fresenius health partners esco overview · 5/23/2019 · fresenius health partners esco overview....
TRANSCRIPT
For Internal Purposes Only.
May 23, 2019
Glenda Wooten
Senior ESCO Program Manager
Fresenius Health Partners ESCO Overview
For Internal Purposes Only.
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
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Disclaimer
For Internal Purposes Only.
Renal Care in a Value-Based Model
Opportunities
The Nephrologist is the
principal care provider for
the ESRD patient and
are involved in most
major care decisions
The ESRD patients are
in the dialysis clinic three
times a week making it
the logical medical home
Fragmented Care
negatively impacts the
patient’s quality of life
and increases the risk of
hospitalizations
This is a resource
intensive cohort of
patients, with annual
costs 10 times that of an
average Medicare
patient
Challenges
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For Internal Purposes Only.
End Stage Renal Disease Seamless Care Organization or ESCO
Partnerships between CMS, nephrologists and dialysis providers
Accountable for all facets of their matched beneficiaries’ care
Share savings with CMS if matched beneficiaries’ expenditures decrease and quality is maintained or improved
Share losses if beneficiaries’ expenditures increase
Understanding ESCOs
CMS
ESCO
Dialysis Units Nephrology Practices
Others
Medicare FFS Beneficiaries
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For Internal Purposes Only.
Patient Eligibility
Enrolled in Medicare Parts A and B
Medicare is primary payer
Not be enrolled in a Medicare Advantage plan,
cost plan, or other non-Medicare Advantage
Medicare managed care plan
Not be affiliated with an existing shared
savings program
At least 18 years of age & reside in the US
Not received a kidney transplant in the last 12
months
Matching through “first touch”
Receive at least 50% of annual dialysis
services in the ESCO’s market area
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For Internal Purposes Only.
Beneficiary matching is based on the dialysis unit
Initial matching is preliminary
Final matching for shared savings/loss is retrospective
Beneficiaries retain all of their freedom of choice
Medicare continues to pay claims
Patient Attribution
Note: A beneficiary will be removed from the ESCO’s list of aligned beneficiaries for the entire Performance Year if the patient received more than 50 percent of his or her dialysis services from one or more Dialysis Facilities outside of the Market of the ESCO during the Performance Year. *
*Beginning in 2018 (PY3) geographic exclusions may apply.
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For Internal Purposes Only.
Fresenius – 6 ESCO’s
DCI – 3 ESCO’s (Nashville, Spartanburg, Newark)
DaVita – 3 ESCO’s (Phoenix, Miami and Philadelphia)
Non-Large Dialysis Organizations
• Rogosin Kidney Care Alliance (NY)
October 2015 – December 2016
Initial 13 ESCO Programs
For Internal Purposes Only.
Fresenius – 24 ESCO’s
DCI – 5 ESCO’s (Nashville, Spartanburg, Newark, Kansas City, Pittsburgh)
DaVita – 3 ESCO’s (Phoenix, Miami, Philadelphia)
Non-Large Dialysis Organizations (1 ESCO each)
•Rogosin Kidney Care Alliance – NY
•Northeast Ohio Renal Alliance – Cleveland
•The Gotham City Kidney Care ESCO – NY
•Northwest Kidney Alliance – Seattle
ESCO Programs 2017 to present: 36 Total
For Internal Purposes Only.
Fresenius ESCO Experience
ESCO/Location Seamless Care of Atlanta Seamless Care of Houston
Seamless Care of Central
Alabama Seamless Care of Indianapolis
Seamless Care of Central
Illinois Seamless Care of Las Vegas
Seamless Care of Central North
Carolina Seamless Care of Louisiana
Seamless Care of Central
Texas Seamless Care of Maryland
Seamless Care of Charlotte
Seamless Care of
Massachusetts Seamless Care of Chicago Seamless Care of Michigan
Seamless Care of Columbia Seamless Care of Minneapolis
Seamless Care of Dallas Seamless Care of New York
Seamless Care of Delaware Seamless Care of Philadelphia
Seamless Care of Erie Valley Seamless Care of Portland
Seamless Care of Gulf Shore Seamless Care of San Diego
2015 – 6 Cohort 1 ESCO’s
2017 - 24 ESCO’s
For Internal Purposes Only.
Care Navigation Unit
For Internal Purposes Only.
CNU Focus:
to reduce
unnecessary
hospital
admissions
CNU is a team of nurses, social workers and service operations specialists who provide 24/7 coordination of care support
Care Navigation Unit (CNU)
Monitors patients real time allowing for “just in time”
interventions to find solutions and remove
obstacles
Increasing communication between key stakeholders
in a fragmented system
Empowered to take extraordinary measures to safely coordinate care at
the lowest level of intensity
24/7 access to all patient data contained in the dialysis center EHR
Caring for >48,000* patients in various programs across
North America
* As of October 2018
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For Internal Purposes Only.
CNU Focus: Reduce Unnecessary Hospitalizations
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For Internal Purposes Only.
1%
10%
16% 16%
12%
10% 8%
6% 5%
3% 3%
11%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Same 2 4 6 8 10
Admits LOS
CNU Focus: Reduce Unnecessary Hospitalizations
$7,541
$9,128
$10,133
$10,568
$0 $5,000 $10,000 $15,000
Same
1
2
3
Avg Cost/day
0-3 day stays are often treatment adherence
related
All admits are high cost DRG
w/MCC
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For Internal Purposes Only.
FHP Care Navigation Unit Coordination
• Scheduling medical appointments
• Coordinating home health services
• Obtaining DME covered by health
plan
• Locating community resources
• Coordination of transportation
• Provide short term
transports during
temporary disruption of
permanent transportation
• Locate long term solutions
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For Internal Purposes Only.
Predictive Analytics and Clinical Insights: FHP teams have developed technology and predictive models to identify a list of high risk members, enabling the front line CNU to reach out in advance of clinical issues either telephonically or face to face.
Clinical Member Surveillance
Multiple hospital
admissions and /
or ER visits < 90
days
Local CNU,
Provider or
Clinic Insight
and Requests
Clinical
Indicators
EOL Predictive
Model
Weekly No Show
Predictive Model
Hospitalization
Risk Predictive
Model
High Visibility Member List
Incident
Members
F2F Visits by CNU RN
Contact the CNU at
mycarenav@fmc-
na.com with member
needs & F2F requests
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For Internal Purposes Only.
Safe and Effective
Care Coordination
Providing care
opportunities in outpatient
setting
● Reduce unnecessary ‘emergency’ services
● Reduce unnecessary hospital admissions
● Reduce unnecessary hospital re-admissions
For Internal Purposes Only.
Quality
For Internal Purposes Only.
Quality Categories - 2017
• Combination of claims data and chart review 10 Hybrid Measures
• All based on claims or other CMS documentation – upside is that shared savings strategies work in tandem with 2 of these measures.
3 Standardized Ratio Measures
• KDQOL – This is a Health Outcome Survey (HOS) methodology
• ICH-CAHPS – uses Dialysis surveys conducted for Dialysis Clinic Quality
7 Survey Measures
• Patient Safety and Clinical Quality of Care 6 QIP Results
Total of 26 measures
For Internal Purposes Only.
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Quality Categories -2018
9 Hybrid Measures
Standardized Ratio Measure
•2 measures of patients on transplant waitlist
• standardized ratio of First kidney transplant waitlist
•percentage of Prevalent patient on a waitlist
•Based on medical records and CMS Data Warehouse
Transplant Wait List
2 Surveys
ICH CAHPS & KDQOL
Total of 19 Measures
Based on hospital claims or CMS Clinical Data Warehouse
Combination of claims data and medical records
For Internal Purposes Only.
3 - Hybrid Measures
1 - Standardized
Ratio Measure
1 - Survey
Total of 5 Measures
Quality Categories- 2019
Combination of Medicare claims data and medical record data
• Influenza, Depression, Advance Care Plan
Hospital claims or other CMS documentation
ICH-CAHPS – dialysis survey conducted for Dialysis Clinic Quality
• 6 Domains
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For Internal Purposes Only.
PY 1 Results – All 13 ESCOs
For Internal Purposes Only.
Questions??????
For Internal Purposes Only.
Glenda Wooten, RN, MN, NEA-BC
Senior ESCO Program Manager
Cell – (704) 412-0004
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Contact Information