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8/28/2018

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Post-Acute Networks Why Are Health Systems Developing Them?

John Barkley, MD, FCCP

Atrium Health

Angela Orsky, DNP, LNHA, RN

Greenville Health System

Innovation and Excellence in Advanced Illness at End of Life 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, NC

Agenda

• Rationale for post-acute networks

• Creation and management of post-acute networks

• Strategies for hospice & palliative care providers to engage health systems

Innovation and Excellence in Advanced Illness at End of Life

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* denotes enterprise-wide data or PE plus some regional data

Size and Scope

28+urgent care locations*

$9.77 billionnet operating revenue*

25+cancer care locations*

47hospitals across

three states*

65,000+employees*

350+primary care practices*

35emergency

departments,

including

freestanding*

7,400+licensed beds*

Who We Are Today

16,000+Nurses*

$1.87 billionin community benefit and

uncompensated care in 2016

$5.1 millionIn uncompensated care and

community benefit every day

Continuing Care Scope of Services


• An integrated network and full continuum solution for post acute service needs

• Services provided at 73 locations

• Average Daily Census > 14,000

• > 525,0000 outpatient visits

• >70,000 Unduplicated Patients

• >2,600 teammates

Value - The Why

• Government, commercial payers & employers are transferring risk to providers, and demanding accountability

• Payment for quality & cost effectiveness outcomes

• Current trajectory is unsustainable – economically & politically not viable


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National Landscape – Market Pressures

1. Aging Population

2. Chronic Conditions


National Landscape – Market Pressures

15.5%

16.0%

16.5%

17.0%

17.5%

18.0%

18.5%

19.0%

19.5%

20.0%

20.5%

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

National Health Expenditures, per capita4. Not Fiscally

Sustainable

3. Significant Spend Increases

National Health

Expenditureas a % of

GDP

Value-based Care


BPCI-AValue-basedpurchasing

MACRA

CMS Quality ReportingPrograms

Medicare Advantage

ACOs BPCI

Commercial PayorRisk Contracts

Self-insuredEmployers

CMS Payment PenaltyPrograms

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Patient Protection and Affordable Care Act (ACA)Enacted March 23, 2010

Make affordable health insurance available to more citizens through the creation of

subsidies.

Expand the Medicaid Program

to cover adults with an income

below 138% of the federal poverty

level.

Support innovated medical care

delivery methods designed to lower

costs of health care generally.

Go

als

of

the

AC

A


CMS=Centers for Medicare & Medicaid Services; DRA=Deficit Reduction Act; IOM=Institute of Medicine; MMS=Medicare Prescription Drug, Improvement and Modernization Act; QI=Quality Improvement;

Health Care and Education

Reconciliation Act of 2010 amends PPACA

Mar 30, 2010

Patient Protection and Affordable

Care Act (PPACA) establishes and

maintains quality-

related initiatives

Mar 23, 2010

CMS adds Outpatient Data

to Hospital Compare Website

Jul 8, 2010

EHR Registration

begins

Jan 3, 2011

CMS to launch Physician

Compare Website

Jan 3, 2011

HAC Expanded to Medicaid

Jul 1, 2011

Physician Resource Use

Reporting to begin

2012

20132011 2012 20142010 2015

Payment Reductions for

Readmissions to begin

Oct 2012

Medicare VBP to begin

2013

EHR Meaningful Use must be

achieved or Medicare

Reimbursement

PenaltiesJan 2015

CMS goal to have EHR

interoperable

2014

Value Based Payment

Modifier to Physician Fee

Schedule

Jan 2015

Readmission rate penalty

2013

Public Reporting and Penalties

relating to HAC begins

2014

ACO Launched

2012

Shift to Focus on IncentivizingQuality & Efficiency


ACOs and Covered Lives


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ACO Types

• Pioneer ACO

• Medicare shared savings programs

• Next generation ACO

• ACO Investment Model

• Advanced Payment ACO Model

• Comprehensive ESRD Care Initiative

• Oncology Care Model

• Comprehensive Primary Care (CPC+) Model


What is an Accountable Care Organization?

• MSSP Definition: • “…a legal entity that is recognized and authorized under applicable State, Federal, or Tribal

law, is identified by a [TIN], and is formed by one or more ACO participant(s) that is (are) defined at § 425.102(a) and may also include any other ACO participants described at §425.102(b).” 42 CFR § 425.20.”

• Functional/Operational Definition: • Partnerships among health care providers to coordinate and deliver high quality, cost

efficient health care services to defined populations

• Purpose: • Promote accountability for Medicare FFS beneficiary population

• Improve the coordination of FFS items and services

• Encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery

• Promote higher value care


Value to Physicians Value to Payers Value to Health Systems

Affiliation with the ACO brand and

strategy

Redefine provider relationship from

combative to collaborative

Aligned independent practices and

physicians

A more powerful voice in health plan

relationships

Extensive, stable and top-tier network for

products

Spread Health System reach (and risk)

across broader population and

geography

Demonstrate, improve and be rewarded

for clinical quality

Collaboration in improving value for

beneficiaries , members and customers

Communication venue with independent

“affiliates”

ACO governance, leadership and input

roles

Transition from FFS payment; address

cost and quality

Demonstrate value to payers,

businesses, and community

Participate in development of

• Value-based compensation models

• Evidence-based care etc.

Shift resources from Medical

Management to other areas (benefit

design, etc.)

Strategy to assess and assure quality

practitioners support hospitals


ACO Value Proposition

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How to Share in Savings


Meet the Minimum

Savings Rate for Assigned Beneficiaries

(2-3.9%)

Meet the Quality

Performance Standards for

Assigned Beneficiaries

Maintain Compliance

and Eligibility within the MSSP ACO Program

If all requirements

are met within the MSSP, the ACO will share in savings with a rate of up to

50%

BPCI Advanced

• Voluntary bundled payment model that ties physician & hospital payments to quality and cost of services provided under a 90-day clinical episode (“bundle”)

• Actual FFS spend vs. target price determines gainsharing

• Multiple waivers of fraud and abuse and anti-kickback laws


BPCI-A

• 29 Inpatient episodes

– Ortho

– Cardiac

– Pulmonary

– CVA

– GI

– Renal

– Infection

• 3 Outpatient episodes

– PCI

– Defibrillator implantation

– Back & neck


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Continuing Care


One in Five Acute Patients Discharged to

Post-Acute

What is Continuing Care?

9%

50%

LTACH

IRF

SNF

$39,493 per episodeALOS 26.2 Days



$2,677 per episodeHome Health

1%

2%$11,510 per episode

Hospice


38%

Why is Continuing Care PerformanceImportant?

0% 20% 40% 60% 80% 100%

Heart Failure

Cardiac Bypass

Hip and Knee

Stroke

Episode Cost

Hospital MD Post Acute Readmit

Post Acute Spending Represents

20-25% of all Medicare Expenditures

73%

27%14% 14%

3%0

20

40

60

80

PAC Acute DX(Tests)

PX RX

Regional Variation -Spending

Medicare Would Save

$10 BillionAnnually if Patients used the

Appropriate Post Acute Setting

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What Challenges Exist Today?

Home Health?

“Post acute looks like an archipelago of little islands with no

bridges. Consumers are at a loss about which island to approach,

with poor transportation and communication options.”

- Physician Interview, Deloitte

Decreased Payments to PAC

• SNF – patient driven payment model (PDPM) -October 2019

• Home health – Patient-driven groupings model (PDGM) – January 2020

• Post-acute site neutral payments – 2021

• Hospice – future cuts???

Continuing Care Networks


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The Continuum of Care –Rethinking Post Acute

Fragmented

Seamless Episode of Care41 Days

$

Reh

ab

Home

Acute Care SNF

Home Health

$6 Days

$20 Days

$30 Days

Each component across the continuum of care serves a unique role in achieving the goal of returning to health


Key Components of Strategic Management

1. Risk Stratification

2. Cross-Continuum Care Management

3. Network Management

4. Post Acute Service Evolution


1. Risk Stratification

High Risk

Moderate Risk

Low Risk

• Begins with discharge planning and assessment:

Right Place, Right Time, Right Cost

• Data driven process

• Requires elevating communication, coordination, and navigation across settings

• Goal is to manage higher risk patients to proactively intervene prior to readmission or ED visito e.g. flags for missed appointments, blood

pressure, etc.

Key Factors:Socioeconomic

Complex Chronic


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2. Cross Continuum Care Management

Mu

lti-

Dis

cip

linar

y Te

am

Triage

Place

Track/ Monitor

Identify

Manage

Risk Stratification

Care Pathways (Projected)

Attribution (Medicaid, ACO, BPCI, MA)

Discharge to Highest Value Network

Optimal Post Acute Placement/DWD

Advanced Discharge Planning

Via Population Health Platform

Via Virtual Monitoring/Exception/Trend

Care Management Interventions

Hospice and Palliative Care Involvement

Active SNF Patient Management (LOS)

Connecting back PCP/Complex Chronic

3. Network Management

• Education and Best Practice Sharing

• SNF Collaborative, Home Health Collaborative

• Medical Directorships

• Focus on Readmissions and ED Visits

• Identify and Select the Right Partners using Data

• Preferred Network

• Continuous Engagement of Physicians and ACPs in Quality Improvement

• Focus on Episodic Cost, Quality and Experience = Value

Options For Discharge Network for Value


4. Post Acute Service Evolution

Sharing Risk with PAC Partners


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Atrium Health SNF Network

To improve outcomes and overall Medicare spend

To establish the largest, best network

To focus on partnership and shared accountability

To proactively address opportunities for improvement

We want to partner with facilities that

share a Vision and Commitmentto Quality


All Facilities

Tier 1(30-50)

Tier 2(20-29)

Tier 3(1-19)

Score (0-50)

Will receive patient placements

Will receive patient placements; will engage with CHS around opportunities

Will receive patient placements only if specifically requested by a patient

Meets Network Criteria

Star Rating 3 or Above

2 or Below

SNF Preferred Network Design


Metric Source Weight Top Performer Acceptable Needs Improvement

Readmission Rate O/E Premier 40% < 0.9 < 1.1 > 1.1

% Medicare/ MA Placements

CHS 2017

25% < 80.0% < 90% > 90.0%

Market Payment Ratio

CMS(2016)

35%<1 SD Below

Market AverageMarket Average

(+/- 1 SD)>1 SD Higher than Market Average

Weighted Score 30.0 – 50.0 20.0 – 29.9 0.0 – 19.9

SNF Network Performance Metrics


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SNF Network Scorecard

GG Peak Resources Gastonia Y 1 Gaston West 3 5 1 93.8% 0.92 0.000 36.2 1 16

YY Belaire Y 1 Gaston West 2 3 3 89.4% 1.20 0.000 33.0 5 47

FFF Brian Center Gastonia Y 2 Gaston West 4 5 3 75.0% 1.20 0.666 27.8 17 68

JJJ Cleveland Pines Y 2 Cleveland West 3 5 2 88.5% 1.03 0.614 27.7 30 261

R Lincolnton Rehab Y 2 Lincoln West 3 4 2 91.0% 1.09 0.594 26.5 10 111

FF White Oak Manor - Kings Mountain Y 2 Cleveland West 5 5 4 100.0% 0.86 0.697 26.4 0 48

AA Peak Resources Cherryvi lle Y 2 Gaston West 4 4 98.8% 1.08 0.660 23.8 2 172

White Oak Manor - Shelby Y 2 Cleveland West 2 3 2 98.0% 0.95 1.163 19.4 4 203

XX Brian Center Lincolnton Y 2 Lincoln West 4 4 3 96.8% 1.00 0.867 22.8 7 218

J Peak Resources Shelby Y 2 Cleveland West 5 5 2 94.9% 0.89 1.145 21.3 8 157

N Gastonia Care and Rehab Y 2 Gaston West 3 3 3 84.2% 1.10 1.000 22.7 3 19

HH Carol inas Care Health and Rehab Y 3 Gaston West 3 4 2 93.3% 1.21 1.365 13.9 7 104

M Cardinal Healthcare N Lincoln West 1 1 1 87.8% 1.35 0.937 18.8 6 49

Stanley Total Living Center Y 3 Gaston West 2 5 3 100.0% 1.53 1.000 12.2 0 36

Source CMS CHS CMS Premier CHS CHS

Met Time Period Through January 2018 12 M Feb 18 CY 2016 YTD Oct 2017 2017 2017

Code Facility NameQuality

> 3Tier County Market Overall Quality Staffing

% Medicare/MA

Market Payment Ratio

O/E ScoreNon Medicare

AdmitsTotal

Admissions


Greenville Health SystemPost-Acute Care

Medicare Shared Savings Program

Hospice Performance

Innovation and Excellence in Advanced Illness at End of Life 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, NC


7 Campuses

6 Acute Care

2 Specialty Hospitals

3 Long-Term Care Facilities

1,537 Licensed Beds

9 Outpatient Facilities

More than 200 Practices

Home Health Agency

Hospice Agency

Number of Providers:

1,100+ Employed Physicians

300+ Advanced Practice

Providers

The University of South Carolina

School of Medicine – Greenville

(graduated first class – May 2016)

9 Residencies and 7 Fellowships

Division of Research – partnership

with Clemson University

ACO/Clinically Integrated Network

Not-for profit academic health care delivery system (now part of SC Health Company)

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SC Health Company


Are You Committed?


Integrated Post-Acute Network


Source: The ChartisGroup

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Network Priorities


Health System Network Analysis

• Criteria for selecting a network participant:


Geographic Location Financial/Quality Performance Diversity of Services Financial Stability

Bi-Directional Collaboration

GHS Clinical Priorities

Innovation and Excellence in Advanced Illness at End of Life The Carolinas Center’s 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, ,NC

Enhance Experience

Improve Health Status

Reduce Variations in Care

Eliminate Disparities

Data Driven Decisions

Care Model Transformation

Highly Reliable Organization

Value Based Care

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Care Model


Care Model


MyHFN PreferredPartners

• 30 Skilled Nursing Facilities

• 8 Home Care Facilities with multiple locations

• 16 Hospice providers with multiple locations

• 4 Inpatient Hospice Houses

Care Management Engagement

• Dedicated Care Manager

• Onsite rounding with patient and staff

• Care Transitions between care settings

• Education & Training (i.e. Sepsis, COPD, etc.)

Quality Monitoringand Reporting

• Site specific metrics

• Quality reporting to Quality & Care Model Committee

• Improvement Action Plans

GHS in MSSP


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GHS in MSSP


Network “Value”

• Hospitals/ACOs are “new buyers” of service to:

– Improve hospital mortality rates

– Improve hospital length of stay

– Reduce overall Medicare spend


Value-Based Purchasing

Data Considerations


• Medicare Shared Savings Program (Track 1 – 2016 & 2017 performance years)

• Assigned MSSP beneficiaries

• Source: Claims and Claim Line Feeds (CCLFs)

Definitions:

• Allowed $ per Service/Stay – Allowed amount per continual service period/stay

• Average Visits/ALOS – Average number of continual visits in service period or days

• 30 Day Readmit Rate – Number of qualified readmissions within 30 days of

discharge divided by total number of discharges

• Case Mix Index – hospital relative resource use index

• Quality Score – average of 7 hospice compare quality measures

• Service Count – Number of continual service periods/stays

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GHS Post-Acute Care Utilization


14.9%

1.4% 2.3%

25.3%

56.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Home Health Hospice IRF SNF Home - Community

Pe

rce

nt

Uti

liza

tio

n

Current Performance

*Not adjusted for patient expiring in PAC setting

40% of Medicare Patients Use Post-

Acute Services

GHS Post-Acute Care Spend


$2,797

$7,720

$19,413

$9,439

$7,804

$0

$5,000

$10,000

$15,000

$20,000

$25,000

HomeHealth

Hospice IRF SNF

All

ow

ed

$ p

er

Serv

ice

/Sta

y

Current Performance System Average


GHS Post-Acute Care ALOS


10.1

16.3

14.7

22.9

18.1

0.0

5.0

10.0

15.0

20.0

25.0

HomeHealth

Hospice IRF SNF

Ave

rage

Vis

its/

ALO

S

Current Performance System Average


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Hospice Performance


Post-Acute ProviderAllowed $

per Service/Stay Average Visits/ALOS Service Count30 Day

Readmit RateCase Mix

IndexAverage

Quality Score

Provider 1 $5,596 7.44 116 0.0% 1.99 98.74%

Provider 2 $6,786 14.21 72 2.8% 1.37 99.73%

Provider 3 $7,299 7.20 61 0.0% 1.86 98.46%

Provider 4 $7,800 13.22 51 0.0% 2.64 88.46%

Provider 5 $11,004 30.44 50 6.0% 1.60 99.31%

Provider 6 $8,622 21.07 30 10.0% 2.02 96.77%

Provider 7 $7,786 21.28 25 4.0% 1.87 87.76%

Provider 8 $5,595 5.96 25 0.0% 1.82 86.90%

Provider 9 $7,016 7.13 23 0.0% 2.31 98.26%

Provider 10 $8,005 19.36 22 4.5% 1.47 92.41%


Hospices scored 93% or higher on 6 of 7 measures (2016)

Hospice High Performer





IndexAverage

Quality Score

Provider 2 $6,786 14.21 72 2.8% 1.37 99.73%

Provider 3 $7,299 7.20 61 0.0% 1.86 98.46%

Provider 4 $7,800 13.22 51 0.0% 2.64 88.46%

Provider 5 $11,004 30.44 50 6.0% 1.60 99.31%

Provider 6 $8,622 21.07 30 10.0% 2.02 96.77%

Provider 7 $7,786 21.28 25 4.0% 1.87 87.76%

Provider 8 $5,595 5.96 25 0.0% 1.82 86.90%

Provider 9 $7,016 7.13 23 0.0% 2.31 98.26%

Provider 10 $8,005 19.36 22 4.5% 1.47 92.41%*Not adjusted for patient expiring in PAC setting

Provider 1 $5,596 7.44 116 0.0% 1.99 98.74%

Hospice Low Performer





IndexAverage

Quality Score

Provider 1 $5,596 7.44 116 0.0% 1.99 98.74%

Provider 2 $6,786 14.21 72 2.8% 1.37 99.73%

Provider 3 $7,299 7.20 61 0.0% 1.86 98.46%

Provider 4 $7,800 13.22 51 0.0% 2.64 88.46%

Provider 5 $11,004 30.44 50 6.0% 1.60 99.31%

Provider 6 $8,622 21.07 30 10.0% 2.02 96.77%

Provider 8 $5,595 5.96 25 0.0% 1.82 86.90%

Provider 9 $7,016 7.13 23 0.0% 2.31 98.26%

Provider 10 $8,005 19.36 22 4.5% 1.47 92.41%


Provider 7 $7,786 21.28 25 4.0% 1.87 87.76%

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Diagnosis Grouping


28.4%

27.3%

13.9%

11.6%

19.0%

27.2%

18.7%

11.0%

18.0%

25.1%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

Cancer

Cardiac

Respiratory

Dementia

Other

Percentage National Percentage

Visit Distribution


- Provides clear understanding of distribution of number of visits/length by provider- Account for outliers and provides context by provider

Data Interaction


X-axis: Average Visits/ALOSY-axis: 30 day Readmit Rate

Size: # of ServicesColor: Allowed $ per Service/Stay

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Data Interaction with Quality


Color: Allowed $ per Service/StaySize: Average Visits/ALOS

X-axis: 30 day Readmit RateY-axis: Average Quality Score*

*Quality scores based on latest Hospice Compare data from data.medicare.gov

Future Analytics


Strategic Approaches forHospice & PC Providers


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Data Sources

• Understand the health system’s problems to solve

– Corporate goals including focused populations

• Resources

– www.hospitalcompare.hhs.gov

– http://www.leapfroggroup.org/compare-hospitals

– https://www.ibm.com/watson-health/services/100-top-hospitals

– Statewide health data organizations

– State and regional coalitions

– Private/proprietary data for purchase


Data Sources

• Evaluate your data/impact by potential “solutions”

– Diagnosis

– Provider

– Site of care

– Cost

– Mortality

– Readmissions


Knowledge

• Know the literature

– What has approaches have proven effective in patients with advanced illness?

• ACP

• Home-based palliative care

• Care management

– Health systems may or may not know this information


http://www.hospitalcompare.hhs.gov/

http://www.leapfroggroup.org/compare-hospitals

https://www.ibm.com/watson-health/services/100-top-hospitals

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Action

• Health systems/ACOs not looking for a sales pitch –need solutions

• Engage wherever you can

• Create targeted outcomes with leadership

– Hospice LOS by provider group

– Number of ACP conversations

• Think scale – not looking for “one-off” solutions


Questions

• What do you know about your health system partners including their employed physicians?

• What do you know about your own organization and performance?

• What do you know about non-health system PAC partners? SNFs/HH/IRF/LTACH?

• Who can you start a dialogue with?

• Do you have business model beyond days of care?


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