Health Care Reform: Seizing the Opportunity to Transform the Care Delivery System for Our Elders

Transcription

1 May 5, 2011 Health Care Reform: Seizing the Opportunity to Transform the Care Delivery System for Our Elders WAHSA 2011 Spring Conference & Annual Business Meeting: New Thoughts, New Directions Kathleen M. Griffin, PhD, National Director, Post Acute and Senior Services, Health Dimensions Group

2 Health Care Reform Moved the Cheese 2

3 Health Care Reform: Juggernaut on Aging Services Providers Medicare payment Hospital readmission penalties Bundled B dl d paymentt Accountable care organizations Home-based services PCMHs 3

4 Medicare Payment Will Change Regardless of any changes to the health care reform law, Medicare payment changes will be implemented If we don t bend the cost curve, no funding for Medicare after

5 Why Skilled Nursing, Home Health, and Hospice are Key to Bending the Cost Curve But rehospitalizations from SNFs and home health agencies not good 5

6 30-Day Rehospitalizations High, but Worse for Medicare Patients Discharged to SNFs 19.6% of Medicare patients are readmitted within 30 days, and 28.2% within 60 days; only 10% of these readmissions are planned Jencks S et al. N Engl J Med 2009; 360:

7 Penalties for Hospitals with Excessive 30-Day Readmissions: October 1, 2012 Hospitals in quartile with highest rate or lowest improvement in rate of 30-day readmissions for heart attack, heart failure, and pneumonia will lose a percentage of total Medicare e payments Penalty at 1% in FY2013 and increases to 3% in FY2015 More penalty conditions will be added, such as COPD, stents 7

8 Impact on Skilled Nursing, Home Health, & Hospice: Hospital Readmission Penalties Preferred provider networks for health systems Selection criteria: Data: low readmission rate; Medicare Part A go homes from subacute to home health Manage high-acuity patients Physician integration with health system s doctors Care transitions for seniors no one falls through the cracks High priority on appropriate use of hospice 8

9 Bundled Episodic Payment Pilot January 1, 2013 One payment to hospital for hospitalization + 30 days of care Hospitalization and rehospitalizations Physician services ED Post-acute (LTACH, rehab hospital, SNF, home health, hospice) Outpatient services If spending reductions, expand at least by January 1,

10 Impact on SNFs, Home Health, Hospice: Bundled Payment Payment Bundle for subacute episode or entire post-acute episode Cost accounting essential Shorter Medicare stays in subacute (12 15 days) Must double market share to maintain Medicare census Need ownership or control of home health costs and ability to reduce re-hospitalizations Partnering Medicare bundled payment pilot may require hospital bids; winner significantly enhances market share Aging services providers must pick the right hospital partner for market share 10

11 Why SNF-Home Health Continuum Attractive for Bundled Payment Source: MedPAC, March

12 CARE Report Due June 2011 Continuity Assessment and Evaluation (CARE) piloted at 150 PAC sites; report due to CMS June 2011 Web-based based measurement: At acute hospital discharge At admission to PAC At discharge from PAC Measures: PAC providers concerned that study group too small to yield valid results, but no single PAC voice to provide input to CMS; LTACH & IRFs fear subacute & home health substitutes Health status Diagnoses, procedures, medications, allergies, skin integrity, and physiologic factors Prior use/pre-morbid status Functional status/physical issues Changes in severity Cognitive status 12

13 Accountable Care Organizations or Accountable Health Networks: The Promise Goals: Deliver seamless, highquality care for Medicare beneficiaries A patient-centered organization where patient and providers are partners in care decisions Reduce costs by bending the Medicare cost curve 13

14 ACO Rationale: Current Care Continuum = Fragmented and Silo-ed 14

15 Accountable Care Organizations: Coordinated and Integrated ACO Population 5,000+ Medicare fee-for-service beneficiaries Accountable for all Medicare Part A & Part B services EHR across settings Focus on primary care, prevention, avoiding institutions Adapted from Premier, Inc. 15

16 ACO Statutory Requirements Legal structure t to receive, distribute savings Primary care professionals to serve minimum of 5,000 assigned Medicare FFS beneficiaries Three-year commitment to participate p 16

17 Proposed Rules: Who Can Be An ACO? Who Can Be An ACO? Group practices Networks of individual practices Partnerships or JV arrangements between hospitals and ACO professionals Hospitals employing ACO professionals Such other groups of providers of services and suppliers as the Secretary determines appropriate ACO Professionals Doctor of medicine or osteopathy Physician assistant, nurse practitioner, or clinical nurse specialist Hospitals IPPS Acute Hospitals Other Groups of Providers/Suppliers FQHCs, RHCs SNFs, LTACHs Critical Access Hospitals But costs of organizing and financial risks limit the number of post-acute providers that have the ability to create or participate in legal structure of ACO 17

18 ACO Proposed Rule: Payment via Shared Savings 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 ACO Launched Projected Target Actual Shared Savings Adapted from Brookings Institute 18 18

19 ACO Proposed Rules: Quality Year 1: Report on 65 quality measures; later, shared payment only if thresholds met Quality measures important to aging services providers: Care coordination: avoidable hospital admissions for diabetes, COPD, CHF, dehydration, bacterial pneumonia, UTIs Patient safety, HACs: Decubitus ulcer, infections due to medical care At risk population/frail elderly: medical management for diabetes (e.g., foot exams), HF (e.g., weight, patient education), CAD 19

20 ACO Proposed Rules: Risk Can elect one-sided or two-sided risk for Years 1 and 2; all two-sided risk in Year 3 One-sided: share 50% of savings if exceed threshold target: Rural ACOs = 0% Large populations = 2% Small populations = 3.9% Two-sided: share 60% of savings if exceed threshold target, but subject to penalty if expenses exceed 2% of target, with shared loss caps (5%, 7.5%, and 10% during three years) Waivers for Physician Self-Referral Law, anti-kickback, and civil money penalties for hospitals that induce physicians to reduce or limit care; but no information in proposed rules on 3-day prior hospitalization requirement for SNFs 20

21 ACO Activity in Wisconsin October 2010: ProHealth, which operates Waukesha Memorial and Oconomowoc Memorial hospitals, announced..it would form a joint accountable care organization, or ACO, with Waukesha Elmbrook Health Care. March 2011: Agnesian Healthcare (Fond du lac), Aspirus (Wausau), Bellin Health (Green Bay), Columbia St. Mary s (Milwaukee), and Froedtert Health (Milwaukee) created a limited liability company Accountable Care Solutions, LLC (ACS) to serve as the clinically integrated contracting entity for the regional network. Premier Readiness Collaborative: Aurora Health System Brookings Dartmouth Learning: Gunderson Lutheran Health System (LaCrosse), Ministry Health Care (Milwaukee) 21

22 How Will SNFs, Home Health, Hospice Be Paid By ACOs? Shared Savings? Unlikely very difficult to assess the contribution to savings by the SNF or HHA or hospice Bundled Payment? More likely predictable and can incentivize with bonuses Just SNF or all post-acute? Will vary by market One Midwest health system + PAC provider example $10, = 30 days 22

23 ACOs: Impact on Aging Services Providers Preferred Networks of Aging Services Providers Reduced rehospitalizations Outstanding patient outcomes and lower costs Likely fewer days in SNF; more use of home health and hospice Manage crises for both short-term Medicare patients and long-term care residents Procedure rooms for replacing g-tubes 24/7 physician-np coverage Reduced ED visits and hospitalizations of LTC residents CCRCs have lives attractive to ACOs; opportunity for patient centered medical homes (PCMHs) on larger campuses 23

24 Subacute or Long-Term Care Some metro area aging services providers will partner with hospital, physician group, or ACO Significant increase in Medicare market share (but much shorter stays in subacute) EHR with physicians, hospitals, other providers Share risk for payment bonuses Other metro area SNFs = long-term care (LTC) and more Medicaid Rural providers will partner with networks of independent d physicians i and critical i access hospitals for subacute and LTC All institutional LTC providers Frailer, sicker, more cognitively impaired, closer to end of life 24

25 Institutional LTC in the Future Flat or declining over next 10 years Demographics: age trough ACA money for rebalancing Proven HCBS Medicaid id models in bellwether states Beacon Hill Village model Home technology Transparency requirements, educated consumers Private pay will choose attractive SNFs with proven quality care, resident satisfaction ratings, specialty end-of-life programs 25

26 Aging Services Provider Winners Control post-acute and long-term care continuum either via ownership or partnering Enhanced clinical staffing and skills 24/7 coverage by physicians/nps; P4P for quality outcomes & reduced rehospitalizations Care pathways jointly developed with hospital; and tools to reduce rehospitalizations, ED visits (Interact2) Data driven with sophisticated systems that constantly measure costs, efficiencies, patient/resident outcomes Allow SNF, home health agency to assume payment risk Rock-solid transitions to home; control of home health care Willing for PCMH on campus 26

27 Questions 27

28 There are risks and costs to a program of action. But they are far less than the long-range risks and costs of comfortable inaction. John F. Kennedy Kathleen M. Griffin, Ph.D. National Director, Post Acute and Senior Services Health Dimensions Group 4400 Baker Road, Suite 100, Minneapolis, MN fax:

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