Managed Care Trends for Strategic Positioning

Transcription

1 Managed Care Trends for Strategic Positioning NELLIE JOHNSON AUGUST 25, 2016

2 Overview - The P s of Managed Care Trends 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 2

3 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 3

4 Making the Transition to Risk-Based Medicare Payment Population-Based Payment/ Shared Savings/ Total Cost of Care Significant Change Significant Change Bundled Payments Negotiated Episode Price Longitudinal Accountability Risk based Risk based Collaboration Predictive modeling Global budget or subcapitation Fee For Service No risk payments Common payments Predictable Significant Change Value Based Reimbursement New metrics Best practices Performance based Uncertainty Electronic communications

5 No Shortage of Changes/Experiments

6 Medicare Advantage National Enrollment

7 Medicare Advantage National Growth Implications

8 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 8

9 Implications of Medicare Payment Reform Preferred Network and Physicians 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 9

10 More States Moving to Medicaid Managed Care Programs Traditional Fee-for- Service Enhanced Primary Care Case Management Model Waiver Programs (i.e. HCBS) Partial Risk MCO Primary Care Case Management Model Health Home Model Provider Sponsored Organization - Share Savings (ACO) Full Risk MCO & ACO Traditional Fee-for-Service (FFS) Full Risk-Based Managed Care Low or no care management or care coordination Enhanced PCP payment or case management fees Enhanced federal funding for enhanced services 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) 10

11 Implications of Medicare/Medicaid Payment Reform Performance Data 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 11

12 12 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 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)

13 CJR Key elements Starts April 1, 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)

14 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.

15 CJR CMS Waivers for Care Delivery Flexibility Three-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!!!!

16 CMS Announces Two New Mandatory Bundles on July 25, 2016 Effective July 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

17 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. 17

18 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)

19 How do you Strategically Partner with Entities 1. Clinical Protocols by diagnosis develop with speciality groups/medical director 2. Control Length of Stay A. monitor by diagnosis 3. Control Readmissions Best Practices INTERACT Care Transitions (hospital-nh-home) Person Centered Care Coordination 19

20 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 years Give them other Nursing Home Compare scores; 20

21 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 homes Has 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: 21

22 INTERACT Key Tools Quality 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: 22

23 23 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

24 24 Best Practices: Overview Care Transitions Process Definition 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 : ) 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 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

25 Implications of Medicare Payment Reform Person-Centered Care Coordination 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 days) upon discharge to determine if plan was successful 25

26 LeadingAge Avalere Collaborative Reports- How do you use these reports Avalere VantageCare Positioning System Post-Acute Scorecard Core Analytics 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. 26

27 Other Issues of Importance Role 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 Costs Use of generics Pharmacy contract Interoperability- sharing of patient care information across provider groups 27

28 Provider Responses to Trends/Health Care Initiatives Providers- do it alone Join a Network Consolidate Business/Sell 28

29 How Did LeadingAge Michigan Respond to These Trends? Formed SeniorCare Resources, for profit Limited Liability Corporation (LLC) LeadingAge Michigan owns 100% of this subsidiary Mission 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 29

30 Network Year Formed # of NH Homes # of SNF Beds Member Criteria CareChoice MN Members/ 37 NHs 4900 Not for profit with nursing home Care VenturesMN Florida (FAHA H&S) Not for profit LeadingAge member Michigan-SCR LeadingAge member LeadingChoice/ LCN/WI members/87 NH s 8100 LeadingAge member 30

31 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 31