integrating care
20
STATUS OF MEDICARE ADVANTAGE PLANS
TODAY
Growing PACE While Navigating Competition
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October 24, 2016
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21
MEDICARE ADVANTAGE GROWTH CONTINUESDEFACTO PAYMENT REFORM – NATIONAL ENROLLMENT 31%
Source: Gretchen Jacobson, et al., as published on Kaiser Family Foundation May 11, 2016,
http://kff.org/medicare/issue-brief/medicare-advantage-2016-spotlight-enrollment-market-update/
22
OVERALL MEDICARE ADVANTAGE PENETRATION
AT 31% BUT GREAT VARIATION ACROSS STATES
Source: Gretchen Jacobson, et al., as published on Kaiser Family Foundation May 11, 2016,
http://kff.org/medicare/issue-brief/medicare-advantage-2016-spotlight-enrollment-market-update/
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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23
D SNP ENROLLMENT VARIES BY STATE
Source: Kaiser Family Foundation State Health Facts. Medicare Advantage:
Special Needs Plan (SNP) Enrollment, by SNP Type http://kff.org/medicare/state-
indicator/snp-enrollment-by-snp-type. Retrieved 10/201/16
• Goals of MLTSS:
• Hold a single entity accountable for outcomes (quality, cost)
• Have a predictable budget
• Shift balance from institutional care to HCBS
• Improve coordination of care across settings and providers
• 23 states have implemented one or more types of MLTSS
programs
• Enrollment increased from 800 K in 2012 to 1.2 million in 2015
• States leveraging housing and social services to keep people in
the community (Arizona, Texas)
• States expanding to ID/DD Populations (Tennessee, Texas,
Kansas)
24
STATUS UPDATE OF MLTSS PLANS
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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MLTSS PLANS ARE INTEGRATING WITH MEDICARE
AND EXPANDING POPULATIONS SERVED
Types of MLTSS
Medicare MCO: includes
Medicaid acute & LTSS
Medicaid LTSS only
Medicaid MCO
incorporated into FAD
Demonstration
Medicaid MCO + Medicare
D SNP
Medicaid MCO + FIDE SNP
Populations Served:
Seniors
Persons with ID/DD
Non-elderly adults with
physical disabilities
Full-benefit dually
eligible beneficiaries
26
DISRUPTORS WITH NEW BUSINESS MODELS
TRY TO BEND THE COST CURVE FOR HIGH
RISK/HIGH COST POPULATIONS
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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CHRONIC CARE MANAGER:
STARTING WITH HOME BASED
PRIMARY CARE AND IDT TEAM
• Provides home-based medical care to individuals
with multiple chronic conditions. 24/7 care is
provided by a team of physicians, physician
assistants, and nurse practitioners who deliver
house calls as part of an IDT team.
• Contracts with health plans and receives a
percent of premium and a share of savings.
• Currently contracting with 7 health plans serving
30,000 lives including 2 plans in NY State.
27
Source: CRAIN’s Health Pulse NY, September 7, 2016; Company Offering House Calls for
Medicare Patients expands to Metro New York
CHRONIC CARE MANAGER:
STARTING FROM PACE
• For profit venture-backed PACE program with
current enrollment of about 2,500 in Colorado
seeks SCALE
• Now expanding InnovAge Care Management to
help consumers, managed care and associated
senior service organizations provide life-long care
management services to members
• Care navigation team assesses every participant to
determine how older adults can best be served
28
Source: http://myinnovage.org/ProgramsandServices/InnovAgeCareManagement.aspx
Accessed on October 18, 2016
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October 24, 2016
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DUAL ELIGIBLES IN ORGANIZED SYSTEMS OF
CARE
Source: BiPartisan Policy Center report on Delivery System Report, September 2016, page 18
http://cdn.bipartisanpolicy.org/wp-content/uploads/2016/09/BPC-Health-Dual-Eligible-Recommendations.pdf
Total Dual Eligibles 10.3 million
Total D SNP enrollment 1.7 million
Total MMP Enrollment 355 thousand
Total PACE Enrollment 33 thousand
Combined 20 % of
Dual Eligible Population
New Opportunities for PACEGrowth and Expansion
National PACE Association Annual Conference
October 24, 2016
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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©2016 Trinity Health - Livonia, Mich. 31
*Owned, managed or in JOAs or JVs.
**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.
***Includes multiple locations for Trinity Home Health Services, Trinity Senior Living Communities and PACE facilities.
Our 22-State Diversified Network
Home Care & Hospice Locations Serving 116 Counties47 Continuing Care
Facilities59PACE CenterLocations14
Hospitals* in 20 Regional Health Ministries**92 Mission Health
Ministries4Employed Physicians 5,300
Affiliated Physicians23,900National Health
Ministries***3
Trinity Health
• Dr. Richard Gilfillan, CEO of Trinity Health (TH) and past director of CMS Center for Innovation
• As the Innovation Center's first leader, Dr. Gilfillan was instrumental in ushering in new payment and delivery models such as Medicare ACOs and bundled payments and is using his vision to change how TH operates
“Continue to be the sponsor of the largest number of PACE organizations in the country”
32©2015 Trinity Health PACE - Livonia, Mich.
Trinity Health’s Visionary Leadership
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
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Trinity Health PACE National Footprint
33
1
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCO
UT
TX
NMSC
FL
GAAL 1MS
LA
AR
MO
IA
VA
TN
IN 1
KY
IL
M 1I
WV
WA
OH
PA 3
NY 2
VT
ME
CT
NJ 2
D.C.
WINH
MA
RI
DE 1MD
NC 1
AK
HI
PACE State
Non-PACE State
TH PACE State
Program State City Date Opened October 2016 Census
Catholic Health LIFE New York Buffalo 1-Nov-09 227
Eddy SeniorCare New York Schenectady 1-Oct-96 190
LIFE at Lourdes New Jersey Camden 1-May-09 235
LifeCircles Michigan Muskegon 1-Feb-09 292
LIFE St. Francis New Jersey Trenton 1-Apr-09 325
LIFE St. Joseph of the Pines North Carolina Fayetteville 1-Apr-11 280
LIFE St. Mary Pennsylvania Langhorne 1-Mar-10 244
Mercy LIFE (AL) Alabama Mobile 1-Jan-12 169
Mercy LIFE (MA) Massachusetts Springfield 1-Mar-14 177
Mercy LIFE (PA) Pennsylvania Philadelphia 1-Oct-98 718
Saint Francis LIFE Delaware Wilmington 1-Feb-13 195
Mercy LIFE –West Philadelphia Pennsylvania Philadelphia 1-Oct-98 454
Saint Joseph PACE Indiana South Bend 1-Aug-16 4
Total 3,510
Trinity Health PACE Organizations
TH PACE has experienced over 125% census growth since 2012
Growing PACE While Navigating Competition
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Trinity Health PACE Operating Model
35
• Trinity Health PACE (TH PACE) was formed in early 2015 to manage and support Trinity Health System's PACE assets including Trinity Health owned PACE organizations (PO) and POs operating under TH PACE ownership and management.
• TH PACE aligns with TH’s Continuing Care strategic initiative to expand services in the care of the dual eligible and service to the poor and underserved by:• Developing an infrastructure to support the delivery of services to the
PACE population• Leveraging the expertise of PACE Interdisciplinary Teams to manage
the dual eligible population in Non-PACE expansion programs• Developing new PACE through the operating company• Utilizing the combined strength of the PACE operating company to
shape industry and regulatory direction
As a National Health Ministry, TH PACE has multiple functions:
• Operator with direct ownership of PACE plans
• Manager of non-owned plans
• System level support to Trinity Health System PACE plans
36
TH PACE Functions
TH PACE
Operator ManagerSystem Support
Mercy LIFE of AlabamaMercy LIFE – West Philadelphia
Saint Joseph PACE
Future OpportunityTrinity System PACE
Organizations
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•Expansion into Albany CountyEddy SeniorCare – New
York
•Expansion into Burlington CountyLIFE at Lourdes – New
Jersey
•Expansion into mid Bucks CountyLIFE St Marys –Pennsylvania
•Replacement Center in Bordentown
•Expansion into Middlesex County
LIFE St Francis – New Jersey
•Expansion into Montgomery CountyMercy LIFE SEPA –
Pennsylvania
•New center in existing service area St Francis LIFE – Delaware
•Existing center expansion
•Expansion into additional countiesLIFECircles – Michigan
37©2015 Trinity Health PACE - Livonia, Mich.
FY 2016-2017 Growth Initiatives
• New Jersey – Lourdes Health System and St Francis Medical Center• Existing initiatives through DSRIP and Medicare Shared
Savings Program are effective; however, additional focus needed
• Developing through partnership with the Safety Net and Community Health
• Initiative resembles Patient Centered Medical Home
• Enter into a full risk arrangement with third-party payor to manage the health of dual eligible participants
• Establish clinic under the comprehensive care model to support high-risk dual eligible population served under full-risk arrangement
38©2015 Trinity Health PACE - Livonia, Mich.
New Growth Opportunities: PACE - Light
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
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Select Health Network, ACO Mishawaka, IN
• Select Health Network is a collaboration between Saint Joseph Health System and over 750 physicians and healthcare providers
• St Joseph PACE contracted with ACO as its provider network
• Select has identified at-risk prospects for referral to PACE
• Opportunity in New Jersey for
partnership with health
system ACO
39©2015 Trinity Health PACE - Livonia, Mich.
New Growth Opportunities: Partnership with ACOs
Initiatives in process:
• New York sisters provide capital to fund PACE center
• Pennsylvania state requesting PACE to serve religious
• Indiana PACE reduce financial burden on brothers through assuming care
40©2015 Trinity Health PACE - Livonia, Mich.
New Growth Opportunities: Partnership with Religious Organizations New York, Pennsylvania and Indiana
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
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• LIFECircles, a partnership between Porter Hills, Mercy Health (Trinity Health), and Senior Resources
• Based on success of LIFECircles, an innovative model TANDEM 365 was developed and included collaboration between four CCRCs and an ambulance company help older adults with complex health needs navigate the complicated health care system
• Provided services not typically reimbursed by insurance companies and working directly with individual primary care providers, team members develop a comprehensive care plan for individuals age 55 and over who don’t necessarily qualify for nursing home care
• The PACE Innovation Act provides an opportunity for using the PACE Model of Care and lessons learned from TANDEM365 as a foundation to create a MediCaring Community which is aimed at meeting the needs of at-risk, Medicare-only beneficiaries
41©2015 Trinity Health PACE - Livonia, Mich.
Michigan
PACE Innovation with or without the
Innovation Act
Edo Banach
October, 2016
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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PACE Opportunities and Threats
• Excitement surrounding PACE Innovation Act, but it is not yet a reality
• PACE Regulation is out, but it is incremental and only proposed
• PACE for-profit expansion, but with growth comes more scrutiny
• More focus on dual eligibles, but many other entities in the mix
• So…what’s a PACE entity to do?
43
PACE: Innovation without the Innovations Act
• Opportunities for Collaboration
• Focus on social supports, housing and employment
• Composition of the IDT
• Alternative Care Settings
44
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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Focus on Social Supports
• Housing
• Employment
• Healthy living
• Mobility
• Social connections
45
Alternative Care Settings
• Explore further CMS flexibility on Alternative Care Settings
• Push the use of technology to supplement in-person care
46
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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Opportunities for Collaboration
• Partnering with MCOs (Medicaid MLTC and Medicare MA)
• Partnering with ACOs
• Joint ventures
• Partnering with MMPs in states pursuing financial alignment demonstrations
• Partnering with religious, social, and housing organizations
47
PACE Innovation Act
• Provides CMS (CMMI) with the authority to waive the PACE Statute. This includes previously non-waivable PACE requirements:
• Under-55
• Non-nursing home eligible
• Also creates opportunities:
• to think about what additional innovations– in IDT composition, PACE Center, or ACS might be possible
• to creatively partner with housing, transportation, or other partners
48
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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DISCUSSION AND QUESTIONS
49
THANK YOU!
50
Jade Gong
703-243-7391
Anne Lewis
406-647-2980
Edo Banach
410-951-1421
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