OBJECTIVES AGING POPULATION AGING POPULATION AGING IMPACT ON MEDICARE AGING POPULATION

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1 OBJECTIVES Kimberly S. Hodge, PhDc, MSN, RN, ACNS-BC, CCRN- K Director, ACO Care Management & Clinical Nurse Specialist Franciscan ACO, Inc. Central Indiana Region Indianapolis, IN By the end of this session the participant will be able to: Verbalize the potential impact of an aging population on the healthcare system. Differentiate Medicare and commercial Accountable Care Organizations. Articulate the rationale for why Advanced Practice Nurses are important to achieving ACO goals. Brainstorm APN opportunities within an ACO structure. United States of America: We are getting older! AGING IMPACT ON MEDICARE US Census Aging population = MORE BENEFICIARIES More beneficiaries = MORE MONEY NEEDED 2011: National Health Expenditure (NHE) accounted for 17.9% of Gross Domestic Product (GDP) or $2.7 TRILLION 2011: Medicare spending was 21% of NHE or $554.3 BILLION in

2 AGING IMPACT ON MEDICARE WHAT IS AN ACO? Medicare spending is estimated to have grown 6.3% in 2011 and PROJECTED TO GROW AN AVERAGE OF 6.1% PER YEAR over the projection period from Per person, personal health care spending for the 65 and older population was $14,797 in 2004, 5.6 times higher than spending per child ($2,650) and 3.3 times spending per workingage person ($4,511). GIVEN HISTORICAL DATA AND PROJECTED GROWTH: HOW DO WE KEEP MEDICARE SOLVENT? Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, WHO COME TOGETHER VOLUNTARILY TO GIVE COORDINATED HIGH QUALITY CARE to their patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get THE RIGHT CARE AT THE RIGHT TIME, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the WHAT IS AN ACO? Types Medicare Shared Savings Program Advance Payment ACO Model Pioneer ACO Model Medicare Shared Savings Program The Centers for Medicare & Medicaid Services (CMS) has established a Medicare Shared Savings Program (Shared Savings Program) to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). Advance Payment ACO Model The Advance Payment Model is designed for physician-based and rural providers who have come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Through the Advance Payment ACO Model, selected participants will receive upfront and monthly payments, which they can use to make important investments in their care coordination infrastructure. 2

3 Pioneer ACO Model Designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program. It is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients. COMMERCIAL Anthem Cigna Others MEDICARE ADVANTAGE PLANS Anthem, Humana, United Healthcare, Advantage Health Solutions, etc Think about the integration of care across the continuum Patient / Caregiver Experience Getting Timely Care, Appointments, and Information How Well Your Providers Communicate Patients Rating of Provider Access to Specialists Health Promotion and Education Shared Decision Making Health Status/Functional Status 3

4 Care Risk Standardized All Condition Readmission Coordination Ambulatory Sensitive Conditions Admissions: Chronic / Patient Obstructive Pulmonary Disease (COPD) or Asthma in Safety Older Adults Ambulatory Sensitive Conditions Admissions: Heart Failure (HF) Percent of Primary Care Physicians who Successfully Qualify for an Electronic Health Record (HER) Program Incentive Payment Medication Reconciliation Preventive Care Influenza Immunization Pneumococcal Vaccination for Patients 65 Years and Older Body Mass Index (BMI) Screening and Follow-Up Tobacco Use: Screening and Cessation Intervention Screening for Clinical Depression and Follow-Up Plan Colorectal Cancer Screening Breast Cancer Screening At Risk Population Diabetes Mellitus: Hemoglobin A1c Control (8 percent) Diabetes Mellitus: Low Density Lipoprotein Control Diabetes Mellitus: High Blood Pressure Control Diabetes Mellitus: Tobacco Non-Use Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease Diabetes Mellitus: Hemoglobin A1c Poor Control At Risk Population Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (100 mg/dl) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Coronary Artery Disease (CAD): Lipid Control Coronary Artery Disease (CAD): Angiotensin- Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF 40%) APNS AND APN OPPORTUNITIES IN Potential roles Care coordinator Manager Director Vice President Provider 4

5 QUESTIONS 5

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