navigating oceans of data - being part of and competing in the aco & bundled payment reforms!
DESCRIPTION
Bundled Payment BPCI and Accountable Care Organizations are changing the paradigm for payment and delivery of post acute care. This change creates episode of care programs. The presentation reviews how New Jersey is affected by BPCI and ACOs.TRANSCRIPT
Navigating Through Oceans of Data: - Being Part of and Competing in the ACO & Bundled Payment Reforms!
Presenter: John Sheridan, MHSA, FACHE
Navigating the Perils of Care TransitionNew Jersey Long Term Care Leadership Coalition2014 Annual Conference
22
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
First Question
• "the great American medical guilt trip“› We spend far more on health care for worse
health outcomes, including higher mortality, compared to other countries.
A.This statement is absolutely True
B.The statement needs clarified
C.The statement is absolutely False
33
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Why must we face and know Data?Or The Question that is the “Elephant in the room.”
“Are we appropriately Doctored”? / Are we well served?
• "the great American medical guilt trip“› We spend far more on health care for allegedly worse health
outcomes, including higher mortality, compared to other countries. › This is an apples-to-oranges comparison of vastly different
geographies, social structures and cultures. After subtracting homicides and automobile fatalities, the mortality discrepancies largely disappear. We cannot cure homicide and automobile fatalities once they have happened
• Medicine, like life [or “Big Data”], inevitably consists of messiness, error, tedium, unresolvable dilemmas and contradictory trade-offs. › Book Review: 'Doctored' by Sandeep Jauhar By THOMAS P. STOSSEL, MD – Wall Street Journal Aug. 25, 2014
44
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Objectives
1. Describe key elements of post-acute care organization's operations
2. Identify metrics for quality and reimbursement influenced by relationships between acute and post-acute care providers
3. Describe how better data and a coordinated process can improve decision making
4. Apply disease state management, EMR, and analytics within your QAPI programs
55
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Where is data taking us?
Slide taken from“In Pursuit of High Value
Care”Shari M Ling, MDDeputy Medical Officer / CMSAHCA Quality Symposium 2/12/14
66
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Interoperability supports a Changing Health System where we face……
1. Continuing the financial penalties for readmissions2. Improving Nursing Workflow for LT-PAC 10/1/2014 Hospital Value-based payment in part
determined by Person Centered Episode (PCE) experience
3. Bundled Care DRG like Payment for episodes4. Person Centered Medical Homes, and5. Continuing reform of Medicare as social insurance
such as creation of Accountable Care Organizations (ACOs) and Medicare Shared Savings plans
77
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Today’s Topics and Lessons
• Part 1› Describe New Jersey - Bundled Payments, Who, What,
Why, How Conclude part 1 with Summary of Programs
• Part 2› Describe New Jersey – ACOs, Who, What, Why, How Conclude part 2 with Summary of NJ ACOs
• Part 3 & Conclusion› Review what we have as data and what is coming!
• Questions
88
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Key elements of post-acute care organization's operations
• Who is served?• Who are the acute and post-acute providers?• What funds are expended and are at risk?• What about ACOs and Bundled Payment options
& conveners?• What might we measure?
99
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Who is served for Long Term Care?Age Cohort Male Percent Female Percent Total Percent
Aged <12 months 56,562 0.6% 54,007 0.6% 110,569 1.3%Aged 1-4 years 227,322 2.6% 217,391 2.5% 444,713 5.1%Aged 5-9 years 291,269 3.3% 277,253 3.2% 568,522 6.5%Aged 10-14 years 289,787 3.3% 275,834 3.2% 565,621 6.5%Aged 15-19 years 298,109 3.4% 281,747 3.2% 579,856 6.7%Aged 20-24 years 271,983 3.1% 260,617 3.0% 532,600 6.1%Aged 25-29 years 286,769 3.3% 270,171 3.1% 556,940 6.4%Aged 30-34 years 283,292 3.3% 270,188 3.1% 553,480 6.4%Aged 35-39 years 300,902 3.5% 297,983 3.4% 598,885 6.9%Aged 40-44 years 323,915 3.7% 330,459 3.8% 654,374 7.5%Aged 45-49 years 351,304 4.0% 358,062 4.1% 709,366 8.1%Aged 50-54 years 322,752 3.7% 334,789 3.8% 657,541 7.6%Aged 55-59 years 264,048 3.0% 281,737 3.2% 545,785 6.3%Aged 60-64 years 215,348 2.5% 241,115 2.8% 456,463 5.2%Aged 65-69 years 157,657 1.8% 186,199 2.1% 343,856 3.9%Aged 70-74 years 117,110 1.3% 145,561 1.7% 262,671 3.0%Aged 75-79 years 91,187 1.0% 127,166 1.5% 218,353 2.5%Aged 80-84 years 67,175 0.8% 109,136 1.3% 176,311 2.0%Aged 85 years and over 51,853 0.6% 119,980 1.4% 171,833 2.0%
Total 4,268,344 49.0% 4,439,395 51.0% 8,707,739 100.0%
Total 65 Years and over 484,982 5.6% 688,042 7.9% 1,173,024 13.5%
Population of New Jersey - estimate 2009
Total USA 65 Years and over 16,823,560 5.5% 22,747,030 7.4% 39,570,590 12.9%
1010
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What is the potential Medicare A Population
Age Cohort Male Percent Female Percent Total PercentAged 65-69 years 157,657 13.4% 186,199 15.9% 343,856 29.3%Aged 70-74 years 117,110 10.0% 145,561 12.4% 262,671 22.4%Aged 75-79 years 91,187 7.8% 127,166 10.8% 218,353 18.6%Aged 80-84 years 67,175 5.7% 109,136 9.3% 176,311 15.0%Aged 85 years and over 51,853 4.4% 119,980 10.2% 171,833 14.6%
Total 484,982 41.3% 688,042 58.7% 1,173,024 100.0%
Population of New Jersey - estimate 2009 - Age 65 and Over
1111
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
New Jersey Hospital Utilization
http://www.healthindicators.gov/Resources/Initiatives/CMS/Hospital-Inpatient-Report_12/Indicator/Report
3.27% of USA
115.6% of USA
105.7% of USA
Centers for Disease Control and Prevention. National Center for Health Statistics. Health Indicators Warehouse. www.healthindicators.gov.
1212
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
New Jersey Medicare Skilled Nursing Services
Health Indicator from CDC 2012 2011 2010 2009 2008
Skilled nursing facility Medicare users (count)
74,046 76,335 75,873 74,618 75,733
Skilled nursing facility Medicare utilization (percent)
6.84% 7.05% 7.13% 7.12% 7.15%
Skilled nursing facility Medicare admissions (per 1,000 beneficiaries)
100 105 107 107 108
Skilled nursing facility Medicare days (per 1,000 beneficiaries)
2,447 2,508 2,512 2,491 2,450
Centers for Disease Control and Prevention. National Center for Health Statistics. Health Indicators Warehouse. www.healthindicators.gov.
Utilization of Skilled Nursing as a Medicare Benefit declines by Admissions/1000 NOT Days
1313
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
New Jersey Inpatient Infrastructure (Providers)
http://www.healthindicators.gov/Resources/Initiatives/CMS/Medicare-Hospital-and-NursingSkilled-Nursing-Providers-Report_16/Indicator/Report
1.82% of USA
364 Total SNFs - 2.40% of USA
Centers for Disease Control and Prevention. National Center for Health Statistics. Health Indicators Warehouse. www.healthindicators.gov.
1414
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Whose care can “we” influence with Bundles and ACOs?
Measure New JerseyNJ
PercentUSA
USA Percent
Acute Care Medicare Adm/1000 312 215Acute Care Medicare People Served 201664 6174844
Medicare A Days/1000 1889 1597
NJ Persons over age 65 1,082,587 3.2% of USA 34,126,305New Jersey Medicare A Beneficiaries 646,359 59.7% 28,720,205 84.2%NJ Estimated Medicare Advantage Beneficiaries 436,228 40.3% 5,406,100 15.8%
Estimated Medicare Acute Care Days 1,220,972 45,866,167
2012
To be in a Bundle Payment Care Improvement Program or an ACO,Beneficiaries must Medicare A & B
1515
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What is a Bundled Payment for Care Improvement (BPCI) Bundle?
• Episode-based payment aggregates Medicare payments to multiple providers and suppliers for services that are related to particular clinical conditions for a period of time (time defines episode length)
• Episode-based payments measure patient experience of care, process, outcomes, and cost of care
• The goals of BPCI are: › align payment incentives among providers & suppliers › improve the health care experience of Medicare
beneficiaries who undergo episodes of treatment for clinical conditions
1616
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What is a BPCI Bundle as 10/2/2014 ?
• 48 distinct Person Centered Episodes (PCE) • Each episode combines related MS-DRGs• Episodes are linked to an acute care hospital
inpatient stay for one of the included MS-DRGs› A hospital admission for the anchor MS-DRG
triggers or initiates a beneficiary’s episode.• Episodes are broadly defined with few exceptions• PCEs include most services covered under
Medicare Part A and Part B that are provided to a beneficiary throughout the duration of the episode
1717
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Bundled Payments for Care Improvement (BPCI)Is it a Bundle of Joy?
1818
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What are the Bundled Episodes – Models 2-3-4?1 Acute myocardial infarction 25 Major bowel 2 Amputation 26 Major cardiovascular procedure 3 Atherosclerosis 27 Major joint replacement of the lower extremity 4 Automatic implantable cardiac defibrillator generator or lead 28 Major joint upper extremity 5 Back and neck except spinal fusion 29 Medical non-infectious orthopedic 6 Cardiac arrhythmia 30 Medical peripheral vascular disorders 7 Cardiac defibrillator 31 Nutritional and metabolic disorders 8 Cardiac valve 32 Other knee procedures 9 Cellulitis 33 Other respiratory
10 Cervical spinal fusion 34 Other vascular surgery 11 Chest pain 35 Pacemaker 12 Chronic obstructive pulmonary disease, bronchitis/asthmae 36 Pacemaker Device replacement or revision 13 Combined anterior posterior spinal fusion 37 Percutaneous coronary intervention 14 Complex non-Cervical spinal fusion 38 Red blood cell disorders 15 Congestive heart failure 39 Removal of orthopedic devices 16 Coronary artery bypass graft surgery 40 Renal failure 17 Diabetes 41 Revision of the hip or knee 18 Double joint replacement of the lower extremity 42 Sepsis 19 Esophagitis, gastroenteritis and other digestive disorders 43 Simple pneumonia and respiratory infections 20 Fractures femur and hip/pelvis 44 Spinal fusion (non-Cervical) 21 Gastrointestinal hemorrhage 45 Stroke 22 Gastrointestinal obstruction 46 Syncope and collapse23 Hip and femur procedures except major joint 47 Transient ischemia 24 Lower extremity and humerus procedure except hip, foot, femur 48 Urinary tract infection
BPCI - Bundled Episode Categories
1919
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Examples of the Model 2-3-4 Bundled DRGs in Episodes
48 Episode Categories which Bundle 179 MS-DRGs
Major joint replacement of the lower extremity 469 Major joint replacement or reattachment of lower extremity with major complication or comorbidity470 Major joint replacement or reattachment of lower extremity without major complication or comorbidity
Diabetes 637 Diabetes with major complication or comorbidity638 Diabetes with complication or comorbidity639 Diabetes without complication or comorbidity or major complication or comorbidity
Congestive heart failure 291 Heart failure and shock with major complication or comorbidity292 Heart failure and shock with complication or comorbidity293 Heart failure and shock without complication or comorbidity or major complication or comorbidity
Episode NameMS-DRG
91 of the DRGs are in the TOP 100 2012 Medicare DRGs Paid
2020
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What LTC Provider are involved in Bundles?
Top 10 States with
Model 3
Skilled (SNF) Centers with
Bundle Contract
SNFs in State
Percent
TX 249 1208 20.6%OH 203 953 21.3%PA 173 699 24.7%CA 166 1219 13.6%FL 147 689 21.3%CT 122 229 53.3%NJ 111 364 30.5%NC 103 419 24.6%MA 100 418 23.9%KY 88 284 31.0%
Top 10 1462 6482 22.6%USA 2584 15610 16.6%
Bottom 5 States with
Model 3
Skilled (SNF) Centers with
Bundle Contract
SNFs in State
Percent
WY 4 38 10.5%SD 3 112 2.7%HI 2 46 4.3%AK 1 18 5.6%ND 1 80 1.3%
2121
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
New Jersey SNFs – Leaders in Bundled Payment
ConvenerDRG
EpisodesPhase I - No Risk
Phase II - Risk
Share
GENESIS CARE INNOVATIONS LLC 48 32NaviHealth, Inc. 48 9SNF is its Own Convener 48 1Optum 12 4Optum 36 4Remedy BPCI Partners, LLC 48 106
Total NJ SNFs with Bundled Payment Programs 111 4
New Jersey SNFs with Bundled Payment Agreements in Model 3 - 90 Day Episode and at 97% of Medicare FFS
Contracts for Bundled Programs SNFsThree 1Two 39One 75
NJ Skilled Nursing Homes with Covener Contracts at 97% Medicare FFS for 90 Days
2222
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
35 New Jersey Hospitals Lead the way!
RankTop 10 States
with ACH Bundlers
Acute Hospitalswith
Bundle Contract
Acute Hospitals in State
Percent with Bundle Plan
1 NJ 35 64 54.7%2 VA 45 88 51.1%3 SC 31 62 50.0%4 FL 92 188 48.9%5 TN 55 115 47.8%6 DE 3 7 42.9%7 MA 28 69 40.6%8 NV 13 36 36.1%9 CT 11 32 34.4%
10 RI 4 12 33.3%
Count and Percent of Hospitals with Bundled Payment Arrangements
2323
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Hospital Bundled Discounts or Captured Savings?
• 35 New Jersey Hospitals with bundled payment programs• 20 are Phase I – No Risk • 28 have Phase II with Risk Sharing• 1 Model 4 program (Cooper Medical Center)
• Discounts are not of Medicare FFS, they are of the target cost prior to reconciliation of BPCI program
Count of Hospitals Particpating at the Bundled Discount Level 95% 96.75% 97% 98% TotalPhase I - No Risk Share 0 0 1 19 20Phase II - Risk Share 14 1 4 9 28
Hospitals Participating at Discount Level 14 1 5 21
2424
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
How does Bundled Risk Work? The Triple Crown!
• Risk Tracks, for each episode.› Awardee may opt to bear risk up to the 75th, 95th, or 99th percentile. Awardees
bear 100 percent of the risk up to the risk track threshold and 20 percent of payments above the threshold for a given risk track.
› Risk tracks may be changed quarterly.
• Medicare pays the Awardee the difference between the target price and the actual cost of care for an episode if the actual cost is less than the target price.
• If the actual cost of care exceeds the target price, the Awardee pays Medicare the difference between the target price and actual spending.
• Supporting Awardee preparation, CMS provides Phase 1 participants with monthly beneficiary-level claims data for episodes of care. › Phase 1 participants also engage in a variety of learning activities › Phase 1 and Phase 2 participants and receive target pricing information to
inform their assessment of opportunities under BPCI.
2525
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Imagine –
• Value = Quality/Cost or Outcomes/Efficiency• Does this change the paradigm?
Activity / Episode of Care = All Care…
$$ 3 Days prior to Admit + $$ for Hospital
stay+ $$ 30+ days after hospital dischargeOr maybe 60, 90 or 120 days after discharge??
ImagineYou may say I’m a dreamer, but I’m not the only one.I hope someday you’ll join us and the world will live as one.
Lyric from Imagine by John Lennon
2626
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
BPCI Revenue is Data Driven
• Bundled (data defined) Payment› Like DRG: Defined by clinical and quality parameters
– the difference in patient before and after treatment Admissions and length of stay are central measures
– Do you know the LOS / admission combination for your SNF?
› Operators’ Strategy More thorough assessment of patient Core measures of clinical practice
– Best practice supported by literature (QAPI) Better Treatment at each step of the episode = Better Payment
– And Better Outcomes….
2727
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Model 3 – Simplified Bundle Example
• Model 3 – CHF – (3 MS-DRGs) 90 Day Period› $18,000 – for 90 days Post Acute Care X .93 for
Organization Costs = $16740.00a. 20 days RUB X $639.43 = $ 12,788.60
1. Readmissionb. 20 days RUB X $639.43 = $ 12,788.60
2. Readmissionc. 20 days RUB X $639.43 = $ 12,788.60 X 3 = $ 38,365.80
Or a loss of –($20,365.80)
2828
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Alternate Model 3 Examples
• Model 3 – CHF – (3 MS-DRGs) 90 Day Period› 40 days RLA X $265.27 = $ 10,610.80 + 60 Days Home Care =
$3,000 + supplemented 30 Treatment Days Out Patient Therapy = $3,000 – Total Medicare FFS Cost = $ 16,610.80
Or SNF profit of $1,389.20 – Who has oversight for 90 Days?• OR
› 20 days RUB X $639.43 = $ 12,788.60 › 60 days Home Health = $3,000.00› 10 days outpatient rehab $1100.00
Total FFS Cost = $16,888.6Or profit of $ 1,111.40 – Who has oversight for 90 Days?
2929
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Model 1
All DRGs
Hospital Only
3030
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Model 2
HospitalsPhysiciansHealth SystemsConveners
48 Groups/179 DRGs
Choice of 30, 60 or 90 day risk
Risk = level of ACH oversight of PAC
3131
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Model 3
LT-PACSNFHome HealthPhysicianConvener
48 Groups/179 DRGs
90 day risk
Risk = 100% LT-PAC
oversight
3232
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Model 4
3333
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Taken all 4 models together New Jersey leads Bundled Pricing Care Initiatives
HospitalsHealth SystemsPhysiciansPost Acute CareConveners
Prospective Risk
30/60/90 days after Admission
3434
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Bundled Payment Care Initiative Summary-1Model Summary Model 1 Model 2 Model 3 - LTC-PAC Model 4
Examples of organizations that may participate in Model:
• Acute care hospitals
• Acute care hospitals• Health systems• Physician hospital organizations• Physician group practices• Conveners of health care providers
• Skilled nursing facilities• Inpatient rehabilitation facilities• Long-term care hospitals• Home health agencies• Physician group practices• Conveners of health care providers• Health systems
• Acute care hospitals• Health systems• Physician hospital organizations• Conveners of acute care hospitals
Entities that can initiate episodes in Model:
• Acute care hospitals• Acute care hospitals• Physician group practices
• Skilled nursing facilities (SNF) • Inpatient rehabilitation facilities (IRF) • Long-term care hospitals (LTCH) • Home health agencies (HHA) • Physician group practices (PGP)
• Acute care hospitals paid under the Inpatient Prospective Payment System (IPPS)
• Receives inpatient hospital care at an Episode Initiator
• The beneficiary is admitted to or initiates services with an Episode Initiator within 30 days after the beneficiary has been discharged from an acute care hospital for an MS-DRG included in a clinical episode associated with the Episode Initiator.
• Receives inpatient hospital care at an Episode Initiator, and on the day of admission, has either one lifetime reserve day or one day of utilization that is also a day of entitlement remaining
Start of episode:• Acute care hospital admission by Episode Initiator for ALL DRGs
• Acute care hospital admission by Episode Initiator for included clinical conditions (identified via MS-DRG)
• Post-acute care with an Episode Initiator (SNF, LTCH, IRF, or HHA) within 30 days after discharge from an acute care hospital for an MS-DRG included in a clinical episode associated with the Episode Initiator. In the case of a PGP Episode Initiator, post-acute care by any SNF, IRF, LTCH, or HHA within 30 days after discharge from an acute care hospital for an MS-DRG included in a clinical episode associated with the PGP Episode Initiator where any physician member of the PGP was the operating or admitting physician for the inpatient stay.
• Acute care hospital admission by Episode Initiator for included clinicalconditions (identified via anchor MS-DRG).
• The beneficiary is eligible for Part A and enrolled in Part B.• The beneficiary must not have End Stage Renal Disease• The beneficiary must not be enrolled in any managed care plan (for example, Medicare Advantage, Health Care Prepayment Plans, cost-based health maintenance organizations). • The beneficiary must not be covered under United Mine Workers; and Medicare must be the primary payerCriteria for
beneficiaryinclusion in episode:
• Receives inpatient hospital care at an Episode Initiator• includes most Medicare fee-for-service discharges for the participating hospitals
3535
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Bundled Payment Care Initiative Summary-2Model Summary Model 1 Model 2 Model 3 - LTC-PAC Model 4
End of episode: Discharge• 30, 60, or 90 days after acute care hospital discharge
• 30, 60, or 90 days after the initiation of the episode
• 30 days after acute care hospital discharge for anchor MS-DRG (following discharge, only related readmissions are included in the episode for the 30 day period)
Types of services included inBundle, which include broad clinical episode categories:
Inpatient Hospital Services
• Physicians’ services• Inpatient hospital services• Inpatient hospital readmission services• Long term care hospital services (LTCH)• Inpatient rehabilitation facility services (IRF)• Skilled nursing facility services (SNF)• Home health agency services (HHA)• Hospital outpatient services• Independent outpatient therapy services• Clinical laboratory services• Durable medical equipment• Part B drugs
• Physicians’ services• Inpatient post-acute care services• Inpatient hospital readmission services• Long term care hospital services• Inpatient rehabilitation facility services• Skilled nursing facility services• Home health agency services• Clinical laboratory services• Durable medical equipment• Part B drugs
• Physicians’ services for inpatient hospital care• Inpatient hospital services• Inpatient hospital readmission services
Payment from CMS toEpisode Initiators:
IPPS MS-DRGs• Single prospectively determined bundled payment
5% provided to Medicare
• 2% discount for episodes 90 days in length 3% discount for episodes of 90 days
Reconciliation:
hospitals and physicians will be permitted to share savings arising from the providers’ care redesign efforts.
• Medicare pays a predetermined bundled payment amount to the Episode Initiator, which is responsible for paying physicians and non-physician practitioners that furnished services to the beneficiary during the episode.
• Medicare pays the Awardee the difference between the target price and the actual cost of care for an episode if the actual cost of care is less than the target price. If the actual cost of care exceeds the target price, the Awardee pays Medicare the difference between the target price and actual spending.
• 3% discount for episodes of 30 or 60 days in lengthDiscount
provided toMedicare:
• 3% discount for episodes that do not include MS-DRGs included in the ACE Demonstration• 3.25% discount for episodes that include MS-DRGs that were included in the ACE Demonstration
• Traditional FFS payments
3636
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Question 2
• As a New Jersey Care Provider, I would describe my experience in bundled payment as A. Examine, treat or see a bundled service
combination almost dailyB. Examine, treat or see a bundled service so
little I would not know I had done soC. I have no idea what this bundled payment is
about and am now hopelessly confused
3737
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Bundles and ACOs have “Big Data” in common
• CMS uses FFS Beneficiary Part A and B claims to establish a target cost for Bundled Episodes and for ACOs
• Target cost = 3 year history X trend factor minus the CMS Episode Discount
• The ACO and Bundle target dollars are a CMS determination by use of data to forecast and determine expected future payments.
• In this theory for innovation…› Healthcare cost is predicted & controlled
3838
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
New Jersey Acute and Post Acute Expenditures (2012) [3 days prior to index Admission + 30 days PAC]
Total Costs per Period Reported % Calculated*Day 1-3 Prior to Adm $66,205,522 1.3% $66,205,522Index Admission $2,563,702,946 51.2% $2,563,702,946Days 1-30 post Index AdmissionLong Term Care
$2,379,987,730 47.5% $2,379,987,730
Complete Episode Costs $5,009,841,634 100.0% $5,009,896,198
Medicare A Episodes of Care 249919Medicare Benefic iaries Served 201664Estimated Medicare A Episodes per Person Served
1.24
New Jersey Medicare Part A Expenditures for 2012
Transitions per person per year
*Note Addition differences reported by CMS as rounding errors
If all Medicare A Episodes were set for 2012, targeted cost would be$4,859,546,385 – or $150,295,249 less than spent
Ideally savings will be greater than 3%
3939
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Type of Medicare Claim
1 to 3 days Prior to Index
Hospital Admission
During Index Hospital
Admission
1 through 30 days After
Discharge from Index Hospital
Grand Total
Percent of Episode of
Care Expenditures
Elegible Practitioner and Carrier Paid
$37,657,659 $533,304,086 $341,339,212 $912,300,957 18.2%
Durable Medical Equipment $2,165,718 $4,934,110 $25,359,561 $32,459,389 0.6%
Home Health Agency $2,249,522 $0 $156,249,211 $158,498,733 3.2%
Hospice $109,134 $0 $23,800,210 $23,909,344 0.5%
Inpatient $1,055,515 $2,025,464,750 $649,753,170 $2,676,273,435 53.4%
Outpatient $22,095,316 $0 $147,578,830 $169,674,146 3.4%
Skilled Nursing Facility $872,658 $0 $1,035,907,536 $1,036,780,194 20.7%
Total $66,205,522 $2,563,702,946 $2,379,987,730 $5,009,841,634 100.0%
Percent of Episode Expenditures 1.3% 51.2% 47.5% 100.0%
Sum of 2012 Medicare Part A Expenditures per Beneficiary in New Jersey for 2012
Acute and Post Acute Expenditures by Claim Type
Source: Data.Medicare.Gov – Medical Spending per Beneficiary
4040
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
New Jersey ACOsACO Legal or Name/Doing Business As ACO Service Area ACO Website Address
Advocare Walgreens Well Network New Jersey Allegiance ACO New Jersey, Pennsylvania http://www.allegiancehealthgroup.comAtlantic ACO New Jersey, Pennsylvania http://www.atlanticaco.orgAtlantiCare Health Solutions, Inc. New Jersey http://www.atlanticare.orgBarnabas Health ACO-North, LLC New Jersey http://www.barnabashealthaconorth.orgCentral Jersey ACO LLC New Jersey http://www.centraljerseyaco.orgDelaware Valley ACO New Jersey, Pennsylvania http://www.jeffersonhealth.org/aco-pa/Hackensack Physician-Hospital Alliance ACO, LLC New Jersey, New York http://www.hackensackumc.org/our-services/medical-services/aco/about-us/HNMC Hospital/Physician ACO, LLC New Jersey JFK Population Health Company, LLC New Jersey http://www.jfkaco.orgLHS Health Network, LLC New Jersey, Pennsylvania http://www.lourdesnet.org/acoMeridian Accountable Care Organization, LLC New Jersey http://www.meridianhealth.comNEPA ACO Company, LLC New Jersey NJ Physicians ACO New Jersey Optimus Healthcare Partners, LLC New Jersey http://www.optimushealthcarepartners.comPartners In Care ACO, Inc. New Jersey http://www.partnersincareACO.comRWJ Partners LLC New Jersey Summit Health-Virtua, Inc. New Jersey http://www.virtua.orgNJ MSSP ACOs 18
NJ Medicaid ACO ApplicantsCamden Coalition of Healthcare ProvidersCoastal Healthcare Coalition, Inc.Healthy Greater Newark ACONew Brunswick Health PartnersPassaic County Comprehensive Accountable Care Organization, Inc.The Healthy Cumberland Initiative, Inc.The Healthy Gloucester Initiative, Inc.Trenton Health TeamNJ Medicaid ACOs - Start 2015 8
4141
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
ACO Payment – determined by targets and quality
• One Sided ACO – shared savings with Medicare• Two Sided ACO – share risk with Medicare – the greater
the savings the greater the shared savings• New Jersey – 3 Years Federal FFS Cost data =
183,267,328 bytes = 174 MB• 2010, 2011, 2012 Inpatient, Physician and Outpatient/ASC
data on Claims for 750 New Jersey distinct zip codes• ACO has data from CMS shared quarterly • Strategy effort for ACOs
› Find and refer to Providers – who are effective, efficient and are efficacious!
4242
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
ACO Beneficiary Assignment and Cost
• Based on where services are received› Chosen ACO = Primary Care Services From ACO Physicians (FP, IM, GP, Geriatrics) And/or (PA, NP, Clinical Nurse Specialist or Non PCP physician)
› Beneficiary Cost 3 yrs. risk adjusted for health status & demographic factors Year 1 = 10%, Year 2 = 30%, Year 3 = 60% - trend forward
– (Yr. 1 = $10K, Yr. 2 = $11K, Yr. 3 = $12K ) = $11.5K X Trend X discount – Claims exceeding a threshold are excluded– Medicare saves twice?
4343
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
ACO Payment, Risk and Reward
• ACO providers are paid Fee For Service• Payments are made by Medicare when claims are received• Providers participating in an ACO may share risk according
to their provider agreements• No Risk ACO =
› Savings capped 10% of total Benchmarked Expenditures• Risk Share determination
› Share – ACO meets Minimum Savings Rate (MSR) & quality standard goals Risk Sharing ACO = Savings capped at 15% of Benchmark / Losses 5% Yr. 1, 7.5%
Yr. 2 and 10% YR. 3 (We are expected to get better in each succeeding year)
4444
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Revenue Management ACO/MSSP Contract with LTPAC Providers
• Episode initiator / ACO incentive is to influence census toward high value providers
- ACO Exclusive Contract (i.e. Sharp Health Care and Shea Family Homes)- Risk share determinants:
- Discount @ 70% Medicare Rate- Readmissions not to exceed X %- Mortality not to exceed X %- Length of Stay not to exceed X days
• Result:› Reward to ACO/MSSP/Bundling providers for directing
care to high quality, low cost receiving providers› Risk Share by LT-PAC Provider
4545
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What happened with Sharp and Shea
• Between 2010 and 2013, Shea Family Homes increased Medicare payment from @ $50 million to $85 Million
• Sharp reduced readmissions, LOS, increased satisfaction and all providers work diligently
• 60,000 Medicare Beneficiaries were served• AND…
4646
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What happened with the Sharp Health Care (SHC) ACO?
• SHC holds a one third percentage interest in Sharp ACO. • For 2012 and 2013, Sharp ACO’s performance was under a defined 2% and 1.9%
minimum threshold, respectively, so no shared savings payments were earned and no increased cost payments were due.
• SHC re-evaluated participation for the year ended December 31, 2014 (“Performance Year 3”), Sharp ACO determined it was at risk for a significant shared loss, despite meaningful reductions in readmission rates and hospital and skilled nursing utilization.
• In June 2014, Sharp ACO determined it would not continue in the Pioneer ACO Program for Performance Year 3 and notified CMMI of its decision on June 20, 2014.
4747
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What’s Next?
• More than the Elephantin the room!
• Bundles / ACOs –› CMMI or the Center for Medicare and Medicaid
Innovations is a data driven enterprise of Clinical Informaticists who seek to drive costs down, improve satisfaction and improve quality for beneficiaries.
• Data is the currency for CMMI and for Bundlers and ACO explorers
4848
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What should LTC Leaders do? What might we ask? / What are we asked?
• How can we end up differently than Sharp?• Long Term Care Leaders may want to make better
use of the data gathered and focus on two things: 1. Training IDT to increase their data literacy and more
efficiently incorporate information into decision making.2. Giving IDT team the right tools3. Use the MDS / OASIS data you have to prove outcomes
Therefore – is it your mission to place the right tools into the hands of staff and facilitate both data literacy and its use in making decisions?
4949
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Beyond 2014:Alternatives
• Pursuit of Sustainable Care› Affordable Care Act Moved CMS from payer to policy maker CMS Actuary simulation predicts Medicare rates 1/3 those of private pay and ½ of
Medicaid in 75 years
› Therefore / ACOs (420+ ACOs serving 5.0 to 7.0+ Million Beneficiaries) – Savings so far estimated at $1.00 per Beneficiary/Yr.
• Deficit Reduction Act 2005 › Bundled payments› Person centered episodes – 4 models – just getting started.› CMS using Hospital Value Based Payment (HVBP) to “bundle”
Episodes of 30-60 days care services
5050
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
In the end Critical Thinking, Judgment and Action….
• Recent financial and business events show all too plainly what can happen when rich data and analytics collide with gaps in knowledge or lapses in judgment.
…So…› Leaders need to ensure that their processes and human
capabilities keep pace with the computing firepower and information they import.
› To overcome the insight deficit, Big Data—no matter how comprehensive or well analyzed—needs to be complemented by Big Judgment.
Good Data Won't Guarantee Good Decisions by Shvetank Shah, Andrew Horne, and Jaime Capellá - Harvard Business Review, April 2012
5151
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Starting Today it is clear that
• Every enterprise needs to fully understand health care event data› what it is, what is does, what it means – and the potential
of data-driven decisions at each part of the episode• Waiting for someone else to generate the data will only delay
the inevitable and make it even more difficult to prevent financial loss
• Once you start tackling all the health data from the episode care processes, you’ll learn what you don’t know, and you’ll be inspired to take steps to resolve any problems.
• You can use the insights gathered at each step along the way to start improving your stakeholder engagement strategies;
5252
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
2014 Sources of LTC Revenue
5353
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Payer Payer – Who is the Payer?
5454
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Forecast Changing Payer Mix
21%
66%
13%
Payers 2010
MedicareMedicaidOther
10%
11%
30%36%
5% 8%
Estimated Payer Sources 2020
Medicare
Managed Medicare
Medicaid
Managed Medicaid
Other
Managed Other
Government is still payer with different flavors to transmit funds
5555
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
The Future?
Bipartisan DiscussionDraft for a BillIntroduced 3/21/2014Passed 9/21/2014
In review of this possibility, former Senator Bill Frist, MD noted that Post Acute care is fragmented and out of control –
More reform is coming, Congress and the President have acted
5656
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
CMS Mandated to Change Health SystemsAKA – “New Navigation Principles”• Hospital Value Based Payment (HVBP)
› Withhold of all Hospital Med A Revenue› Withhold return earned by Benchmark Performance and
Improvements› Person Centered Episode cost efficiency (PCE)
• PLUS:› Creating bundled care payment for episodes› Continuing financial penalties for readmissions› Continuing Person Centered Medical Homes (PCMH)› Reform of Medicare as insurance
ACOs Medicare shared savings plans
5757
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
The 3-Legged Technology Stool
• Disease State Management› Create cost savings by intensive focus and proactive management
of nursing core services – changed fundamentally from DRG to Bundle
• EMR- Electronic Medical Records› Investment toward federally mandated electronic patient records
ideally shared between providers in a fluid and transparent manner
• Analytics › Optimize care process, outcomes, RUGs distribution, QMs, etc.› For SNFs improve 5-Star, Survey Results, Staffing and
Reimbursement achieved by taking action based on data for targeted improvement (essential step of QAPI)
› For Home Health follow Post SNF and share risk
5858
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Interoperability
• Syntactic interoperability› If 2 or more systems are capable of communicating and
exchanging data, they are exhibiting syntactic interoperability
• Semantic interoperability› …..semantic interoperability is the ability to automatically
interpret the information exchanged meaningfully and accurately in order to produce useful results as defined by the end users of both systems.
• HL7 sets standards for clinical documents› Clinical Document Architecture (CDA R2) both syntactic
and semantic
5959
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
S&I [Standards & Interoperability]
CDA TemplatesS&I Framework CEDD
Care Transition Datasets
Patient Assessments
Encounter Summaries
Longitudinal Plan of Care
CEDD [Common Element Data Dictionary]
CDA [Clinical Document Architecture]
What is “the” EHR?
Congress made the laws for MU2
CMS will act
Providerscomply
6060
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Example CCD – originated by a Hospital
6161
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
6262
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Discharge Summary Does this need seen by all PAC care givers?
6363
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Patient Care
Physician
Staff
Patient
Care Transitions & Coordination
Quality Reporting Payment
Research Survey and CertificationSatisfaction
Standard PAC Assessment success hinges on reporting as a byproduct of patient care using standardized IT processes
Only defining Payment and Quality data elements will not improve patient care
6464
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Group Home A SNF B Home
Health CAcute
Hospital DAssisted Living E
MS Dynamics CRM / Management System
Health System and or Medical Group Web API
Life Event
Flagged Note Incident Clinical
Summary
Medical Groups
Combined Social / Clinical CCD document data stored in data analytics warehouse for analysis, reporting, and wider HIE interchange. Elder Care services from HIEs utilized to leverage similar social data for seniors already available from hundreds of shared care sites
Primary Care EHR
Clinical Summary
CCD Database
eHealth Data Solutions Analytics Engine / Data
Warehouse (CW Connect)
New York HIEs
Department of Health / Medicaid ACO / HMO
Oversight Reports
EPIC, Cerner, MediTechMcKesson
Siemens, GE, etc.
CHIC HIE
Maryland HIEs
IOD HIE
Pennsylvania HIEs
New Jersey HIE
Research(Market,
Scientific, Social)
6565
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Why does this matter?2013 – Lifetime Medicare per Beneficiary Cost= $440,000
50 Work Years X $30,000/Year X 3% Medicare Tax = Lifetime Medicare Tax Paid =$45,000 + Employer $45,000 = $90,000
Short Fall = $440,000 - $90,000 = $350,000 per person
6666
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
What must we do?
Slide taken from“In Pursuit of High Value
Care”Shari M Ling, MDDeputy Medical Officer / CMSAHCA Quality Symposium 2/12/14
6767
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
Questions?
6868
| 10
/5/2
014
| ©
eH
ealth
Dat
a So
lutio
ns
References
• Centers for Disease Control and Prevention. National Center for Health Statistics. Health Indicators Warehouse. www.healthindicators.gov
• http://innovation.cms.gov/initiatives/Bundled-Payments/index.html
• Source: “What is Big Data?” Lisa Arthur Contributor 8/15/2013 http://www.forbes.com/sites/lisaarthur/2013/08/15/what-is-big-data/
• Wall Street Journal Aug. 25, 2014