Why Do We Now Have ACOs? ACOs: What are they? What do they mean for home care? What you should do about them now! Fazzi Fast Facts Webinar.

Transcription

1 Fazzi Fast Facts Webinar ACOs: What are they? What do they mean for home care? What you should do about them now! April 13, 2011 Presenters Bob Fazzi Founder and Managing Partner Fazzi Associates Patty Upham Director FirstHealth Home Health Tim Ashe Partner and Director of Operational Improvement Fazzi Associates Why Do We Now Have ACOs? Financial Crisis in the United States + Quality Crisis in the United States 1

2 Growth in the U.S. Deficit Deficit or Surplus in Billions of Dollars 1,413 1, Source: Congressional Budget Office (CBO); Department of Commerce, Bureau of Economic Analysis; Office of Management and Budget, Table E-11. Deficits, Surpluses, Debt, and Related Series, 1971 to 2010 Growth in the Percentage of Dollars Going to Health Care National Health Expenditures as Percent of GDP 12.3% 13.6% 14.3% 15.7% 16.2% 17.3% 17.5% 7.2% Source: CMS/OACT: U.S. Bureau of the Census; and U.S. Department of Commerce, Bureau of Economic Analysis, Table II.9. National Health Expenditures: Public and Private Funding, Selected Calendar Years; CMS National Health Expenditures and Selected Economic Indicators, Levels and Annual Percent Change: Calendar Years (Sept. 10 Projections) Even With All This Money, Quality is Seen as a Problem 1. Institute of Medicine reports 98,000 patients die each year due to hospital errors.* 2. 1 out of 3 hospitalized patients are harmed while in the hospital.* 3. In October 2008 alone, 134,000 experienced at least one adverse event.*** 4. In 1.5% of hospitalized Medicare patients, a harm event contributed directly to the patient s death.** 5. 44% is clearly or likely preventable.** Source: *To Err Is Human, Institute of Medicine, 1999 ** Hospital Errors Ten Times More Than Thought, Health Affairs, April 7, 2011 ***OIG, Adverse Events in Hospitals: National Incidence Among Medicare Patients, Nov

3 Quality is Bad and Patients Really Are at Risk % of Medicare patients discharged from a hospital are readmitted within 30 days % of Medicare patients are re-hospitalized within ihi 60d days.* 3. Home care s re-hospitalization rate nationally is at 30%. 4. Patients with chronic diseases are most at risk and most costly. Source: * New England Journal of Medicine, 2009 (pages 1,418-1,428) The Problems ACOs Are Designed to Address...patients have gaps in their care, receive duplicative care, or are at increased risk of suffering from medical mistakes. Accountable Care Organizations i will improve coordination and communication among doctors and hospitals, improve the quality of the care their patients receive, and help lower costs. Kathleen Sebelius Secretary of the U.S. Department of Health and Human Services Side Note: Systems Are Not Aligned and Are Siloed 3

4 The Realities 1. Payments in most parts of the country are sector specific. 2. A win for one sector is often a loss for another sector, i.e. early discharge (hospital win) while inability to serve high risk patient (home care loss). 3. Sectors fight (lobby) to get the maximum for their sector. Bigger, richer sectors win. 4. Poorer (less powerful) sectors lose even if they are better and more cost effective. Why the Drive to ACOs? In many settings no single group of participants takes full responsibility for guiding the health of a patient or community, care is distributed across many sites, and integration ti among them may be deficient. Fragmentation leads to waste and duplication and unnecessarily high cost. Dr. Donald M. Berwick, MD, M.P.P. Administrator, CMS How Do We Stop It? 4

5 What If There Was a System Where 1. Costs are controlled and lowered. 2. Quality matters BIG. 3. Financial rewards are related to quality. 4. Two issues have strong focus: reducing unplanned hospitalizations and dealing with chronic diseases. 5. Sectors are incentivized to work together. 6. Communication is seamless and in real time. 7. Technology is fully maximized. 8. Patients are the center of the full systems. Accountable Care Organizations A Shared Savings Initiative ACOs are One Form of Value Based Purchasing Value Based Purchasing is a concept that links payment directly to the quality of care provided and is a strategy that can help transform the current payment system by rewarding providers for delivering high quality, efficient clinical care. 5

6 ACOs are Also One Form of Medicare Shared Savings Program Shared Savings Programs (providers share in savings) are designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare FFS beneficiaries, i i reduce unnecessary cost, improve outcomes, and increase value by: Improving accountability for the care of FFS patients. Requiring coordinated care for all services. Encouraging investment in infrastructure and redesigned care process. What Valued Based Purchasing and Shared Savings Programs Mean in ACOs Medicare will share a percentage of the achieved savings with the ACOs. ACOs will only share in savings if they first generate shareable savings and then meet the quality standards. Triple Aim of ACOs 1. Better care for individuals. 2. Btt Better health lthfor populations. 3. Lower growth in expenditures. 6

7 Accountable Care Organizations How They Will Work 1. Structure: A formal collaborative effort where different sectors of health care work together to manage patients throughout their involvement with the health care system. 2. Who is in the Collaboration? Four groups have been named: ACO professionals in group practice arrangements. Network of individual practices of ACOs. Partnership or joint venture between hospitals and ACO professionals. Hospitals employing ACO professionals. Why the Move to Accountable Care Organizations The Affordable Care Act is putting patients and their doctors in control of their health care. For too long, it has been too difficult for health care providers to work together to coordinate and improve the care their patients receive. Kathleen Sebelius Secretary of the U.S. Department of Health and Human Services Accountable Care Organizations How They Will Work 3. Who is presently not included in list of eligible ACO partners but is mentioned in the draft? Five groups: FQHC: Federal Qualified Health Centers RHC: Rural Health Centers LTC: Skilled Nursing Homes LTCH: Long Term Care Hospitals CAH: Critical Access Hospitals 4. Who is not mentioned at all? Home Care 7

8 Accountable Care Organizations Some Questions 1. Why should hospitals, physicians, and others join? Opportunity to get bonuses if they are at least 2% under FFS payment and meet or exceed 65 quality measures. 2. How will ACOs be managed? Board made up of 75% of partners plus at least one beneficiary representative. 3. Minimum number of patients needed? 5,000. Big enough for valid performance measurement. 4. When will it start? January 1, Who is the target patient population? Medicare patients who are not part of Medicare Advantage. Accountable Care Organizations More Questions 6. How many patients are expected to be covered by ACOs? 2M to 5M. 7. How important will Electronic Health Records be? Very important. 50% of physicians must meet HITECH EHR meaningful use requirements. 8. How will patients get into an ACO? They don t. They will automatically be assigned based on their Primary Care provider. 9. Do patients have choice? Absolutely. They don t have to stay with providers in the ACO. No penalty. 10. What is a major theme throughout? Patient centered. What Does Patient Centered Care Mean? Patients should have: 1. Individualized care based on their own unique needs, preferences, values, and priorities. 2. Access to their own medical records and to clinical knowledge so that they make informed choices about their care. 3. Encouragement to be partners in care, along with their caregivers and/or family members. 4. Experience of care that is routinely assessed, with the ACO seeking to improve it where opportunities for improvement are identified. 5. Care integrated with the community resources required to maintain well-being. 8

9 Patients Will Matter We envision that successful ACOs will honor individual preferences and will engage patients t in shared decision i making about diagnostic and therapeutic options. Dr. Donald M. Berwick, MD, M.P.P. Administrator, CMS How Will Quality Be Measured? 65 Measures Better Care for Individuals 1. Patient/Caregiver Experience 7 Measures Care Transitions 1. Care Coordination/Transitions 4 Measures 2. Care Coordination 7 Measures 3. Care Coordination/Information Systems 5 Measures Patient Safety 1. Patient Safety 2 Measures How Will Quality Be Measured? Preventative Health 1. Preventative Health 9 Measures At Risk Population 1. At Risk Population/Diabetes 10 Measures 2. At Risk Population/Heart Failure 7 Measures 3. At Risk Population/Coronary Artery Disease 6 Measures 4. At Risk Population/Hypertension 2 Measures 5. At Risk Population/COPD 3 Measures 6. At-Risk Population/Frail Elderly Health 3 9

10 How Will Shared Savings Work? 1. One Sided Model: a. No risk for the first two years. b. Can gain from savings. Smaller than two sided model. c. Full risk in year three. 2. Two Sided Model: a. Full risk starting in year one. b. Higher shared savings. 1. Save money. Goals of Accountable Care Organizations 2. Improve clinical quality outcomes. 3. Be patient centered and improve patient experience. 4. Address patients with chronic disease and/or high risk patients. 5. Reduce unplanned hospitalizations. 6. Increase the use of EHR, technology such as telehealth and best practice. Electronic Health Records and Information Management Will Be Critical Information management making sure patients and all health care providers have the right information i at the point of care will be a core competency of ACOs. Dr. Donald M. Berwick, MD, M.P.P. Administrator, CMS 10

11 Patty Upham Director FirstHealth Home Health How Have Agencies Approached This? Moving From Being a Referral Source to a Partner How we did it. Change the language It s not about referrals - it s about relationships. Raise the bar of your agency s performance Quality: Lower Hospitalization Rate. Financial: Lean guided management aligned with strategic plan. Clinical: Integrated Chronic Disease Management Certification; Health Care Coach Certification; Standard Practice Protocols. Understand your partners challenges Core measures, 30 day re-admission rates, and care management. Five Core Aims of ACOs Patient centered care Hospital to Home Project Post-Acute Care Team SNF Transition Team Primary care redesign Guided Nurse Model Population management Care Management Program Care Navigation System 11

12 Five Core Aims of ACOs Quality Outcomes (IHI s Triple Aim) Improve quality of care Reduce or control healthcare costs Improve patient experience Value based reimbursements The financial plan is the quality plan Other Thoughts and Insights Build relationships on performance, credibility and results. Build a change happy, competitive and fired-up team. Look outside of home health for new ideas and people. Maximize benchmarking, networking, list serves and other forums. Be prepared - you never know where opportunity will appear. Tim Ashe Partner and Director of Operational Improvement Fazzi Associates So What Should We Do? 12

13 Start by Looking at the Goals of Accountable Care Organizations 1. Save money. 2. Improve clinical quality outcomes. 3. Be patient centered and improve patient experience. 4. Address patients with chronic disease and/or high risk patients. 5. Reduce unplanned hospitalizations. 6. Increase the use of EHR, technology such as telehealth and best practice. Now Imagine a Home Care Agency That 1. Saves money In lowest third of cost per visit. 2. Improves clinical quality outcomes Highest third in composite Home Health Compare scores. 3. Is patient-centered and improves patient experience Highest third in CAHPS. 4. Address patients with chronic disease and/or high risk patients. You have a formal chronic disease management program with measurable outcomes. 5. Reduces unplanned hospitalizations Best third in Home Health Compare unplanned hospitalization rates. 6. Successfully uses EHR, technology such as telehealth and best practice. You have an integrated EHR and use telehealth. What Should You Do Now? 1. Create an Organizational Structure that is highly effective and highly cost efficient. 2. Re-engineer and standardize your workflows to: a. Eliminate non-value added waste and lower cost. b. Improve the efficiency and cycle time of your processes. c. Improve the Quality of your care coordination, care delivery, and revenue cycle. 3. Implement a best practice based, patient population focused Care Management Program to improve episode performance and to improve Quality Outcomes. 4. Focus on your Acute Care Hospitalization rates as a primary outcome of your Care Management Program! 13

14 Closing Thoughts Final Thoughts! 1. Positioning your agency for ACOs is the responsibility of leadership. 2. Do not approach this as a poor me provider. 3. Do not approach this as being a referral source. 4. Approach this as being a post acute provider the primary provider and manager of post acute services. 5. Position your agency to offer four things as a package: i. Top third composite Home Health Compare scores. ii. Top third in CAHPS scores. iii. Top third in lowest re-hospitalization rates in your service area. iv. Top third in lowest cost/visit in your service area. 6. Act now! Fazzi Associates, Inc. 243 King Street, Suite 246 Northampton, MA info@fazzi.com 14