Collaboration Across the Care Continuum. Susan Kratz, Nilan Johnson Lewis Donna Loomis, Benedictine Health System Jacqueline Moen, Allina Health

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1 Collaboration Across the Care Continuum Susan Kratz, Nilan Johnson Lewis Donna Loomis, Benedictine Health System Jacqueline Moen, Allina Health

2 Overview Why is collaboration important Examples of Models of Collaboration and Legal Issues Collaboration among primary care, specialists and hospitals Collaboration between integrated health system and payer Collaboration outside traditional health care Collaboration with post-acute care providers Health Information Exchanges

3 Example of Continuum Physician Clinic Home/Community Specialist Post-Acute Care Outpatient Care Inpatient Care

4 Fragmentation of System (Where We ve Been and May Still Be) Reactive versus pro-active care system Multiple caregivers Each responsible for discrete part of patient s care Inefficiencies in, or barriers to, information sharing Historically, provider s financial interests best served by doing as much as possible Patients forced to navigate care and payer systems alone Lack of accountability

5 Why is Collaboration Important? Eliminating (or reducing) fragmentation Pursuing the Triple Aim improving care for individuals improving health of populations lowering per-capita costs Taking aspirational goal into day to day work

6 Why is Collaboration Important? Patient Care Considerations Need we say more? Financial Considerations Hospital Readmission Penalty Value Based Purchasing Program Bundled Payments Medicare Shared Savings Program State DHS accountable care programs Commercial Payer Total Cost of Care Contracts

7 Why is Collaboration Important Collaboration comes in many different forms Collaboration tomorrow may look quite different than today Following are merely some examples

8 Collaboration Among Primary Care, Specialists and Hospitals (Co-Located Services) Continuum of care at one site Easy for patient Easier provider communication? Purchased Services Arrangements Lease of Space Stark Time share considerations Anti-kickback HIPAA (if sharing PHI) Patient authorization Exception for treatment purposes Tax-Exempt Bond Facility Considerations

9 Collaboration Among Primary Care, Specialists and Hospitals (Narrow Networks) Some may be ACOs also participating in MSSP Can be for specific purpose Unique commercial payer product/population Employer self-insured program offering Generally have total cost of care (TCOC) or other cost/quality incentive Coordination = Lower cost/better outcomes = TCOC payment Financial reward alignment creates better collaboration to benefit patient care

10 Collaboration Among Primary Care, Specialists and Hospitals (Narrow Networks) Anti-trust and fraud and abuse considerations Waivers available if network is an MSSP ACO HIPAA considerations If not eligible for waivers: Anti-trust: Act separately with payer/purchaser Clinical integration or financial integration

11 Collaboration Among Primary Care, Specialists and Hospitals (Narrow Networks) Stark Are non-employed physicians part of network? Could payments to physicians come from third party instead of hospital/another provider? If payment flows through entity to which physician refers, Stark exception required

12 Collaboration Among Primary Care, Specialists and Hospitals (Narrow Networks) Anti-kickback Even if no federal program beneficiaries served in network, state anti-kickback statute applies (no payment from other providers in network in return for referrals to such providers) If incentive payment disbursed by one entity in network, unlikely to satisfy a safe harbor No OIG Advisory Opinions on narrow networks and remunerations to providers complying with innetwork referral expectations

13 Collaboration Between Provider and Payer and Among Providers BluePrint Health Plan Collaboration between Allina Health and Blue Cross Blue Shield of Minnesota Open to anyone, but targets people with diabetes, hypertension and high cholesterol Plan members get discounts for participating in workshops aimed at encouraging healthy decision

14 Collaboration Between Provider and Payer and Among Providers BluePrint Health Plan In developing the benefit plan, Blue Cross led focus groups with doctors, patients and employers Goal to create a plan that would make health care less overwhelming and encourage plan members to take a more active role in staying on top of their health Built from the ground up, rather than taking an existing product and network and just bolting them together (StarTribune, 8/7/2013)

15 Collaboration Between Provider and Payer and Among Providers BluePrint Health Plan Narrow network health plan Allina Health Network, which includes non-allina Health facilities and providers who participate in a clinically integrated network Comprehensive network of primary and specialty care providers throughout the 11-county metro area 25 hospitals 225 clinics 4,000 physicians

16 Allina Integrated Medical Network Members participate in performance improvement initiatives Share patient health information to support performance measurement and reporting as well as care coordination Commit to performance improvement Members participate in Network payer products such as BluePrint Members participate in AIMN governance

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18 Collaboration Outside Traditional Healthcare myhealthcheck Allina Health collaboration with LifeTime Fitness LifeTime provides comprehensive health and wellness assessment and health promotion program to Allina physicians, nurses and staff Allina Health physicians connect to Life Time destinations in Minnesota to provide medical education and counseling to Life Time members and staff and medical services for Life Time endurance events Together, both explore innovative opportunities to inject health and fitness expertise into traditional health care delivery Allina Health and Life Time partner to provide integrated community health and wellness programs to the community with the goals of reducing overall health care costs and improving access to preventative health and wellness education and services

19 HIPAA Patient Privacy Issues [A] covered entity may use or disclose protected health information [PHI] for treatment, payment, or health care operations, provided that such use or disclosure is consistent with other applicable requirements of this subpart. 45 CFR (a)

20 Patient Privacy Issues HIPAA A covered entity may disclose [PHI] to another covered entity for health care operations of the entity that receives the information, if each entity either has or had a relationship with the individual who is the subject of the [PHI] being requested, the [PHI] pertains to such relationship, and the disclosure is: (i) For a purpose listed in paragraph (1) or (2) of the definition of health care operations (i.e., quality improvement and credentialing). 45 CFR (c)(5)

21 Patient Privacy Issues HIPAA Organized Health Care Arrangement An organized system of health care in which more than one covered entity participates and in which the participating covered entities: Hold themselves out to the public as participating in a joint arrangement; and Participate in joint activities that include at least one of the following:» Utilization review» Quality assessment and improvement activities» Payment activities if some or all financial risk is shared 45 CFR

22 HIPAA Patient Privacy Issues A covered entity that participates in an organized health care arrangement may disclose protected health information about an individual to another covered entity that participates in the organized health care arrangement for any health care operations activities of the organized health care arrangement 45 CFR (c)(5)

23 Patient Privacy Issues Minnesota Health Records Act A provider may not release a patient s health records without: signed, dated consent; specific authorization in law; or representation of consent A provider may release to other providers within related health care entities when necessary for current treatment

24 Patient Privacy Issues Minnesota Health Records Act Forever consent: This consent will continue forever unless you cancel it by writing us at: Allina Health, Information Management, Mail Route 20300, 800 East 28th Street, Minneapolis, MN 55407; but if the consent is cancelled, it will not change releases that have already been made. 86th Legislature, st Special Session, Ch. 1 H.F. No. 1, Art. 20, Sec. 7. Minnesota Statutes 2008, section , subdivision 4, is amended to read: Subd. 4. Duration of consent. Except as provided in this section, a consent is valid for one year or for a lesser period specified in the consent or for a different period provided by law.

25 Triple Aim & PAC PAC = 11% of Medicare spend; significantly faster rate than acute 51% of bundle costs are post-discharge 73% of health care cost variation occurs in PAC 40% of hospitalized Medicare PAC (1/2 SNF) Daily cost of care: Hospital = $1500; IRF & LTAC = $1,300; SNF = $425; HH = $24 Rehospitalization during/after SNF: 23% Multiple patient assessment processes

26 Legislative Developments IMPACT Act of 2014 Standardized PAC assessment tools Standardized quality data reporting Reform PAC payments (site neutral, bundled) BACPAC Act of 2014 Establishes post-acute bundled payment for Medicare A & B services starting in 2016 Covers post-acute services within 90 days of hospital discharge (excluding physician, outpatient hospital, therapy and hospice) PAC Coordinator receives and distributes bundled payments Waives 3 day hospital stay and home health homebound requirement

27 PAC Options Integration (build/buy/utilize swing beds) Know-how; core competency Moratorium Undermines cost differential Collaboration Joint Venture Contractual Arrangements

28 PAC Collaborations Hospitals/ACOs establishing preferred PAC relationships to reduce cost & improve quality Quality metrics EHR Patient Choice & leakage management Clinical support & collaboration Three-day hospital stay waiver Bed Reservation Agreements

29 Legal Issues Patient Choice Fraud & Abuse Patient privacy & data security Moratorium

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33 Concept Interlude Key Features Hospitality atmosphere Guest driven Younger and/or higher acuity guests LOS under 18 days Able to discharge back to home Remote pharmacy for quicker 1 st dose Nurse-to-nurse hand-off between transitions Common quality measures being determined Transition Nurse

34 Joint ownership Interlude Collaboration Clinical Steering/Oversight Clinical Practice - Care pathways; forms; Quality - Care metrics Transitions process; admission, discharge & continued stay criteria Operating agreements EHR CCD; Epic read-only access

35 Pioneer ACO Collaboration Waiver of 3 day SNF qualifying stay SNF admit from home, clinic, ED, observation status Unity & Mercy Hospitals & 4 SNFs Medicare Advantage & MSHO experience Interdisciplinary teams Transition process Care metrics, reporting & oversight Admission criteria Patient Choice & Disclosure financial implications

36 Bed Reservation Agreements Authority in Reimbursement Manual More interest with acute care providers/acos being more discriminating in PAC relationships Per bed payments to ensure availability of preferred discharge location Issues: Payment only for reserved beds not occupied # of beds vs hospital s discharge need Reasonable Payment ($ or in-kind, but cannot supplement Medicare payment)

37 Health Information Exchange Examining the care provided in 2012 to 1,419 ER patients at four Allina Hospitals, [Dr. Paul] Satterlee and other researchers found that 560 tests and procedures were avoided when doctors first checked their patients records at other hospitals and clinics. Four angiograms, 115 CT scans and 58 ultrasounds were among the procedures avoided because they were recently performed elsewhere, according to the study results... StarTribune 4/18/2014 (emphasis added)

38 Health Information Exchange Epic Care Everywhere Framework for interoperability Consent for Common Record form EpicCare Link Extends read-only access to hospital records on Epic to independent referring physicians so they can follow inpatient progress MyChart Portal for patients to be able to view test results, schedule appointments, refill prescriptions, e-message their providers, e-visits, after visit summary

39 Healtheway Health Information Exchange Non-profit, public-private collaborative Operationally supports the ehealth Exchange Formerly referred to as the Nationwide Health Information Network Exchange Participants sign a Data Use and Reciprocal Support Agreement (DURSA)

40 Health Information Exchange Legal issues Patient privacy Consent issues Data security Professional liability risks

41 Thank You