Structuring Your ACO Business Model To Achieve Success in a Post Acute Continuum Annual Summit of the Executive Operators Forum

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1 Structuring Your ACO Business Model To Achieve Success in a Post Acute Continuum 2011 Annual Summit of the Executive Operators Forum

2 Healthcare Reform and What it Means to You Loren Claypool CIO, Extendicare

3 3 3

4 4 They will blow up Wait & see We better get moving Hospital Strategy Source: Kubler Ross Grief Cycle

5 What s different now vs. the 1990s 5 Bigger cost and quality problems Evidence-based medicine Linking of outcomes, patient sat, and cost efficiency Integration and risk contracting IT has advanced significantly Pilots and demonstrations showing promise Source: Royal Pingdom #1 December 1990 info.cern.ch Source: KPMG

6 Why reform #1: Cost too much, quality too low 6 Sources: UC Atlas of Global Inequality: Health Care Spending

7 Source: Care delivery Issues: -Medications - Re-admits -Accountability -COST!

8 Source: CBO 8 Why reform #2: Unsustainable 8 The projected date of HI Trust Fund exhaustion is Source: 2011 report by the Social Security and Medicare Boards of Trustees

9 Value-based programs 9 Value-based programs Medicare Hospital Gainsharing 2008, 9 NJ hospitals, rewarded physicians who reduced costs while improving quality and efficiency Physician Hospital Collaboration 2009, 72 hospitals, tested bundled payments Tracks entire episode of care beyond hospitalization Hospital Quality Incentive Demonstration 2003, 200 hospitals, tested pay for performance Links incentives to improved quality Physician Group Practice 2005, 10 physicians groups, tested ACO idea Medicare Care Management Performance Through 2011, 560 small physicians earned incentives for quality Double bonuses for meeting benchmarks and using EMR

10 Source: Perspectives: Controlling US Health Care Spending Separating Promising from Unpromising Approaches, Hussey, Peter, Ph.D., et. al., NEJM, 11/09; accessed via the web 12/09. Follow the Money 10

11 Source: Section 3022, Medicare Shared Savings Program Accountable Care Organization (ACO) 11 Legal Evidence-based medicine Patient- Centered 5000 Medicare Fee-forservice Beneficiaries Physicians & specialists Administrative Processes

12 Milestones 12 Medicaid global payment demonstration in 5 states January October January January October Center for Medicare & Medicaid Innovation to test payment models Final set of rules to form ACOs available Formal implementation of ACOs begins Bundled episodic payments Hospital Medicare cut 2% Beginning Oct. 1, 2012, total Medicare payments to hospitals with high readmission rates will be reduced: FY2013: Up to 1% FY2015: Up to 3% Source: Sections 1151 and 3025 of the Patient Protection and Affordable Care Act

13 Source: PricewaterhouseCoopers, 2009 The Risk Shifts to Providers 13 Fee for service Pay for performance Value-based purchasing Bundled payments Shared savings Global payments Capitation Services are unbundled and paid for separately. Incentives for higher quality measured by evidencebased standards. Percentage reimbursement at risk, earned back by high-quality outcomes. Single payment for episodes of treatment, shared by hospitals, physicians and other providers. Percentage of savings from reduced cost of care shared with providers. All services compensated in one payment that manages a patient across a delivery system. A fixed "per capita" amount that is paid to a delivery system.

14 Where savings will come from: reducing readmissions % of hospitalized Medicare patients are readmitted within 30 days. 1 Section 3025 requires HHS to establish a Hospital Readmissions Reduction Program effective 10/1/2012 for potentially preventable Medicare inpatient hospital readmissions. Number of days after discharge Rate of potentially preventable readmissions Spending on potentially preventable readmissions Within 7 days 5.2% $5 Billion Within 15 days 8.8% $8 Billion Within 30 days 13.3% $12 Billion Source: New England Journal of Medicine, 2009.

15 Where savings will come from: care transition management 15 $47 Billion Cost of drug-related hospitalizations Among seniors with at least three chronic health conditions, nearly three of four (73%) take five or more medications regularly and more than half (52%) do not take all their drugs as Source: prescribed. Kaiser Family Foundation $290 Billion Avoidable healthcare expenditures if medication adherence was improved Source: The New England Healthcare Institute

16 The Audition 16 Costs Quality Readmits By 2014, Accountable Care Organizations (ACOs) will shop around and award business to providers with the best outcomes related to quality, costs, and hospital readmission rates. Dr. Kathleen Griffin, PhD, National Director, Post-Acute and Senior Services, Health Dimensions Group

17 Source: Larson Allen 7 Themes Providers will be asked to accept greater financial risk for outcomes 2. Operational efficiency will be critical 3. Better collaboration across providers 4. Investments in technology will be needed 5. Increased quality expectations, reporting, and monitoring 6. Elevated regulatory risk 7. Increased focus on community-based services and care

18 Source: Health Dimensions Group Strategic Implications 18 Ask a hospital CFO: Top 5 DRGs? Top readmit DRGs? Goals? US averages Heart attack 19.9% Heart failure 24.7% Pneumonia 18.3% How you can win: Specialize Help the hospital solve a problem Prove avoidable readmits Know how your outcomes compare to others Communicate outcomes Getting a patient home is no longer enough. Because outcome-based bonuses will be paid across the network of providers.

19 USA Today s 100 Worst Hospitals KS Hospital MC Revenue $300M 19 Sources:

20 20

21 21

22 Cincinnati, OH 22 1

23 3-D, Zero Sum 23

24 Technology Implications 24 Technology Implications Business intelligence EMR HIE(s) Outcomes reporting Disease management DRG-based cost accounting Always-on

25 Source: Savage-Gutkind EMR adoption model for LTC. LTC Adoption Model 25 Stage 10: Interoperable EHR Stage 9: Decision support Stage 8: EDM and ancillary integration Stage 7: Clinical documentation Stage 6: Care planning Stage 5: Assessments Stage 4: e-mar and e-tar Stage 3: Order management Stage 2: CNA documentation Stage 1: ADT (census) and MDS Stage 0: Manual/paper-based processes

26 26 Always On 4-5X

27 Source: CIOC Electronic Medical Records (EMR) Cost Study Final Report, February 2011 CIO Consortium Companies 27 ACTS Retirement Life Communities Avalon HCI Avamere Brookdale Senior Living Christian Homes Complete Healthcare Resources, Inc Covenant Care Covenant Retirement Communities Cypress Health Group Diakon Lutheran Social Services Diversicare Ensign Facility Services, Inc Erickson Retirement Comm. Extendicare Five Star Quality Care Fundamental Genesis Golden Living Good Samaritan Society Gulf Coast Health Care HCR Manor Care Harden Healthcare Services Health Care Navigator Kindred Healthcare LaVie Administrative Services Life Care Centers of America / Affinity Hospice of Life / Life Care at Home Medical Facilities of America NHS Management, LLC Reit Management and Research, LLC SavaSeniorCare Signature HealthCARE, LLC Skilled Healthcare Sun Healthcare Group Sunrise Senior Living / Greystone TAG-IT / The Asbury Group Tara Cares, LLC UHS-Pruitt Corp

28 Source: CIOC Electronic Medical Records (EMR) Cost Study Final Report, February 2011 CIO Consortium Study 28 What does it cost for a typical 25-facility chain providing nursing care and rehabilitation services to evaluate, deploy, and operate an Electronic Medical Record (EMR) system? EMR costs per facility

29 It s Not a Technology Initiative 29 Clinical EMR Technology 1) The implications are strategic for the 2014, outcomes-driven world of healthcare to come. 2) EMR will fundamentally change the way you deliver care.

30 Impact on Your Business 30 People # of people using technology increases 4-5X First time many have interacted with technology Major training requirements Major communication requirements Process Complex implementation requires dedicated project management Workflows totally transformed Data will be available to drive clinical outcomes Technology Managed Secure Available Disaster recovery Discovery protection Ready for images HIPAA HITECH Encryption Monitoring Filtering Provisioning Separate clinical & consumer traffic Minutes vs. hours of downtime 24 x 7 support

31 4 Take-Aways C-Suite ACOs Fee for Service Phase-out Health Exchanges Differentiate Tighten a value proposition Scale is not necessarily a competitive advantage for post-acute providers Value not volume Quality Cost Readmissions Care transitions Outcomes reporting

32 32 If we cannot demonstrate value The value to others is zero.

33 Healthcare Reform and What it Means to You Loren Claypool CIO, Extendicare

Plenary Session 1. Health Dimensions Group. 2010 Health Dimensions Group

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