Annual Conference November 12, 2015 Presented by: Jane Jerzak, RN, CPA, Partner Clinical Integration Concepts for Agenda Population Health and the Movement Toward Clinical Integration Consumerism Patient Care Redesign Concepts Objectives To understand the business trends facing health care providers today To evaluate how clinical integration is changing the care delivery process To assess how value-based care is impacting reimbursement methods To determine how patient care redesign programs are emerging to create a new model of care delivery 2 November 12, 2015 Page 1
Population Health is Emerging Transforming the Care Delivery Process Through Clinically Integrated Systems of Care Clinical Integration is Changing the Focus of Health Care What is Clinical Integration? Coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused. An organization-wide quality infrastructure. The goal is to coordinate patient care and position participants for success by leveraging quality. Source: AHA description of clinical integration 4 November 12, 2015 Page 2
Clinical Integration is Changing the Focus of Health Care The Changing Health Care Landscape Clinically integrated networks (CINs) of care are forming with the continued pressure to bring down health care costs and reduce reimbursement. The shift to Accountable Care and value-based reimbursement is tied to the performance of services with an expected quality outcome. The World as Our Health Care Clients Know it Is Changing Health care provider revenue stream equals service volume (and service mix) multiplied by reimbursement rates for services. Clinical integration is placing downward pressure on both service volumes and reimbursement rates. Clinical integration is adding a quality (and outcome) expectation to the service delivery model. 5 Clinical Integration is Changing the Focus of Health Care The Organized System of Care Clinically Integrated Network Governance Clinical Programs Care Management Contracting Infrastructure 6 November 12, 2015 Page 3
Clinical Integration is Changing the Focus of Health Care Key Drivers Reimbursement (FFS vs. Capitation) Cost-of-care (PMPM) Patient Access Reconciliation Period Provider/Member Attribution Value- Based Contract Products Employers Care Management and Quality Indicators Patients 7 The Care Delivery Process is Changing Accountability for Care CIN will add financial incentives (or penalties) to provide the appropriate level of care therefore, volumes may shift downward as a result. We are seeing that health systems (and hospitals) are often willing to take on the downside risk, with the upside benefit accruing to physicians in the CIN. Unless the reduction in volumes is offset by market share increases, health care organizations may be negatively impacted. The fight for market share could be significant patients in their networks will be key particularly their narrow networks. 8 November 12, 2015 Page 4
The Care Delivery Process is Changing Patients are placed into care categories (well, rising risk, and chronic care patients). Reimbursement systems may include a per member per month payment for a care team to manage the care of a population (or for chronic conditions only) in addition to fee for service payments. Welcome to Medicare visits may be done by a RN/social worker or other ancillary providers thus revenue streams may change. 9 The Care Delivery Process is Changing End of life care is being redefined. Volume reductions in hospital care is expected. Health systems are creating "SNFist" programs trained primary care physicians and care teams who manage care of patients in nursing homes moving the SNF to a medical model of care with clinical outcomes expected. We believe the percentage of patients dying in the hospital will decrease over time. 10 November 12, 2015 Page 5
The Care Delivery Process is Changing Patient care protocols and expectations are changing. Care may be done in the home, via e-monitoring systems, etc. Nonclinical providers may be doing portions of the care. 11 The Care Delivery Process is Changing Integration Shifting Volume to Value Non-value-based care will be challenged and care at the wrong settings (inpatient vs. outpatient vs. home-based) may be denied. Claim denials create a potential liability for the health care organization watch for denial trends, percent of denials, and if any pending claim denials should be allowed for at year-end. Physician education will be required to understand the changing landscape. Based on our review of critical access hospital claims, we see a substantial portion of inpatient cases admitted for what Medicare considers ambulatory sensitive conditions risk of future inpatient volumes! 12 November 12, 2015 Page 6
Value-Based Care Will Change Reimbursement Methods Value-Based Contracting Value-based contracting = accountability for cost and quality Value-based contract goals: Deliver a clinically integrated network of providers Assume accountability for patients (members) within the contract Manage patients around the total cost of care Use quality metrics to drive outcome improvement 13 Value-Based Care Will Change Reimbursement Methods Value-Based Payment Models Fee-for- Service Pay-for- Performance Value-Based Purchasing Bundled Payments Shared Savings Global Payments Fee-for- Service Providers are paid a specified amount for each service provided. Pay-for- Performance Incentives for higher quality are measured by evidencebased standards. Value-Based Purchasing Percentage reimbursement at risk, earned back by high-quality outcomes. Bundled Payments Single payment for episodes of treatment, shared by hospital and physicians. Shared Savings Percentage of savings from reduced cost of care shared with hospitals and physicians. Global Payments All services compensated in one payment that manages the patient across the delivery system. Consumers Employers Health Plans Government Payors Physicians Medical Groups Hospitals Other Providers Source: HFMA 2010 The Advisory Board 2010 14 November 12, 2015 Page 7
Value-Based Care Will Change Reimbursement Methods Fee-for-service models are changing with more fixed payments for outpatient and other services in contracts. Percent of charge contracts are shifting to fixed payment rates for some or all outpatient services as providers, you will need to carefully validate estimated reimbursement on accounts receivable historical trends may be only marginally useful in this period of change. 15 Value-Based Care Will Change Reimbursement Methods Pay for performance with upside and downside risk Need to understand upside and downside contract risk and impact on reimbursement by payor. These settlements (and analysis of contract performance) should be monitored throughout the contract year need to consider the potential of a loss contingency. We are seeing that the CIN downside risk may be absorbed entirely by the health system rather than by individual physicians or physician groups in the CIN. 16 November 12, 2015 Page 8
Value-Based Care Will Change Reimbursement Methods Bundled payments across providers Bundled care models may commit to a fixed price for hip surgery, as an example, to encompass the surgeon, anesthesia provider, hospital, rehab provider, and possibly more providers involved in the care for a period of time post surgery. We have not seen providers be successful at these bundled care programs thus far; often they are put in place with payment changes driving the concept, not care changes driving the concept. Therefore, the endpoint thus far has simply been a reduction in reimbursement for the same services. 17 Value-Based Care Will Change Reimbursement Methods Current Fee-for-Service Model Future State Bundled Payment Reimbursement Model 18 November 12, 2015 Page 9
Value-Based Care Will Change Reimbursement Methods Movement toward a percent of premium (more mature system) Providers will be assuming clinical care risk (may not contract for "insurance risk" what is not controllable) under these contract types. Actuarial estimates may be required to estimate the portion of liability associated with total cost of care for services not provided within CIN. 19 Value-Based Care Will Change Reimbursement Methods Health exchange product rates may be close to Medicare rates or less Depending on number of lives covered, these plans may increase patient volumes at "Medicare like" rates. However, this may be better than uninsured rates, which may be close to no reimbursement. An analysis of patients gained vs. any negative reimbursement impact will need to be understood before such contracts are agreed to. 20 November 12, 2015 Page 10
Information Technology and Big Data Are Driving Change Supporting CIN Development Data Is Being Transformed Into Information Quality metrics are expanding Electronic Medical Record ( EMR ) investments are now being used to track care and "quality" with greater transparency (CMS's Hospital Compare, Nursing Home Compare, etc.). Data from both EMRs and claims is used to understand what services are provided to a given population and the outcome of those services. Where is value really created? 22 November 12, 2015 Page 11
Data Is Being Transformed Into Information Care processes are being analyzed with a shift to predictive analytics Medicare reimbursement penalties are now in place for "poor" quality metrics. Care will be predicted in the future based on historical clinical data at the patient level and the probability that care intervention will impact potential care outcomes. Higher level analytical tools may also be required for billing Medicare Chronic Care Management Code requirements. Kryptiq is first among PHM vendors to meet the CCM requirements. Source: Kryptiq.com 23 Consumerism November 12, 2015 Page 12
Consumerism Is Placing Downward Pressure on Price Price transparency Potential need for Strategic Pricing Study to adjust price-sensitive services (imaging/lab, etc.). Non-urgent outpatient care is shifting to lowerprice options (MRI/CT, etc.) for people with high deductible plans. Insurers are recommending where services should be provided based on cost to the consumer (reimbursement rates to the provider). This is likely to shift volumes to imaging centers or other lower cost providers. 25 Consumerism Is Placing Downward Pressure on Price Retail medicine For people with no chronic conditions, there is a shift toward fixed price urgent care services from Walgreens and other market players (using this as a "loss leader" for higher margin pharmacy sales). This shift could erode ambulatory service volumes in traditional health care organizations. 26 November 12, 2015 Page 13
Consumerism Is Placing Downward Pressure on Price Insurance coverage and high deductible plans High deductible plans create a shift from commercial insurance to self-pay accounts, which may require an increase in revenue allowance amounts for health providers. Be careful to value receivables accurately are these dollars in commercial accounts or have they been reclassified to self-pay? Given high deductible plans, reimbursement from commercial insurers in aggregate may be less than Medicare rates considering patient responsibility, which often turns into bad debts. 27 Patient Care Redesign Concepts November 12, 2015 Page 14
Physician Risk Quadruple aim Triple aim plus one (lower cost/higher quality/greater patient satisfaction and provider satisfaction). Physicians are leaving practice or moving to other practice locations creating care gaps and risks for health systems. This may place risk on an organization s revenue stream. Particularly for small hospitals this could change financial performance substantially. Patient Care Redesign programs are also emerging to create a new model of care delivery. 29 Background on Patient Care Redesign Programs Providers 30 November 12, 2015 Page 15
Background on Patient Care Redesign Programs Providers (Continued) 31 Background on Patient Care Redesign Programs Maximizing Resources PROVIDER 50 % 50 % Provider Level License Non Provider License Level Work STAFF 50 % 50 % Staff Level License Non Staff License Level Work 32 November 12, 2015 Page 16
Patient Care Redesign Programs Moving to a clinically integrated model of care with reimbursement shifting from fee for service to value-based pay will further stress current state operations particularly in the primary care ambulatory care setting, along with: RAF score coding requirements Risk Adjustment Factor (address coding requirements to maximize appropriate level of service with acuity) UHC premium and other insurer designation programs Meaningful use requirements ICD-10 implementation Open access expectations public demand Competition Etc., etc., etc.... How can the care process change to successfully care for patients, staff, and providers? 33 The current practice model in Primary Care is unsustainable. C. Sinsky, MD et al 34 November 12, 2015 Page 17
Team-Based Care Concepts Three Core Principles for Team-Based Care Office Visit Redesign In-Between Visit Redesign Population Health Management Definition of Team Each member of the team plays a defined role to care for a patient population Core team: MD, NP/PA, Registration/scheduling, RN, Care Team Coordinator (CMA/LPN) Extended care team: Behavioral Health, Diabetes Educator, Case Manager, Health Coach, RN Care Coordinator, and Pharmacist 35 Team-Based Care Concepts Office Visit Care team meetings Co-location of core team members Evolving Patient Admission Rep role (Schegistration) Evolving role of CMA/LPN = Care team coordinator Evolving role of the RN Huddles 36 November 12, 2015 Page 18
Team-Based Care Concepts Office Visit Before Provider Care Team Coordinator: Follows standard rooming process Populates visit diagnoses from problem list Sets up refills Identifies visit agenda Identifies and addresses care gaps Pulls up appropriate templates Starts documentation 37 Team-Based Care Concepts Office Visit With Provider Care Team Coordinator: Presents patient to provider Continues team documentation Enters orders for consults, new meds, and tests needed Acts as patient advocate Provider focuses on the patient, examination, and decision making. 38 November 12, 2015 Page 19
Team-Based Care Concepts Office Visit After Provider Care team coordinator: Reviews plan of care Reviews ordered tests or consults Enters future orders Schedules next appointment Reviews AVS with patient Engages extended care team member as needed Escorts patient to next station Provider responsible for editing and finalizing the team documentation for visit. 39 Team-Based Care Concepts In-Between Visit (In basket tasks) RN/Care team coordinators assist with in basket items shared with provider Test results (normal and abnormal following protocols) Medication refills Orders needed queue them up for provider to sign Intercept unnecessary messages to provider Increased verbal communication between members of the care team decreases electronic messaging Panel management in conjunction with Central Care Management Team Provider responsible for signing off on in basket items. 40 November 12, 2015 Page 20
Team-Based Care Concepts Support Population Health What Is Population Health Management? The health outcomes of a group of individuals including the distribution of such outcomes within a group. Requires the following steps: Define the population Stratify risks Identify care gaps Engage patients Manage care Measure outcomes It is an approach to health that aims to improve the health of an entire population. Population health management includes all factors including social, environmental, cultural, and physical that have a measurable impact on the health of the population. 41 Team-Based Care Concepts Support Population Health Stratifying patients by risk will allow Clinically Integrated Networks to target the most acute patients; ultimately, all patients within the system will have a Comprehensive Health Profile and corresponding Care Plan that matches their acuity. Low Population Acuity High Self-Managed Single Condition Traumatic Event Highest-Risk Patients High Risk Profile Past ED High-Use Past Readmission(s) Current Admission, Discharge or ED Visit Readmission Physician Referral Condition Care Plan Well Patient Care Plan Care Coordination Primary and team-based care, specialty care, and community resources 42 November 12, 2015 Page 21
Team-Based Care Concepts Support Population Health Population Health Risk stratify patient population to determine the appropriate care team member(s) to engage with the patient. Proactive approach examples in prototype: Medications >15 Pharmacist activated A1c s > 9 - Diabetic Educators activated Depression screening Behavioral health activated (process in development) Highest risk RN Care Coordinator activated 43 Team-Based Care Concepts Support Population Health Population Health (Continued) Real-time approach example in prototype RN visits with rising-risk patients Involvement of extended care team member with high-risk patients at the time of the visit Maximize the talent and skill of each care team member Provide resources to support the provider and care team in improving the health of patients. 44 November 12, 2015 Page 22
Team-Based Care - The Triple Win 1) Win for the Patient Improve patient experience during office visit by maximizing direct provider engagement via reduction in clerical and computer tasks. More resources to support the needs of the patients via extended care team. Improve patient engagement and self-management skills by maximizing involvement of the health care team. 45 Team-Based Care - The Triple Win 2) Win for the Care Team Improve provider experience by assistance with refill management, documentation, order entry, in basket management, and help with high-risk patients via the extended care team. Improve staff experience by maximizing direct patient care to the level of clinical licensure. Improved efficiency of the office visit allows for improved access and more time to deal more effectively in meeting patient needs. Improved satisfaction of all staff by working together as members of a health care team. 46 November 12, 2015 Page 23
Team-Based Care - The Triple Win 3) Win for the System Access to more market share as a result of improved patient experience and engagement. Retain existing staff and providers and effectively recruit due to improved care team experience and engagement. Generates confidence in participating in risk-based contracts as a result of improved quality measures and team-based care. Improve financial viability in both current and future health care environments. 47 Team-Based Care - The Triple Win for Population Health Sample Measures Win for the Patient Quality Measures (WCHQ) Patient Satisfaction (CG CAHPS 3,4,5 or special survey) Access to care team member for appointments Win for the Care Team Care team satisfaction (team culture survey pre/post) Patient Panel Health (change in WCHQ measures) Win for the System ROI Financial and Quality Value-Based Contracts 48 November 12, 2015 Page 24
Team-Based Care - In Summary Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. C. Sinsky, MD et al 49 Population Health Concepts - In Summary We have an opportunity to redesign how we think about health and the delivery of health care services through Clinical Integration (organized systems of care) and Population Health concepts. We also have an opportunity to redesign care and how we get paid for what we do. As providers, you will need to take the lead on this journey to make it happen successfully. Are you up for the challenge? 50 November 12, 2015 Page 25
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Contact Information Jane Jerzak, RN, CPA Partner, Wipfli Health Care Practice 469 Security Boulevard, Green Bay, WI 54313 920.662.2821 jjerzak@wipfli.com wipfli.com/healthcare 53 wipfli.com/healthcare 54 November 12, 2015 Page 27