Medicare Bundling: Lessons Learned From Conveners

Transcription

1 Medicare Bundling: Lessons Learned From Conveners Tuesday, 8:30 am 10:00 am 2 1

2 Jade Gong, Principal Jade Gong & Associates Panel Discussion Judy Amiano, CEO Franciscan Ministries Sponsored by the Franciscan Sisters of Chicago Michael N. Rosenblut, President & CEO Parker Jewish Institute for Health Care and Rehabilitation Lorraine Breuer, Senior V.P. for Research & Grants Parker Jewish Institute for Health Care and Rehabilitation 3 Is Medicare Bundling in Your Future? CMS seeks 50% Value Based Payment by 2018 through ACOs and Bundles Mandatory CJR as of April 1, 2016 in 67 MSAs Additional SHFFT and Cardiac Bundles Proposed as of July 1, 2017 in 98 MSAs TBD CMS Planning New Voluntary Bundled Payment in CY 2018 and Condition Specific Models 4 2

3 BPCI Awardee Types PAC Providers Bear Risk Under Model 3 Possible Roles Risk- Bearing Non-Risk- Bearing Single Awardee (Episode Initiator) Awardee Convener Facilitator Convener Parker Jewish Institute for Health Care and Rehabilitation Franciscan Ministries Episode Initiator Designated Awardee Episode Initiator Designated Awardee Convener Episode Initiator 5 Expanding CJR to Include SHFFT CJR + SHFFT Episode Payment Models CJR Lower Joint Extremity MS-DRGs 469 and 470 All care during index hospitalization through 90-days post-discharge Hospital would be financially responsible for cost, quality of the episode SHFFT Surgical Hip and Femur Fracture Treatments in MS-DRGs All care during index hospitalization through 90-days post-discharge Hospital would be financially responsible for cost, quality of the episode Add SHFFT July 1, 2017 in the 67 CJR MSAs and Hospitals 6 3

4 Introducing CABG and AMI Episode Payment Models Cardiac Episode Payment Models CABG MS-DRGs All care during index hospitalization through 90-days post-discharge Hospital would be financially responsible for cost, quality of the episode AMI MS-DRGs ; All care during index hospitalization through 90-days post-discharge Hospital would be financially responsible for cost, quality of the episode Bundles to begin July 1, 2017 in 98 MSAs that are not yet selected 7 Hospitals Can Gainshare with Collaborators GAIN SHARING Participant hospital can gainshare with CJR collaboration Participant hospitals can share: Reconciliation payments internal cost savings achieved through care redesign Collaboration Agreement RISK SHARING Participant hospital can share repayment responsibilities Participant hospital must retain responsibility for 50% of repayment amt. A single collaborator can pay up to 25% of repayment amt; ACOs up to 50 percent of repayment amount. 8 4

5 Program Waivers Allow for Care Redesign SNF 3 Day Stay Home Visits Telehealth Waives the 3 day rule for coverage of a SNF stay following anchor hospitalization SNF must have 3 stars or higher for at least 7 of the previous 12 months CMS will post list of qualified SNFs on website CJR begins on 1/1/2017 AMI begins on4/1/2018 Not applicable for CABG or SHFFT Waives the incident to direct supervision rule for physician services Allows clinical staff of physician or non physician practitioner to furnish a visit in the home under the general supervision of a physician Permitted only for beneficiaries who do not quality for Medicare HH coverage CJR 9 visit maximum AMI 13 visit maximum CABG 9 visit maximum SHFFT 9 visit maximum Waives the geographic site requirement and the originating site requirement Allows telehealth services to originate in the beneficiary s home 9 Care Redesign is a Business Imperative Risk stratify patients Manage care across the episode Create diagnosis specific pathways Right size post acute care use Gainsharing and Risksharing permissible with PAC to align incentives 10 5

6 Lily Tomlin Judy Amiano, CEO Franciscan Ministries Sponsored by the Franciscan Sisters of Chicago 12 6

7 Our Service Area 13 Franciscan Model 3 BPCI Program Entered Phase II Model 3 BPCI in July 1, 2015 Facilitator Convener with 2 Episode Initiators 2 Episodes Chronic Obstructive Pulmonary Disease ( COPD ) and Urinary Tract Infections ( UTI ) Traditional Medicare is primary insurance Episode length: 90 days Utilize Archway consultants to mine the data, assist with strategic decision (risk tracks, episode selection), and care redesign 14 7

8 Overall Cost Breakdown Episode Initiator 1 5% 9% Avg. SNF Avg. HHA 2% 14% 4% 4% 62% Avg. LTCH + IRF Avg. OP Avg. Readmission Avg. PAC PB Avg. PAC DME 15 Overall Cost Breakdown 1% Episode Initiator 2 3% 5% 11% Avg. SNF 4% Avg. HHA Avg. OP 76% Avg. Readmission Avg. PAC PB Avg. PAC DME 16 8

9 Key Areas to Reduce Episode Costs Post Acute LOS SNF LOS continues to decrease quarter over quarter. Work with SNF team to continually assess care redesign and improve outcomes. Identify barriers to timely discharge and transition to home (i.e., no PCP, conducting home assessments). Designate Core Transition Coordinators at each Episode Initiator site. 90 Day Readmissions Average readmission costs per episode are $36,080 vs $28,970 for cases without a readmit. 14% of episodes had a readmission. When a readmit occurs 16% of total episode costs are related to readmission. Lower Cost Settings The goal is to continue to reduce ALOS and if appropriate, to move to an assisted living environment with related services > How can we affect these drivers of episode savings? 17 Goals of Franciscan Care Redesign Enhance transition experience for patients between levels of care Improve communication between providers Improve health for bundled patients Focus on bundle diagnosis management in relation to co-morbidities Reduction in acute episodes and/or readmissions Reduce costs per episode Increase use of home care Lower cost 18 9

10 Components of Care Redesign Transitioning Nurse Liaison who serves as bridge between hospital and Franciscan community Transition Nurse who case manages the bundle in-house and postdischarge Communication Weekly meetings Identify billing contract at hospital to assist in identifying bundled patients upon admission Work closely with therapy to ensure LOS is appropriate Care Pathways Use of wellestablished INTERACT clinical pathways Incorporate training and education of resident throughout LOS Post-discharge Provide an opportunity for patients remain in ALU up to 3 days Follow-up calls Trigger responses forwarded to Transitional Nurse Provide home monitoring devices Encourage SNF return if needed 19 Care Redesign Results 44.6 Initial SNF Admission - Average Length of Stay Percent of Episodes Using HHA 58.30% 42.90% 33.30% 28.60% 3Q Q Q Q Q Q Q Q 2016 Note: Volume extremely low Q3, Q

11 Care Redesign Results Readmission Rate During SNF Stay 90-Day Readmission Rate 25.00% 12.30% 14.30% 16.70% 7.10% 7.10% 0.00% 3Q Q Q Q % 3Q Q Q Q Q 2016 Care Redesign Results Medicare Spending Compared to Target Price 1Q Q Q 2015 $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 Target Price for Selected Risk Tract Medicare Spending 22 11

12 Learning curve was steep and in the rear-view mirror Lessons Learned Challenges Who are the patients? CMS delays were frustrating Change is difficult. Scale was difficult. So many new areas to be concerned with cost who knew how long 90 days is Successes Staff pride in being innovators Teamwork on care design Change is difficult and took longer than we thought Positioned the organization strategically Data partner is key Care Navigators Improved competitive position Sharing data more timely with front-line staff What We Need to Do Better Communication Manage readmission process very tightly Still have opportunities to do better Drive analytics & share w/ care partners along the continuum Staff training 23 Michael N. Rosenblut President & CEO Lorraine Breuer Senior V.P. for Research & Grants Parker Jewish Institute for Health Care and Rehabilitation 24 12

13 Our History Founded in 1907, the Institute was established by a group of benefactors as a shelter for homeless older people in 1914 and incorporated as the Harlem House of the Daughters of Israel. Due to the changing needs, the Home gradually expanded its services to include health care. Eventually, the high prevalence of medically complex residents led to the development of a modern facility with the resources to provide more sophisticated care. This led to the development of a geriatric facility with a revolutionary vision to create an institution that would provide total care for the geriatric patient. Its orientation would be unique: rehabilitation, restoration, and return to the community. 25 Parker Today A major health and rehabilitation center located in New Hyde Park, NY, comprised of a 527-bed skilled nursing facility, offering a comprehensive system of post-acute care, including short-term rehabilitation, nursing and medical services. We also offer a diversified network of outpatient services including: Social Model Adult Day Care Home Health Care Program Hospice Program Palliative Care Program Research and Grants Pharmacy Physician Services Queens-Long Island Renal Institute, Inc. Lakeville Ambulette Transportation, LLC AgeWell New York, LLC Physician Home Visits Program 26 13

14 Our Service Area We service multiple locations and people from rich and diverse backgrounds. Located in Queens on the border between of New York City and Long Island --- one of the largest and most diverse urban areas in the country. According to the last U.S. Census, 48 percent of the population is foreign-born. The largest ethnic groups in Queens include Asian (Chinese, Korean), Hispanic, Jewish, Persian, African-American, West Indian, Italian, Greek, and Russian. Tremendous amount of immigration from South Asia, the Caribbean and South America. Large number of people with limited proficiency in English who are less likely to access appropriate health & social services. 1 locations in Queens, 3 locations in Nassau County, and 1 location in Manhattan. 27 Parker Mission On The Wings Of Compassion, Excellence and Innovation Provide, with compassion and dedication, superior quality health care and rehabilitation for adults. Through continual improvement of Parker s programs and services, it will be a leader in health care delivery and education

15 Parker s Bundled Program Entered in April 1, 2015 Convener and Episode Initiator: Episodes initiate in nursing home and home health agency. No Intermediary 20 Orthopedic DRGs Joint replacements, Fractures of hip pelvis and femur Traditional Medicare is primary insurance Episode length: 60 days Expected number of episodes: 120 Utilize consultants to mine the data, assist with strategic decision (risk tracks, episode selection), and care redesign 29 Why Did We Do This? Looking forward Learning Claims data Calculation of target price Risk tracks Overall benefit to our patients Everyone should be doing this By 2019, majority of SNF payments to be episode based

16 Medicare Spend Phase 1 Data: Q1-3 PAC Stay 81% Physician 8% Acute 6% HHA 2% SNF 2% Hosp OP 1% DME 0% 31 Key Areas to Reduce Episode Costs Post Acute LOS Average SNF LOS for ortho cases ranges from a low of 10 days for commercial payers to 44 days for Medicare. Work with SNF team to improve patient outcomes, particularly readmissions and timeliness of care. Work with staff to identify barriers to timely discharge and transition to home (i.e., no PCP, problems with home environment). Hired staff to provide transitional care coordination. 60 Day Readmissions Average readmission costs per episode are $41,070 vs $29,899 for cases without a readmit. 30% of episodes had a readmission. When a readmit occurs 28% of total episode costs are related to readmission. Lower Cost Settings Average SNF costs per episode are $31,750 versus home health care costs per episode of $7, % of ortho patients are discharged without home care. Work to increase number of ortho patients with episodes initiated in home care setting. > How can we affect these drivers of episode savings? 32 16

17 Goals of Parker s Care Redesign Optimize utilization ensure best care setting Reductions in inpatient LOS. Increase use of home care. Manage consults to reduce redundancies and medically unnecessary care. Enhanced availability of care. Significant reduction in re-admissions. Improve Communication Weekly stand up meetings. Re-engineered discharge planning process and how we assess patients. Manage care so that we beat the target price. 33 Components of Care Redesign Patient Navigators Communication Care Pathways Post-discharge Proficient Experience Familiar with organization Empowered Condition specific coaching for patients and families Weekly meetings Shared decision making Targeted length of stay and readmissions Established protocols Customized Transitions of care Follow up with patient Address problems No network No down stream risk sharing 34 17

18 Care Redesign Results Initial SNF Admission - Average Length of Stay Percent of Episodes Using HHA Jan Mar Q Q Q 2015 Jan Mar Q Q Q Care Redesign Results Readmission Rate During SNF Stay 60-Day Readmission Rate Jan Mar Q Q Q 2015 Jan Mar Q Q Q

19 Care Redesign Results Spending Compared to Target Price Jan Mar 2015 [No Risk Phase 1] 2Q 2015 [Go Live Phase 2] 3Q Q 2015 Target Price Acutal 37 Lessons Learned Challenges Change is difficult. Hard to give up the old way of doing things. Internal forces work against change. Many opportunities to improve care. Successes We jumped in and overall did better than we expected. We managed the model and care redesign ourselves. Change is difficult and took longer than we thought. Positioned the organization strategically. Unexpected champions to drive change. Care Navigators Improved competitive position. Identification of patients. What We Need to Do Better Communication (breakdown silos; follow-up; ask why). Optimize management of non-weight bearing patients. Still have opportunities to do better. Warm handoff. Staff training 38 19

20 What is Your Strategy? When Will You Make the Leap? 39 Where to Begin 40 20

21 Where to Begin Make decision to participate in value based bundling Data analytics Understand utilization, what are the total costs of care, how do you compare with other providers. Use data to identify opportunities to improve care. Select episodes, determine length of episode. Care redesign Outreach to stakeholders, need buy in. Identify leaders who will help drive redesign. Establish a committee made up executive leaders. Review workflows to identify opportunities (i.e., early and comprehensive discharge planning, admissions process, coordination with home care). Use of care paths to standardize care and identify problems early on (systems level and patient level). 41 W. Edwards Deming 21

22 Questions & Dialogue Jade Gong Jade Gong & Associates Lorraine Breuer Parker Institute Judy Amiano Franciscan Ministries Michael N. Rosenblut Parker Institute 43 Evaluate this Session on the Mobile App 44 22