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Managed Care Trends for Strategic Positioning
NELLIE JOHNSON A U G U S T 2 5 , 2 0 1 6
2012-13 Leading Age Michigan Conferences
Product◦ Medicare Advantage◦ ACOs; bundled payment starting (little
emphasis on SNF)
Pricing (how to contract with health plans)
Performance – readmissions / LOS
Today
Product, Pricing and Performance PLUS
Payors
Partnerships/Preferred Networks
Protocols
Prior Authorizations/Preadmission Screening
Person-Centered Care Coordination
Overview - The “P”s of Managed Care Trends
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Managed Care – Concept is Expanding to All Products with Various Partners
Medicare Medicare Advantage Medicare Fee for Service
◦ Accountable Care ◦ Bundled Payment Initiative ◦ Expanded Mandatory Bundles ◦ SNF Value based Purchasing
Medicaid Under 65 Dual (FIDA – Fully Integrated Dual Eligible Long Term Support and Services (LTSS)
Commercial
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Making the Transition to Risk-Based Medicare PaymentPopulation-Based Payment/ Shared Savings/Total Cost of Care
Fee For Service• No risk payments
• Common payments• Predictable
•New metrics•Best practices
•Performance based•Uncertainty
•Electronic communications
•Risk based•Collaboration
•Predictive modeling•Global budget or sub-
capitation
Significant Change
Significant Change
Bundled Payments•Negotiated Episode Price
•Longitudinal Accountability•Risk based
Significant Change
Value Based Reimbursement
No Shortage of Changes/Experiments
Medicare Advantage | National Enrollment
Medicare Advantage | National Growth –Implications
Managed Care – Implications of Population Shifts between Medicare and Medicare Advantage
50% of seniors turning 65 are selecting Medicare Advantage as insurance carrier
Medicare FFS population is aging and becoming more medically complex/fragile
Impacts availability to achieve savings under Medicare ACO/Bundled Payment Initiatives
Changes in Payer relationships/Need for Preferred Network status with ACOs, Bundled Payment and Hospitals
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Preferred Network• Health Plans • ACOs, bundled payment entities • Health System /hospitals –
referral source /payor• Relationships with physician
groups /Bundled Payment
Health systems• Sending out RFPs to form
SNF network• Building SNFs in
partnership with LTC providers
• Converting hospital space into SNF beds
Implications of Medicare Payment Reform –Preferred Network and Physicians
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More States Moving to Medicaid Managed Care Programs
Traditional Fee-for-Service (FFS)
Low or no care management or
care coordination
Enhanced PCP payment or case
management fees
Enhanced federal funding
for enhanced services
Full Risk-Based Managed Care
Higher level of care management
and care coordination with
P4P elements
Shared savings between MCO or
providers and state/feds
Full risk for savings and
losses (MA-SNPs, FIDE SNPs,
Medicaid only ACOs & MCOs)
Traditional Fee-for-Service
Health Home Model
Provider Sponsored
Organization -Share Savings
(ACO)
Waiver Programs (i.e. HCBS)
Primary Care Case
Management Model
Enhanced Primary Care
Case Management
ModelPartial Risk
MCO
Full Risk MCO &
ACO
Focus on the same -VALUE Readmissions to control overall
costs Readmissions to control
penalties/performance metrics Cost – as monitored by length of
stay Quality of care ◦ Scorecards◦ Nursing Home Compare
Health Plans Specific CMS performance metrics will target
plans who have Dual Eligible because of population differences Partner with them to meet these metrics More integration/consolidation of health
plans Dual Eligible Plans have savings taken off
the top and a quality withhold as an incentive to perform
Implications of Medicare/Medicaid Payment Reform –Performance Data
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CMS Final Comprehensive Care for Joint Replacement (CJR) Model Bundled Payment
CMS’ final rule requires all PPS hospitals in 67 Metropolitan Statistical Areas to participate in a Bundled Payment demo for a Lower Extremity Joint Replacement – MS-DRG 469 -470◦ 90-day episode post-discharge◦ Hospitals in these areas are required to participate unless already in a
BPCI model.
Goal: Reduce current variation in cost and quality of care for hip and knee replacements ($16,500-$33,000)
Annually set prices over 5 performance years
Payment reconciled at the end based on price & quality (Fee for Service with Reconciliation)
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CJR – Key elementsStarts April 1, 2016
67 Metropolitan Statistical Areas
Target price = 2% discount on current bundle cost (risk-adjusted)
Bundle includes all Medicare A & B services related to DRG
Hospitals only eligible to receive “savings” if meet quality
Hospitals permitted to share these savings with other collaborating providers (e.g., PAC)
Bundled Episodes: Comprehensive Joint Replacement(CJR) – Payments
All providers continue to be paid FFS
Hospital reconciles its CJR target price to actual price annually with CMS◦ Year 1: No repayment obligation◦ Year 2: repayment up to stop loss of 5%◦ Year 3: repayment up to stop loss of 10%◦ Years 4 and 5: Repayment up to stop loss of 20 %
Hospital is allowed to share: reconciliation payments, internal cost savings, and the repayments with certain providers and suppliers.
CJR – CMS Waivers for Care Delivery FlexibilityThree-day inpatient hospital stay prior to admission for a covered SNF stay
◦ Begins Year 2 of demo
◦ Only SNFs with 3-Star or higher rating are eligible
Payment for certain “in-home” physician visits to a beneficiary via telehealth
Payment for certain physician-directed home visits for non-homebound beneficiaries
Went from proposal to implementation in 9 months!!!!
CMS Announces Two New Mandatory Bundles on July 25, 2016 – Effective July 2017
1. Expanded CJR to include hip and femur fractures
2. Created new cardiac episodes for health attacks and bypass surgery
Pending- CMS notes round of voluntary bundling (BPCI) will start in Cy 2018
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Bundled Episodes – New Use By Health Plans for Medicare Advantage Members
1. Health Plans are contracting with Health systems/care coordination entity and paying capitated rate for 30 day episode
2. CONTESSA- “Contessa Health creates and manages home hospitalization programs. By partnering with Contessa Health, physicians are able to shift complex surgical procedures and chronically-ill patients to the most clinically appropriate site of care, allowing their patients to enjoy home-based recovery. Contessa Health provides clinical, administrative and technological resources to enable physician partners to deliver the highest quality outcomes in a prospective bundled payment arrangement.”
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What does this mean for PAC Providers?
Shorter lengths of stay –
Must control readmissions - -
No 3-Star or higher rating = no referrals without 3-day hospital stay;
. Hospitals may discharge direct to home with or without home health for these DRGs
Hospitals may discharge to SNFs earlier ( = shorter hospital lengths of stay)
How do you Strategically Partner with Entities
1. Clinical Protocols by diagnosis – develop with speciality groups/medical director
2. Control Length of StayA. monitor by diagnosis
3. Control Readmissions – Best Practices INTERACT Care Transitions (hospital-NH-Home)Person Centered Care Coordination
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How do you Strategically Partner with Entities
4. Need to be able to take hospital/ER admissions 7 days week/24 hours a day;
5. Therapy – Start eval/therapy on day admission;
6. Nursing Home Compare 3 Stars and above to accept admission without three day stay; Tell your story – rolling average of 2 yearsGive them other Nursing Home Compare scores;
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Brief Overview of INTERACT
INTERACT- Interventions to Reduce Acute Care Transfers FREE --Evidenced based clinical system that resulted in 20% reduction in readmissions from nursing homesHas moved from a INTERACT 2 took kit approach to INTERACT 4- QAPI
program LeadingAge Michigan offered two 8 hour workshops in March 2016 Some EMR (PointClick Care)- has integrated INTERACT tools into EMR
system
Website: http://www.interact4.net
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INTERACT Key ToolsQuality Improvement collection of data to complete root cause analsyis
Decision Support Tools Care Paths for six diagnostic Onsite capabilities to assess/treat conditions◦ CHF, Pneumonia, UTI, Acute Mental Status, Fever, Dehydration, lower respiratory,
dementia
Communication tools ◦ SBAR Communication tools◦ Stop/Watch
Nursing Home transfer form/Care transitions to ER
Website: http://www.interact4.net
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Successful Implementation of INTERACT
Research study completed by Dr. Joseph Ouslander, M.D. and published in JAMDA (Journal for American Medical Directors) noted following points to be successful:
Executive Leadership support (Administrator, DON, Medical Director, Clinical Pharm) Creates interdisciplinary team and promotes training Reviews and uses data to improve care
Engagement of Direct Care Staff by INTERACT Champion
Facility Culture dedicated to quality improvement Integrated into new hire orientation Part of QAPI program Training and implementation delivered using a nonpunitive approach When avoidable hospitalizaitons are identified, a spirit of inquiry by the multidisciplinary team seeks
improvement, not blame
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Best Practices: Overview Care Transitions ProcessDefinition of Care Transitions – “The set of actions necessary to ensure coordination and continuity of health care as patients transfer between different health care settings or levels of care.” (Coleman and Berenson. Ann Intern.med. 2004 140: 533-536) Four Critical Components of Safe Transfer * Medication reconciliation Patient Education (Coaching)◦ Resolve confusion over medications ◦ Identifying indicators of worsening conditions (red flags) and knowing who to call Communication between sending and receiving providers◦ Discharge summary /Care transitions plan ◦ Patient ◦ Propriety software ◦ Email and/or phone Timely Physician Follow up
*based on research and PPT presented at American Geriatric Society Convention 11/4/2009; “Safe Care Transitions – Bridging the Silos of Care”
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Care transition planning from hospital◦ Know readmission rate; work on
issues with hospital/pharmacy ◦ Take admits on 24/7 basis
Care planning within PAC Unit/LTC◦ Best practices/INTERACT◦ Root Cause Analysis of readmissions
Care transitioning to home ◦ Start at time of PAC admission◦ Connect to physician appointments ◦ Monitor patient (up to 60-90 days)
upon discharge to determine if plan was successful
Implications of Medicare Payment Reform –Person-Centered Care Coordination
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LeadingAge – Avalere Collaborative Reports- How do you use these reports
LeadingAge members have access to monthly reports from Avalere, however, the data is updated annually. This data is presented by market, by hospital, by PAC site and provider.
Avalere VantageCare Positioning System
Core AnalyticsPost-Acute Scorecard
Other Issues of ImportanceRole of the Medical Director Quality control monitoring/part of QI committee; development of protocols Troubleshooting with physicians TCU-oversight of model Separate medical director?
Control of Pharmacy CostsUse of genericsPharmacy contract
Interoperability- sharing of patient care information across provider groups
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Provider Responses to Trends/Health Care Initiatives Providers- do it alone
Join a Network
Consolidate Business/Sell
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How Did LeadingAge Michigan Respond to These Trends?
Formed SeniorCare Resources, for profit Limited Liability Corporation (LLC) LeadingAge Michigan owns 100% of this subsidiaryMission in Bylaws/Contracts: “Develop and support a clinically and financially integrated network of participants who work together with Network to maximize the health and well-being of seniors through innovative, cost effective care management practices and quality improvement activities with entities involved in managed care.”Structure allows Network to share data; meet antitrust concerns as well
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Network Year Formed
# of NH Homes
# of SNF Beds Member Criteria
CareChoice MN 1996 22 Members/37 NHs
4900 Not for profit with nursing home
Care VenturesMN
1999 18 1200 Not for profit
Florida (FAHA H&S)
2012 30 3125 LeadingAge member
Michigan-SCR 2013 21 2100 LeadingAge member
LeadingChoice/LCN/WI
2016 70 members/87NH’s
8100 LeadingAge member
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Summary -Dynamic and Changing Times 1. Managed care Initiatives are happening across all payor types
2. Requires providers to refine Clinical Practices /Protocols and implement best practices to managed length of stay and costs 3. Informatics/Data will be key to survival
4. Need to proactive – develop and refine scorecard and value proposition based on data
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