What Makes An Attractive Post-Acute Partner for ACO's

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1 What Makes An Attractive Post-Acute Partner for ACO's Holli Benthusen, OTR/L Regional Director of Business Development & Client Relations Cell Margaret Kopp, SLP M.S. CCC SLP Vice President of Clinical Services and Quality Management Cell April 2015 Learner Objectives Describe new payment initiatives including ACO s and Bundled Payment models Identify appropriate reporting features to monitor and track quality measures and outcomes Describe strategies for developing positive relationships within the healthcare community Prepare a facility report card to be able to attract partnerships 2 1

2 Healthcare Reform Theme of the Affordable Care Act Increasing value and reducing costs ACO s Bundling 33 Overview This year, we are not looking for rate increases; we are looking for market improvement. Jay Picerno, CFO, COO Barnabas Health a large system in West Orange, New Jersey Its not just financial data. It s also clinical data, quality data, market data, and how it is all integrated so that you can pull it all together and know what your true cost is and what your true outcomes are. They will drive how you are able to enter agreements Jenny Barnett, former EVP of Finance CHE Trinity in Livonia, Michigan 4 2

3 Opportunities Created by Healthcare Reform: Kaiser Health News FAQ On ACOs: Accountable Care Organizations, Explained April 2014 One of the main ways the Affordable Care Act seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks which coordinate patient care and become eligible for bonuses when they deliver that care more efficiently Providers make more if they keep their patients healthy. About four million Medicare beneficiaries are now in an ACO, and, combined with the private sector, more than 428 provider groups have already signed up. An estimated 14 % of the U.S. population is now being served by an ACO. Significant opportunity exists to better manage patients discharged from acute care hospitals. 5 Why address healthcare spending? As lawmakers searched for ways to reduce the national deficit, Medicare became a prime target. With baby boomers entering retirement age, the costs of caring for elderly and disabled Americans are expected to soar. As of July 2014, according to the Congressional Budget Office (CBO) projected growth in federal spending for Social Security and major health care programs will grow faster than economic output per capita 6 3

4 Causes of Projected Growth in Federal Spending for Social Security and Major Health Care Programs from CBO 7 Changes in Population, by Age Group from CBO 8 4

5 Changes in Population, by Age Group, from CBO 9 What exactly is an Accountable Care Organizations-ACOs? CMS developed final rule October 20, 2011 Under the Patient Protection and Affordable Care Act (Affordable Care Act) Improve care coordination to Medicare patients across care settings including: doctor s offices hospitals long-term care facilities The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first 10 5

6 How does CMS describe an ACO? 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 Medicare patients. The goal of coordinated care is to ensure patients, especially the chronically ill: Get the right care at the right time Avoid unnecessary duplication of services Prevent medical errors When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. 11 Key Principles of Accountable Care The Brookings Institution 12 6

7 Medicare ACO Programs as of March 2015 Medicare Shared Savings Program program that helps Medicare feefor-service program providers become an ACO. 360 Medicare ACOs have been established in 47 states, serving over 5.6 million Americans with Medicare Pioneer ACO Model (ongoing) program designed for early adopters of coordinated care. No longer accepting applications. Currently there are 19 ACOs participating in the Pioneer ACO Model Advance Payment ACO Model (ongoing) The Advance Payment ACO Model is meant to help smaller ACOs with less access to capital participate in the Shared Savings Program.- there are 35 ACO s in this program that get up front and monthly payments for participation in the Shared Savings Program. 13 Medicare ACO Programs as of March 2015 Investment Model (Applications under review) New model of pre-paid shared savings that builds on the experience with the Advance Payment Model to encourage new ACOs to form in rural and underserved areas and current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk. Participation in the ACO Investment Model will be limited to two distinct groups: New Shared Savings Program ACOs joining in 2016 rural geographies and areas where there has been little ACO activity, offering pre-payment of shared savings in both upfront and ongoing per beneficiary per month payments. ACOs that joined Shared Savings Program starting in 2012, 2013 and 2014 helps ACOs succeed in the shared savings program and encourage progression to higher levels of financial risk 14 7

8 Medicare ACO Programs as of March 2015 Comprehensive ESRD (End Stage Renal Disease) Initiative (Applications under review) First disease-specific Accountable Care Organization (ACO) model Designed by CMS to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with ESRD. Through the Comprehensive ESRD Care initiative, CMS will partner with groups of health care providers and suppliers ESRD Seamless Care Organizations (ESCOs) to test and evaluate a new model of payment and care delivery specific to Medicare beneficiaries with ESRD. Participating ESCOs will be clinically and financially responsible for all care offered to a group of matched beneficiaries, not only dialysis care or care specifically related to a beneficiary s ESRD. CMS reopened the Request for Applications (RFA) after consideration of stakeholder feedback and revision of the RFA. With this open application period, CMS is interested in creating opportunities for small (non-large-dialysis organization, LDO) to participate Key is to make sure that the financial business case for all ESCOs is compelling enough to partner with CMS under the Comprehensive ESRD Care Initiative. 15 Medicare ACO Programs as of March 2015 Medicare Health Care Quality Demonstration (ongoing) Section 646 of the Medicare Modernization Act (MMA) mandates a 5- year demonstration program under which CMS will test major changes to improve quality of care while increasing efficiency across an entire health care system. Described as an Accountable Care Organization CMS to use this demonstration to identify, develop, test, and disseminate major and multi-faceted improvements to the health care system. Broadly stated, the goals of the Medicare Health Care Quality demonstration are to: Improve patient safety; Enhance quality; Increase efficiency; and Reduce scientific uncertainty and the unwarranted variation in medical practice that results in both lower quality and higher costs. There are 4 participants 16 8

9 Medicare ACO Programs as of March 2015 Next Generation ACO Model (Announced) A new opportunity in accountable care: o More predictable financial targets; o Greater opportunities to coordinate care; o High quality standards consistent with other Medicare programs and models. o Creates a financial model with long-term sustainability The Model seeks to test how strong financial incentives for ACOs can improve health outcomes and reduce growth in expenditures for Original Medicare feefor-service (FFS) beneficiaries Protect Medicare FFS beneficiaries freedom of choice- Allows beneficiaries a choice to remain aligned to the ACO Offer benefit enhancements that directly improve the patient experience and support coordinated care Smooth ACO cash flow and improve investment capabilities through alternative payment mechanisms. CMS expects approximately 15 to 20 ACOs to participate Application process starts June 2015 for January 2016 start 17 Medicare ACO Programs as of March 2015 Private, For-Profit Demo Project for the Program of All- Inclusive Care for the Elderly (PACE) (Ongoing) Congress authorized a study to compare the costs, quality, and access to services provided by for-profit entities to those of nonprofit PACE providers. Background Six providers are participating in the demonstration: serves1,088 beneficiaries in Pennsylvania Pennsylvania PACE, Inc.(started 2007 thru 2015) SeniorLIFE Altoona, Inc. (started 5/2011 thru 12/2015) SeniorLIFE Greensburg (started 2/2013 thru 12/2015) SeniorLIFE Washington, Inc. (started 5/2011 thru 12/2015) SeniorLIFE York, Inc. (started 5/2011 thru 12/2015) SeniorLIFE Lehigh Valley, Inc. (started 1/2014 thru 12/2015) 18 9

10 Medicare ACO Programs as of March 2015 Nursing Home Value-Based Purchasing Demonstration CMS will assess the performance of participating nursing homes based on selected quality measures. incentive payment awards will be made to those nursing homes that perform the best or improve the most in terms of quality For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State s savings pool. 3 states chosen: Arizona, New York and Wisconsin Began July 1, The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes. 19 Medicare ACO Programs as of March 2015 Rural Community Hospital Demonstration (ongoing) The goal of the program is to test the feasibility and advisability of cost based reimbursement for small rural hospitals that are too large to be Critical Access Hospitals. In recent years, hospitals in this category have experienced negative Medicare margins on inpatient services. CMS is conducting an extensive evaluation of the demonstration, testing the benefits to the community and financial impact on participating hospitals. Timeline has been extended another 5 year period 23 Hospitals participating Participating rural community hospitals must be located in one of the 20 states with the lowest population density. These States are: Alaska, Arizona, Arkansas, Colorado, Idaho, Iowa, Kansas, Maine, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, and Wyoming

11 Medicare ACOs continue to succeed in improving care, lowering cost growth CMS Fact Sheet, November 7, 2014 ACO s in the Pioneer Model, and the Medicare Shared Savings Program generated over $417 million in total program savings. At the same time, ACO s qualified for over $460 million in shared savings payments Both had higher quality and better patient experience than published benchmarks in results of the 23 Pioneer ACO s and the first year of performance for the Medicare Shared Savings Program Pioneer Performance Year 2 Results: Estimated saving of over $96 million Saved Medicare Trust Fund ~$41 million 11 Pioneer ACOs earned shared savings, 3 generated losses, and 3 elected to defer payments until year 3 Mean quality score increased by 19% from 71.8% to 85.2% Medicare Shared Savings Year 1 Results 58 held spending $705 million below targets and earned performance payments of $315 million 1 ACO on track 2 overspent its target by $10 million and owed shared losses of $4 million An additional 60 ACOs reduced costs compared to their benchmarks but did not qualify for shared savings Improved quality measures on 30 of ACO Counts by County (May 2014) 22 11

12 Texas Only 23 Texas Only- Listing 24 12

13 Texas Innovation Models 3/2015 State Innovation Models Initiative: Model Design Awards Number of Participants:1 Advance Payment ACO Model Number of Participants:4 BPCI Initiative: Model 2 Number of Participants:137 BPCI Initiative: Model 3 Number of Participants:489 BPCI Initiative: Model 4 Number of Participants:2 Community based Care Transitions Program Number of Participants:4 Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Number of Participants:6 Health Care Innovation Awards Number of Participants:12 Health Care Innovation Awards Round Two Number of Participants:1 Graduate Nurse Education Demonstration Number of Participants:1 Independence at Home Demonstration Number of Participants:2 Innovation Advisors Program Number of Participants:1 Strong Start for Mothers and Newborns Initiative Number of Participants:13 Incentives for the Prevention of Chronic Disease in Medicaid Demonstration Number of Participants:1 25 CMS: Additional Innovation Models The Innovation Center develops payment service delivery models in accordance with the Social Security Act,the Affordable Care Act (ACA) and previous legislation CMS Innovation Models are organized into seven categories and can be found at (http://innovation.cms.gov/initiatives/index.html#views=models) Bundled Payments for Care Primary Care Transformation Initiatives Focused on the Medicaid and CHIP. Initiatives Focused on the Medicare-Medicaid Enrollees. Initiatives to Speed the Adoption of Best Practices Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models 26 13

14 Bundled Payments for Care Improvement initiative (BPCI)-4 models August 23, 2011, CMS invited providers to apply to help test and develop 4 different models of bundling payments with different phases of risk. The Bundled Payments initiative is comprised of four broadly defined models of care, which link payments for multiple services beneficiaries receive during an episode of care. Model 1 includes an episode of care focused on the acute care inpatient hospitalization. Awardees agree to provide a standard discount to Medicare from the usual Part A hospital inpatient payments. Models 2 and 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care. Model 4 involves a prospective bundled payment arrangement, where a lump sum payment is made to a provider for the entire episode of care. Over the course of the three-year initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare. These models may lead to higher quality, more coordinated care at a lower cost to Medicare. 27 Bundled Payments for Care Improvement initiative (BPCI) 4 models 28 14

15 The 4 Models BPCI Model 1: Retrospective Acute Care Hospital Stay Only Episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the Inpatient PPS Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule. Under certain circumstances, hospitals and physicians are permitted to share gains $$ arising from the providers care redesign efforts Number of participants: 21 Participation began in April, 2013 and an additional Awardee was added in January, 2014 and includes most Medicare feefor-service discharges for the participating hospitals 29 BPCI Model 2: Retrospective Acute & Post Acute Care Episode The episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end either 30, 60, or 90 days after hospital discharge. Participants can select up to 48 different clinical condition episodes. Model 2 Episode Initiators are acute care hospitals (ACH) or physician group practices (PGP) The 3-day inpatient hospital stay prior to Medicare Part A covered skilled nursing facility (SNF) services is waived for beneficiaries who are discharged from an inpatient hospital stay of less than 3 days to receive post-hospital care from skilled nursing facilities (SNFs), covered under Medicare Part A, as long as all other coverage requirements are satisfied. The Waiver is made available to Awardees that provide a list of their SNF partners to CMS, where a majority of the SNF partners for a specified period of time had a quality rating of 3 or more stars under the CMS 5-Star Quality Rating System. There are 2,180 participants/awardees 30 15

16 BPCI Model 3: Retrospective Post Acute Care Only For Model 3, the episode of care will be triggered by an acute care hospital stay and will begin at the start of the post-acute care with a participating: skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode. Participants can select up to 48 different clinical condition episodes. There are 4,727 participants/awardees involved 31 In both Models 2 and 3, the bundle will include: Physicians services Care by post-acute providers Related readmissions Other related Medicare Part B services included in the episode such as clinical laboratory services durable medical equipment, prosthetics, orthotics and supplies Part B drugs A target price will be set that will be based on historical fee-for-service payments for the participant s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Any expenditures that are above the target price will be repaid to Medicare by the participant

17 BPCI Model 4: Prospective Acute Care Hospital Stay Only CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit no-pay claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes. There are 17 participants/awardees involved 33 Primary Care Transformation Primary Care Transformation -Primary care providers are a key point of contact for patients health care needs. Strengthening and increasing access to primary care is critical to promoting health and reducing overall health care costs. Advanced primary care practices also called medical homes utilize a team-based approach, while emphasizing prevention, health information technology, care coordination, and shared decision making among patients and their providers. Number of Participants: Comprehensive Primary Care Initiative- 479 FQHC Advanced Primary Care Practice Demonstration- 434 Advanced Primary Care Initiatives- under development Graduate Nurse Education Demonstration-5 Independence at Home-14 Independent Practices and 1 Consortium Multi-Payer Advanced Primary Care Practice-6 Transforming Clinical Practices Initiative-accepting applications 34 17

18 Additional Initiatives for Innovation Initiatives Focused on the Medicaid and CHIP Medicaid and the Children s Health Insurance Program (CHIP) are administered by the states but are jointly funded by the federal government and states. Initiatives in this category are administered by the participating states. Initiatives Focused on the Medicare-Medicaid Enrollees Individuals enrolled in both Medicare and Medicaid (the dual eligibles ) account for a disproportionate share of the programs expenditures. A fully integrated, personcentered system of care that ensures that all their needs are met could better serve this population in a high quality, cost effective manner. Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models Many innovations necessary to improve the health care system will come from local communities and health care leaders from across the entire country. By partnering with these local and regional stakeholders, CMS can help accelerate the testing of models today that may be the next breakthrough tomorrow. Initiatives to Speed the Adoption of Best Practices Recent studies indicate that it takes nearly 17 years on average before best practices - backed by research - are incorporated into widespread clinical practice and even then the application of the knowledge is very uneven. The Innovation Center is partnering with a broad range of health care providers, federal agencies professional societies and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption. 35 Strategies- What Makes an Attractive Post Acute Partner 36 18

19 Episode of Care Medicare Patients Use of Post-Acute Services Throughout an Episode of Care (1) 35% of Medicare Beneficiaries are Discharged from Acute Hospitals to Post-Acute Care *52% of the 35% are admitted to SNFs within 90 days * (1) Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System 37 How Are Hospitals Measuring SNF Performance? As of October 1 st, 2012 hospitals in the bottom quartile will face cuts from Medicare. Adopted readmission measures for the applicable conditions of 1. Acute Myocardial Infarction (AMI), 2. Heart Failure (HF) and 3. Pneumonia (PN) CMS is finalizing the expansion of the applicable conditions for FY 2015 to include: 1. Patients admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) 2. Patients admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). SNFs are in a powerful position to use data to their competitive advantage Data is essential in creating a comprehensive picture 38 19

20 Top Outcomes against which providers will be measured by hospitals include: Perceived quality of care and outcomes. Readmissions-Incidents of hospital readmissions FY and 2014-Adopted readmission measures for the applicable conditions of Acute Myocardial Infarction (AMI), Heart Failure (HF) and Pneumonia (PN) In the FY 2014 IPPS rule, CMS expanded the applicable conditions for FY 2015 to include: (1) patients admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD); and (2) patients admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Communication and coordination of care. Lowest cost, as measured by length of stay (LOS) 39 Why Would You Want to be an ACO Partner? ACOs and Bundled Payment Models are growing Savings are being realized and shared Quality is being measured Opportunity to collaborate with hospital and community healthcare providers Opportunity to obtain data related to DRGs, costs, hospital readmissions Experience in determining risks and rewards Opportunity to determine care paths timely 40 20

21 How to become the Preferred Discharge Destination? Quality measures- Does your facility have these measures? Patient/family satisfaction surveys Statistical reporting including: Patient functional independence measure outcome scores LOS by diagnosis Discharge destination Staffing Therapy Expertise 41 Quality Measures- Rehabilitation Outcomes Implementation 1. Establish a means of collecting rehabilitation data in a consistent manner to allow clinicians to: Follow changes in functional status Measure the effectiveness of treatment Track and report to assess quality and cost effectiveness of program 2. Determine method for obtaining Patient Outcome*: Software/Services/Tool Partnering with Contracted Therapy Established Outcome tool Inter rater reliability Report Capability/level of standardization 3 rd Party Surveys *Currently there is not a universal outcomes measurement tool for SNF/LTC settings; NASL and AHCA have worked together to develop one based on the CARE Tool item sets which has been submitted to NQF for review 42 21

22 Outcome Measures-Report Card of Performance Pull together a profile of the building to help sell value to ACO s Establish method of pulling metrics together to be able to highlight strengths of facility and program Use data to address concerned areas Patient Surveys Annual Surveys 5 Star Rating* *Recently rating measures have been adjusted making this a more challenging achievement 43 Reporting 44 22

23 Facility Outcome Report Facility Facts Age Range accepted Average Age Bariatrics Smoking/ Non smoking Under 60 case by case 74 years old Case by case Non smoking campus 45 Facility Outcome Report Intensity of Therapy/Sub-acute Rehab Average Length of Stay Therapy Availability Therapy Intensity Specialty Programs 16 days 7 days/week 72% receive 2.5 hrs/day Memory Care 46 23

24 Facility Outcome Report Discharge Destination Home 89% ALF 3% SNF 8% 47 Facility Outcome Report Return Home Mng A 81% Med A 94% Total 89% 48 24

25 Facility Outcome Report Patient Satisfaction Physical Therapy Courtesy of PT 4.50 PT explained treatment & program 4.55 Involved in setting PT goals 4.40 PT helped meet goals and overall improvement 4.50 Occupational Therapy Courtesy of OT 4.60 OT explained treatment & program 4.70 Involved in setting OT goals 4.63 OT helped meet goals and overall improvement 4.66 Speech Therapy Courtesy of ST 4.25 ST explained treatment & program 4.25 Involved in setting ST goals 4.25 ST helped meet goals and overall improvement 4.25 Likelihood to recommend program 4.10 Overall level of satisfaction with program 4.47 ***Based upon rating 1 5 with 5 being the highest score 49 Facility Outcome Report Clinical Outcomes g o o d Admission Discharge PT OT ST Clinical Measures Outcomes Measure Scoring PT & OT 1 = Dependent 2 = Maximum Assist 3 = Moderate Assist 4 = Minimum Assist 5 = Supervision 6 = Modified Independent 7 = Independent Clinical Measures Outcomes Measure Scoring Speech Pathology 1 = Severe impairment 2 = Moderate to Severe Impairment 3 = Moderate Impairment 4 = Mild to moderate Impairment 5 = Mild Impairment 6 = Trace Impairment 7 = Within Normal Limits 50 25

26 Diagnosis groups/data on point gain and LOS Row Labels Outcomes Therapy Discharges Avg Avg Days Age Post Onset Avg Admit Score Avg DC Score Avg Avg Gain LOS Avg PreMorbid Avg Goal SELECT MEDICAL REHABILITATION SERVICES (180) Region 1 (1) GK ECC Other CVA Parkinsons Disease Dysphagia Osteoarthritis After Care Trauma COPD Pneumonia Acute Renal Failure CHF Osteomyelitis Joint Replaced Hip UTI Facility Outcome Report Return to Hospital within 30 days 11% What about looking further to determine Return to Hospital by Diagnosis This allows for better planning for those future admissions Do your systems support this? 52 26

27 Key Diagnoses: Hospital Readmissions vs. DC To Lesser Level of Care 7 Point Rating Scale with 7 being Independent DX Therapy D/C Days Post Onset Admit Score D/C Score Point Gain LOS/Tx Duration CHF COPD Hip Knee Pneumonia DX Therapy D/C Days Post Onset Admit Score D/C Score Point Gain LOS/Tx Duration CHF COPD Hip Knee Pneumonia Facility Outcome Report 54 27

28 Improvement of Patients by Hospital Referral Measurements of Functional Improvement Avg Day s Post Avg Avg Ons Admit Avg DC Avg Avg PreM Avg Row Labels Therapy Discharges Avg Age et Score Score Gain LOS orbid Goal Outcomes SELECT MEDICAL REHABILITATION SERVICES (180) Region 1 (1) DW QH Ambulation Bathing/Showering Bed Mobility Cognition Problem Solving Cognition Executive Function Cognition Judgment Cognition Memory Cognition Orientation Dressing Lower Extremity Dressing Upper Extremity Grooming IADLs Medication Mgnt Step Negotiation Swallowing Toileting Transfers Diagnostic Findings by Physician Example: COPD Patients of Dr. C Total Avg Admit Score Avg DC Score Average of Gain 56 28

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