Solving the Medicare Spending Per Beneficiary Measure (MSPB) Puzzle

Transcription

1 Solving the Medicare Spending Per Beneficiary Measure (MSPB) Puzzle Chuck Bongiovanni, MSW, MBA, CSA, CFE

2 Objections 1. Identify how MSPB incentivizes or penalizes acute care hospitals 2. Learn what the highest and lowest post-acute cost categories are and how to utilize the power of patient choice to balance the MSPB equation 3. Determine what hospitals will expect and need from their post-acute providers for better partnership opportunities 4. Understand how MSPB relates to readmissions and Value-Based Purchasing

3 Readmissions & MSPB Goals Readmissions Goal MSPB Goal

4 What Is The Basic Formula?

5 What Is MSPB? A Value-Based Purchasing Formula that is used to assess the cost to Medicare of services performed by hospitals and other healthcare providers during a Medicare Spending per Beneficiary (MSPB) episode. Medicare-Spending Episode begins: 3 Days Prior To Hospital Admission (Index) Continues through Hospitalization Ends 30 Days after Hospital Discharge Average Episode Is 40 Days

6 The Hospital Is Accountable For ALL Spending Inpatient Hospitalization Long-Term Acute Care Hospital (LTACH) Inpatient Rehabilitation Facility (IRF) Hospice Services Outpatient Services Physician and Professional Services Skilled Nursing Facility (SNF) Medicare Home Health Agencies (HHA) Durable Medical Equipment (DME) All Services Associated With A Readmissions During The Medicare Spending Episode Throughout The Continuum: Looks Like A Virtual Bundle???

7 MSPB & Hospital Readmissions MSPB Has Been Called The Other Readmission Penalty Because All Cost Remains Within The Initial Index Admission

8 Which Patients Are Included: Enrolled in both Medicare Parts A and B for at least 93 days prior to IPPS index hospital admission; Enrolled in Medicare Parts A and B for at least 30 days following discharge from a short-term acute care hospital stay (where the stay occurs during the performance period).

9 Which Patients Are EXCLUDED: Currently Enrolled or Enrolled During The Episode To A Medicare Advantage Plan Beneficiary Passes Away During The Episode Medicare is Secondary Payer Medicaid Becomes Primary Payer During The Episode (All payments prior to area included)

10 How Is The Actual Measure Developed? SPENDING DIVIDED BY NATIONAL AVERAGE Hospital Medicare Spend $18, Ave of All Hospitals MSPB Measure $18, MSPB = 1.00 $17, $18, MSPB = 0.96 $19, $18, MSPB = 1.04

11 The LOWER the MSPB Measure, The MORE FINANCIALLY EFFICIENT The Hospital Is. MSPB Measure = 0.96 MSPB Measure = 1.00 MSPB Measure = 1.04

12 MSPB Truths MSPB is a constant rolling measure Hospitals are graded on a moving curve No matter how well a hospital performs, they may continue to be penalized if they are less efficient than other hospitals THE KEY Controlling Unnecessary Spending

13 What Is MSPB Worth To A Hospital?

14 Knowing What Raises & Lowers MSPB Low Cost High Cost

15 MSPB Measures & The Medicare Spending Episode Phases Pre-Hospital Services 3% of Total Spending Weak Correlation Inpatient Acute Hospital Services 56% Of Total Spending Moderate Correlation Post-Acute Services 47% Of Total Spending Strong Correlation

16 Category Spending vs Total Spending HHA 9% Hospice 1% Inpatient (Readmissions LTACH,IRF) 31% Outpatient 8% SNF/REHAB 37% DME 1% Carrier (Physicians etc) 12%

17 Category Spending vs Cause of Increased MSPB HHA Moderate Correlation Hospice Most Cost Effective Inpatient Strong Correlation Outpatient Min Correlation SNF/REHAB Strong Correlation DME Min to No Correlation Carrier (Physicians etc) Moderate

18 A Hospital Example: MSPB 1.09 Hospital Name Period Claim Type Hospital National Over / Underspending REGIONAL MEDICAL CENTER 1 to 3 days Prior to Index Hospital Admission Home Health Agency $20 $13 ($7) 1.08 MSPB MEASURE 1 to 3 days Prior to Index Hospital Admission Hospice $1 $1 $0 1 to 3 days Prior to Index Hospital Admission Inpatient $5 $5 $0 1 to 3 days Prior to Index Hospital Admission Outpatient $101 $117 $16 1 to 3 days Prior to Index Hospital Admission Skilled Nursing Facility $4 $2 ($2) 1 to 3 days Prior to Index Hospital Admission Durable Medical Equipment $8 $9 $1 1 to 3 days Prior to Index Hospital Admission Carrier $566 $532 ($34) During Index Hospital Admission Home Health Agency $0 $0 $0 During Index Hospital Admission Hospice $0 $0 $0 During Index Hospital Admission Inpatient $9,469 $9,108 ($361) Readmissions Problem SNF Highest Cost Category With Carrier During Index Hospital Admission Outpatient $0 $0 $0 During Index Hospital Admission Skilled Nursing Facility $0 $0 $0 During Index Hospital Admission Durable Medical Equipment $26 $24 ($2) During Index Hospital Admission Carrier $1,750 $1,514 ($236) 1 through 30 days After Discharge from Index Hospital Admission Home Health Agency $932 $771 ($161) 1 through 30 days After Discharge from Index Hospital Admission Hospice $211 $118 ($93) 1 through 30 days After Discharge from Index Hospital Admission Inpatient $3,154 $2,665 ($489) 1 through 30 days After Discharge from Index Hospital Admission Outpatient $468 $710 $242 1 through 30 days After Discharge from Index Hospital Admission Skilled Nursing Facility $3,503 $3,251 ($252) 1 through 30 days After Discharge from Index Hospital Admission Durable Medical Equipment $77 $101 $24 1 through 30 days After Discharge from Index Hospital Admission Carrier $1,443 $1,083 ($360) Complete Episode Total $21,738 $20,025 ($1,713)

19 Hospital Strategies: Partner With High Quality Post-Acute Providers Which Are Also The Most Financially Efficient. SNF Low Cost & High Quality SNF High Cost & High Quality SNF High Cost & Low Quality

20 How Do We Maintain Quality Care & Reduce Costs? Get Rid Of Sacred Cows & The We Always Do It This Way Thinking

21 We Can Think Differently? BETWEEN 1990 To 2000 Don t Get Into A Car With Strangers BETWEEN 2001 To 2010 Don t Meet Anyone In Person The You Met On The Internet 2010 to 2017 UBER is valued at $60 Billion Dollars A stranger we meet on the internet and then get into their cars

22 The Continuum Needs To Change What Do All These Have In Common? MEDICARE SPENDING

23 Change Our Thinking Physicians and Case Manager s Solutions MUST CHANGE: What The Next Medicare Benefit THINKING MUST CHANGE TO: What Is The Most Appropriate Care Setting? REGUARDLESS OF MEDICARE BENEFIT ELIGIBILITY

24 KEY QUESTIONS TO ASK REGUARDLESS OF SERVICE ELIGIBLITY CAN THIS PATIENT S MEDICAL NEEDS BE SERVICED BY A HOME HEALTH AGENCY? IF YES, DOES THIS PATIENT HAVE SUPPORT AT HOME OR A HOMELIKE ENVIRONMENT FOR A SUCCESSFUL RECOVERY?

25 The US Supreme Court Olmstead Decision Operationally, for hospital Case Managers, this means that they must identify and determine, as part of the discharge planning process, the least restrictive environment that is appropriate for the Patient patient to Choice be discharged regardless of insurance or available benefits. If A Patient Qualifies For A SNF But Could Also Be Discharged Home or to an Assisted Living with Home Health Services All Options Must Be Offered REGARDLESS OF PERCEPTION OF ABILITY TO PAY

26 Strategy Plan For Hospitals THINK HOME FIRST With HHA or Hospice THINK PRIVATE PAY OPTIONS NEXT Assisted Living & Non- Medical Homecare THINK SNF/REHAB Last WHEN MEDICALLY APPROPRIATE

27 What Should Hospitals Expect From SNF s /Rehab Reduced Length of Stay Offer Home Health Sooner Prepare Patient To Maintain At Home

28 What Should Hospitals Expect From Home Health Reduce Length of Service Front-Load PT Visits Prepare Patient To Maintain At Home

29 What A Hospital Strategy Should Look Like Decreased Addiction To The Next Medicare Benefit Increase The Power Of Patient Choice FOCUS ON DISCHARGE COMMUNICATION

30 Increase Discharge Instruction Communication N E W D O O R Sometimes We Think We Give PERFECT Instructions, Only To Find Out Later.We Didn t

31 The ASSUMPTION that a patient cannot afford private services is ONLY AN ASSUMPTION The Power Of Patient Choice 3 Hospital Systems In Florida SNF Eligible Patients Medically Appropriate To Receive Care With HHA at an Assisted Living Trained Case Management Patient & Families Given The Choice For AL or SNF Assisted Living 35% Patient Discharge Choices SNF 65% SNF

32 How Can Reducing SNF Utiliation Affect MSPB Indiana Hospital: 3,306 MSPB Episodes (MSPB Eligible Patients) Total MSPB Spend: $69,346,284 MSPB Measure: 1.02 Nursing Home Patients: 991 or 30% SNF Utilization Rate Total SNF Cost: $14,388,358 Average Cost SNF Per Patient: $14,519 Average Cost Per Beneficiary: $4,352 Goal: Reduce Overall SNF Utilization By 3% or 23 Patients Per Year Total SNF Cost $12,949,522 Total SNF Reduction: $1,438,835 Average Cost Per Beneficiary: $3,916 New Total MSPB Spend: $67,846, New MSPB Measure 1.00 At Risk: $338, GOAL: 3% to 6% Patients

33 In Summary Post-Acute Providers Reduce Length of Stays/Service Discharge To Alternative Settings or Services When Medically Appropriate Increase Patient Discharge Instructions Hospitals Change Your Perception of What the Continuum of Care Is. Think HOME or HOMELIKE FIRST Increase Patient Choice Reduce Higher Cost Categories When Possible

34 Chuck Bongiovanni, MSW, MBA, CSA, CFE Author of The Community Integration Model CEO of CarePatrol Franchise Systems, LLC Office: Mobile: ?