Retrospective Bundles

Transcription

1 Bundled Payment for Care Improvement (BPCI) Overview Shawn Matheson MBA, LNHA, FACHCA Market Manager Idaho Health Care Association Annual Convention Boise, ID July 13, 2017 Retrospective Bundles Surgeon Hospital FFS Billing SNF as Usual Home Health Retrospective Reconciliation PAC OPPORTUNITY & RISK FROM HOSPITAL EYES Surgeon, Hospital Inpatient Rehab Facility, Long-term Acute Care, Skilled Nursing Facility Home Health 3 1

2 PAC OPPORTUNITY & RISK FROM HOSPITAL EYES Surgeon, Hospital Inpatient Rehab Facility, Long-term Acute Care, Skilled Nursing Facility Home Health Hospital Discharge 90-Day Bundle Risk Hospitals are Increasingly Responsible for the Financial & Quality Outcomes for a Patient s Entire Episode of Care 4 Why Bundled Payments Work Creates accountability for positive outcomes and efficiency Engages clinicians and drives a shift to coordinated, multidisciplinary care over the full Episode Promotes competition in an increasingly uncompetitive market Patients can choose the Provider that best fits their specific needs Providers with the greatest efficiency & best outcomes will grow, improving overall average outcomes and reducing average costs Providers with poor performance will need to either improve, or exit focus on areas where they can deliver clear value 5 Remedy Partners Overview Remedy has created a comprehensive episode of care company with the largest footprint and broadest range of bundled payment capabilities: enabling Payers and Providers to succeed with bundled payments Convener Share By Competitor Remedy s Bundled Payment Spend By Partner ($6.7B) Hospitalists Remedy Partners 66% $6.7B ACH SNFs PGPs Other $4,505M 67% $1,515M 23% $359M 5% $263M 4% $44 M 1% 6 2

3 Remedy Partners Overview Spend & Episodes Remedy Spend Under Management 2015 Q Q2 $ Billions $6.7b Episodes 70,000 60,000 50,000 40,000 30,000 20,000 10,000 Remedy Episodes Under Management 2015 Q Q2 65k Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2-2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 7 BPO for Bundled Payments Remedy s role is to manage the bundled payment program for its Payer Partners including the development, organization, operationalization and ongoing management of the program Remedy supports its Partners with the technology, analytics, expertise, and process implementation to operationalize the program, along with technology and care protocols to efficiently manage the complex program Remedy s Role in Program Success Program Design & Administration Care coordination programs Contracts and protocols Compliance, Quality and Reconciliations Software Tools Episode Connect Patient attribution, patient tracking Assessment, patient stratification and decision support Analytics Risk mitigation and actuarial support Predictive analytics Comprehensive reporting Network Management, Call Center SNF and HHA Performance Networks Post Acute Physician Network Care Innovation Center Portals 8 Full Bundle Administration 48 BPCI Bundles Representing 181 DRGs covering up to 50% of MLR Acute myocardial infarction Amputation Atherosclerosis Automatic implantable cardiac defibrillator Back and neck except spinal fusion Cardiac arrhythmia Cardiac defibrillator Cardiac valve Cellulitis Cervical spinal fusion Chest pain Chronic obstructive pulmonary disease Combined anterior posterior spinal fusion Complex non-cervical spinal fusion Congestive heart failure Coronary artery bypass graft surgery Diabetes Esophagitis, gastroenteritis other digestive disorders Double joint replacement/ lower extremity Fractures femur and hip/pelvis Gastrointestinal hemorrhage Gastrointestinal obstruction Hip and femur procedures except major joint Lower extremity and humerus except hip, foot, femur Major bowel Major cardiovascular procedure Major joint replacement of the lower extremity Major joint replacement of upper extremity Medical non-infectious orthopedic Medical peripheral vascular disorders Nutritional and metabolic disorders Other knee procedures Other respiratory Other vascular surgery Pacemaker Pacemaker Device replacement or revision Percutaneous coronary intervention Red blood cell disorders Removal of orthopedic devices Renal failure Revision of the hip or knee Sepsis Simple pneumonia and respiratory infections Spinal fusion (non-cervical) Stroke Syncope and collapse Transient ischemia Urinary tract infection 9 3

4 Remedy Assets for Success Remedy Network Remedy s existing Partnerships are a platform for serving local Payers and self-funded employers 10 Episode Connect: Provider Platform The Operating System for Bundled Payments User Portals Separate views for case managers, program administrators, patients and physicians Data Aggregation Integration with HL7 feeds from most major EMR systems Patient Attribution Predictive analytics for early DRG assignment and workflow tools to set up patients accreting into bundled payments Onboarding & Assessment Patient risk stratification and post-acute needs assessment Messaging & Alerts Dynamic care team creation and downstream/multi-channel messaging and alerts Open API Full scale enterprise software capabilities enable deep integration with EMRs Content & Engagement Disease and condition-specific digital check-ups, plans for care coordination plans, dietary and supplement protocols, episode length of stay guidelines Workflow Tools Patient tracking and coordination software for call centers, case managers, administrators and physicians Reporting & Analytics Advanced patient and population level analytics, including process and performance reports to manage and track progress Decision Support Validated software tools to guide selection of best site for post-acute care and to calibrate post-acute 11 Current Operating Results Gross Savings Improvement Average Readmission Rate ~320 bps improvement ~570 bps improvement 9% 30% ~17% reduction 25% 4% 4% 0% Q Q Q Q Model 2 Model 3 Discharge to SNF Rate Q Q Average SNF Days per Episode 35% ~6% reduction 29% 34.7 ~15% reduction 29.2 Q Q Q Q Remedy expects to deliver ~$100 million of savings to Medicare in

5 Model 3 Opportunities for SNFs 1. Only 6% of SNFs in the country have put their revenue at risk 2. Model 3 SNFs have a strong incentive to achieve high-quality, lowcost outcomes 3. Remedy s partnership with 435 Model 3SNFs represents over 60% of the entire BPCI Model 3 Program. 4. Helps with Model 2 Providers to see Model 3 Partner Commitment 5. Can retain savings compared to Adjusted Historical Rates 6. Advanced BPCI Forthcoming, narrow window to enroll 13 Shawn Matheson smatheson@remedypartners.com Bundled Payment for Care Improvement Initiative (BPCI) SAHS Director: Becky Swenson, MSN, MHA, RN, NEA-BC 15 5

6 BPCI Initiative Key Terms: Bundles: There are approximately 181 DRGs collapsed into 48 Clinical Bundles Episode of Care (Episode): An episode begins upon hospitalization and includes most services covered by Medicare Part A & B provided to the patient over a period of 90 days including the inpatient stay and the period after discharge, termed the post-acute period Baseline Price: Based on the Episode Initiator's (provider s) historic average costs between July 2009 and June 2012 Target Price: Historical spending/price set by CMS against which current spending is compared to determine savings or penalties in the BPCI program Funds Flow (Revenue Cycle): CMS continues to pay FFS claims directly to doctors and hospitals; episodes are reconciled retrospectively against a Target Price Episode Costs For a typical Model 2 90-day bundle, Medicare spends more on a patient s postacute care than their initial hospitalization. 34.9% 20.6% 14.3% 15.0% 4.6% 1.9% 3.7% 0.9% 4.1% Anchor Admit SNF Readmissions Home Health Long Term Care Inpatient Rehab Part B DME Outpatient Patient Eligibility Patients are automatically enrolled in the BPCI program if they meet all of the necessary criteria. Necessary Criteria Medicare is the primary payer Enrolled in Part A & B for the entire episode of care Condition falls into selected bundles Pt is only enrolled in one episode at a time Excluding Criteria Medicare is not the primary payer for the entire episode Medicare coverage is changed or dropped Pt has ESRD Pt is covered under United Mine Workers 6

7 Key Levers of Success Strong Patient Navigators Appropriate Next Site of Care Decisions Optimal Lengths of Stay at Next Site of Care Strong Preferred Provider Networks Early Intervention Minimal Readmissions What We Ask of Our Partners Manage Length of Stay (Meet/Exceed ELOS) Weekly Care Conferences Involving Pt Navigators Implement Tools to Prevent Readmissions Questions? 7

8 Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) Track 3 Elizabeth Barber, MSN, RN, CCM Manager, Alliance Clinical Team (ACT) 2017 CMS Shared Savings Program - MSSP ACO Track 3 Established by section 3022 of the Affordable Care Act ACOs partner with CMS in Advance Payment Models Contracts (APMs) ACOs are groups of doctors and other healthcare providers who voluntarily work with CMS to provide high quality, cost effective care to Medicare Fee for Service Beneficiaries Saint Alphonsus was an independent Track 1 (Pioneer Model) for 2 years ( ) Now a Track 3 Chapter participant (1 of 5) under Trinity Health Integrated Care (THIC, LLC) Track 3 offers shared savings AND is a risk model if we don t perform, we write a check back to CMS Track 3 has several different benefits/structures from Track 1 of note, the 3 day SNF waiver MSSP ACO T3 Patient Eligibility Traditional FFS Medicare is the primary payer (A&B) Patients may be dual eligible (Medicare/Medicaid) Patient cannot opt out of ACO Must be assigned by CMS to the ACO and on the current year master beneficiary list Patients retrospectively assigned from CMS using their methodology largely claims based can attribute to PCP or Specialist Most participating attributed providers are SAMG one independent provider group 8

9 Proving High Quality Care Some have higher implications for care management than others: Cost savings (must meet a minimum threshold to account for natural variance) - Reduce unnecessary utilization (ED/1000, IP/1000, readmit/1000) - Right level of care/right time (reduce SNF LOS, utilize 3 day SNF waiver) - Care Coordination/Care Management/Transitions Quality: meet report and/or performance thresholds for 34 quality measures Mandatory Reporting Requirements EHR utilization (at least 50%) Patient satisfaction (CAHPS) Survey for ACOs 3 Day SNF Waiver Patient Eligibility Assigned to the ACO in year admitted to eligible SNF Does not currently reside in SNF or other LTC setting Medically stable does not require (further) inpatient evaluation/treatment Has a confirmed diagnoses Has identified skilled nursing or rehab need that cannot be met outpatient Evaluated and approved for admission by an ACO physician 3 Day SNF Waiver SNF Eligibility Must be enrolled in Medicare Existing written SNF Affiliation Agreement with ACO SNF must have and maintain an overall 3 star Quality Rating (this is verified monthly by the ACO and affiliate will be removed immediately if they fall below) Other quality/reporting components as determined by ACO, such as 9

10 Preferred Post-Acute Providers (PAP) Quality data reported to ACO at regular intervals (SNF LOS, readmit rates, etc.) Collaborative Care Coordination RN care managers attend meetings, works with PAP to follow and update Care Plan Engagement in collaborative postacute initiatives (clinical care guidelines, patient education) 24/7 liaisons available for SNF waiver Still a work in progress Questions? 10