3/19/2013. Medicare Spending Per Beneficiary: The New Link Between Acute and Post Acute Providers

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1 The New Link Between Acute and Post Acute Providers Carol Quiring, RN President and CEO, Home Care and Hospice Saint Luke s Health System Shauna Thompson, RHIT Senior Director, Quality & Patient Safety Saint Luke s Health System 1 2 What s Your Point of Reference? Saint Luke s Health System Home Care & Hospice, in downtown, Kansas City, Missouri 4 Branches (Leavenworth, KS; Garnett, KS; Smithville, MO; Chillicothe, MO) Cover Kansas and Missouri (All or parts of 29 counties) Core Services: - Home Health - Palliative Care - Hospice - Tele Health - Home Infusion - Chronic Care 240+ employees patients served daily 3 1

2 The New Link Between Acute and Post Acute Providers In April of 2012, Medicare publically posted hospital specific results of the new efficiency measure, Medicare Spending Per Beneficiary (MSPB). The MSPB measure links performance of multiple health care providers - physicians - hospitals - long term care - home health care - hospice - into a single score, and attributes that score to the acute care hospital. 4 Medicare Spending Per Beneficiary (MSPB) The MSPB episode is defined as all claims whose discharge date falls 3 days prior to an inpatient PPS hospital admission through 30 days post hospital discharge. MSPB episode of care : 3 Days Prior to Index Admission During Index Admission 30 Days After Hospital Discharge 5 Medicare Spending Per Beneficiary (MSPB) 3 Days Prior to Index Admission Spending that begins during the 3 days prior to an index admission. During Index Admission Spending that falls between the index admission date and discharge date. 30 Days After Hospital Discharge Spending for services from the index discharge date up to and including 30 days postdischarge. 6 2

3 Medicare Spending Per Beneficiary (MSPB) 30 Days After Hospital Discharge includes hospital readmissions that begin within the 30 day period following the index admission discharge date. 7 The Evolution of Medicare 1965 The Medicare Program Began The law had provisions preventing the federal government s involvement or interference in treatment decisions. But the visionaries of 1965 were not projecting a health care industry that could not be sustained. 8 The Evolution of Medicare 2010 Medicare Spending Per Beneficiary It was announced that effective FY 2015, Medicare Spending Per Beneficiary would be incorporated into Medicare s Value Based Purchasing equation. Many concerns have been voiced that care might be negatively impacted by imposing incentives for efficiencies. 9 3

4 Medicare s Initial Effort to Promote Quality Home Care and Hospital Parallels 1983 Hospital Prospective Payment (DRGs) 2000 Home Care Prospective Payment (HHRGs) (20+ Years Later) 2007 Hospital Incentive for Pay for Reporting 2008 Home Care Incentive for Pay for Reporting 10 Pay for Performance Introduced The Health Care Recovery Act of 2010 established Value Based Purchasing, also referred to as Pay for Performance. Since introduced, VBP has been deployed with unprecedented momentum. 11 Value Based Purchasing Described A system that is transforming from one that rewards volume of service to one that rewards efficient, effective care and reduces delivery fragmentation. The Patient Protection and Affordable Care Act of 2010 requires the establishment of a VBP program to pay hospitals for performance on quality measures rather than just reporting of these measures. 12 4

5 Value Based Purchasing Described VBP applies to acute care hospitals in the 50 states and the District of Columbia. Hospital excluded from VBP: Psych, Rehab, Long Term Care, Children s Hospitals, and Critical Access Hospitals. 3,000 hospitals nation-wide qualify to participate in VBP. 13 Value Based Purchasing Described The first definition of VBP was finalized in April 2011, and has quickly evolved. The VBP score will be based on performance scores within domains. Funding for the VBP program will be generated by withholding a percentage of all inpatient PPS Medicare MS-DRG payments. 14 Changes in Value Based Purchasing Domains & Withholds Over Time 30% 30% 30% 25% 30% DOMAINS Patient Experience (HCAHPS) Outcomes (Mortality in FY14) 70% FY2013 (Withhold 1.0%) 45% FY2014 (Withhold 1.25%) 20% 20% FY2015 (Withhold 1.5%) Efficiency (Medicare Spending) Clinical Process (Core Measures) Withhold The percentage of DRG operating payments withheld to fund the VBP program. 15 5

6 Number of Clinical Process Measures at 100% Performance Number of Patient Experience Measures Meeting/Exceeding Thresholds 3/19/2013 Is there a correlation between cost, quality, and the patient's perception of care? High Quality Low Quality Cost Low Satisfaction 16 High Satisfaction Peer Comparison Regional Peers 8 Perfect Performance on Clinical Process Measures by Medicare Spending Per Beneficiary Score More Spending Less Spending Individual Hospital Medicare Spending Per Beneficiary Scores There is no obvious difference in performance on Clinical Process Measures based on Medicare Spending. 17 Peer Comparison Regional Peers 9 Patient Experience Measures Meeting Achievement Thresholds by Medicare Spending Per Beneficiary Score More Spending Less Spending Individual Hospital Medicare Spending Per Beneficiary Scores There is no obvious difference in performance on Patient Experience Measures based on Medicare Spending. 18 6

7 Peer Comparison Regional Peers It can be concluded that spending less does not necessarily have a negative impact on quality or perception. 19 Implications for Post Acute Care Providers CMS is moving toward managing the delivery of health care by linking the multiple settings of post acute care to the Medicare Spending Per Beneficiary episode of care. - physicians - hospitals - long term care - home health care - hospice - 20 Bundled Payment for Care Improvement Initiative January 31, 2013 CMS announced the recipients of the BPCI 500 recipients The Models rewarded for innovation that fosters improved coordination and quality Three of the models are a retrospective payment arrangement One model is prospective 21 7

8 Model 3/Post Acute Care Services Examples of diagnoses are: Urinary Tract Infections; Total Joint Replacement; COPD Reengineered care 3-part AIM outcomes Virtuous cycle leading to continuous decrease in the cost of an acute or chronic episode Payment models that extend accountability Shorten cycle of time for adoption of new evidencebased care 22 Medicare Spending per Beneficiary National Breakdown by Claim Type Home Health 4.1% Outpatient 3.4% Skilled Nursing Facility 15.3% Carrier 16.0% DME 0.8% Hospice 0.6% Inpatient 59.7% % of the spending that comprises the MSPB measure is accumulated outside of the inpatient hospitalization. Hospitals will be challenged to form or strengthen alliances with pre- and post acute care providers to address spending. Report to Congress: Post Acute Care Payment Reform Demonstration January 2012 Mandated by the DRA of 2005 Definition of participating facilities: LTCHs, IRFs, SNFs, and HHAs Data Collection from a standardized patient assessment instrument Identification of measures of cost and resource expenditures Focus on increased understanding of factors that predict costs and outcomes for each level 24 8

9 Results and Recommendations IRF s and LTCH s and SNF s are distinctly different from HHA s Going forward would recommend different further analysis Move to uniform definitions and measures between different setting Common payment system for all except HHA s HHA stays are associated with statistically significant positive impact on improving self care functional ability 25 The CARE Tool All setting were able to successfully use this tool for collection of consistent, reliable, and comprehensive data Participant feedback was generally positive High reliability standards Support that CARE tool has life after demonstration project ends Expand and revise the CARE tool for all payment models Strong support that standardizing the collection tool between settings is critical 26 Implications for Post Acute Care Providers Understanding of the 3 components of the episode of care begins to make clearer the steps home care and other acute care providers must take in order to be viewed as a valued partner to the acute care hospital. 27 9

10 The New Link Between Acute and Post Acute Providers With the addition of the MSPB measure to the Medicare reimbursement model, now more than ever, post acute care providers are in a position to influence the success of the acute care hospital. 28 The New Link Between Acute and Post Acute Providers As previously noted, more than 1/3 of spending in a health care episode is outside the acute care hospital stay, and yet the hospital is held accountable. 29 The New Link Between Acute and Post Acute Providers The most highly sought after post acute care providers must be prepared to partner with the acute care hospital to: Improve transitions between settings, Provide the highest quality performance results including patient engagement, and Work to eliminate avoidable readmissions

11 The New Link Between Acute and Post Acute Providers Carol Quiring, RN President and CEO, Home Care and Hospice Saint Luke s Health System Shauna Thompson, RHIT Senior Director, Quality & Patient Safety Saint Luke s Health System 11