Short-term, Redefined By Managed Care. Welcome Everyone!

Transcription

1 Short-term, Redefined By Managed Care Welcome Everyone!

2 Presenter: Christopher B. Bailey, MHA, NHA President of Premier Healthcare Resources Management/Consulting Company serving PA, NJ, OH, & MD 20 years of experience in multi-facility management operations Also serve as Vice President of Operations for our other companies: 2 CCRC s in Western Pennsylvania Allstar Therapies, Inc. Therapy Management Company serving clients in 5 states Express Mobile Diagnostic Services, LLC Mobile X-Ray, Ultrasound, and Diagnostic serving clients in 8 states Allserve Business Support- Back-Office accounting, payroll, accounts receivable, etc. Danan Healthcare Consulting Group Focus on development of new facilities

3 Today s Topic & Agenda Review: The Part A Benefit period in a nursing facility Snapshot Where are we now? Managed Care Organizations Marching in Real-Life Impact of a facility s transition Strategies Learned

4 Review: Medicare Part A = Hospital Insurance Part B = Physician Insurance Part C = Supplemental OR A+B Combined OR A+B+D Combined Part D = Prescription Benefit

5 Medicare A Nursing Home Care Nursing home care How often is it covered? Medicare Part A (Hospital Insurance) may cover care given in a certified skilled nursing facility (SNF) if it's medically necessary for you to have skilled nursing care (like changing sterile dressings). However, most nursing home care is custodial care, like help with bathing or dressing. Medicare doesn't cover custodial care if that's the only care you need. Source: Medicare.gov website

6 Medicare A Nursing Home Care You can get Medicare health care in 2 ways 1. Original Medicare Original Medicare doesn't pay for most nursing home care. Most nursing home care helps with activities of daily living. Medicare covers very limited and medically necessary skilled care or home health care if you need skilled care for an illness or injury and you meet certain conditions. 2. Medicare Advantage Plans and other Medicare health plans If you have a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan, check with your plan to see if it covers nursing home care. Usually, plans don't help pay for this care unless the nursing home has a contract with the plan. Ask the health plan about nursing home coverage before you make any arrangements. If the nursing home has a contract with your health plan, ask the health plan if they check the home for quality of care. Source: Medicare.gov website

7 Redefined Medicare FFS = Traditional Medicare A Government-Managed Plan Medicare Advantage = Managed Care Organization Outsourcing

8 Redefined Medicare Advantage Accountable Care Organizations (ACO s) Bundled Payment for Care Improvement (BCPI) Programs 6 different flavors of BCPI Programs Surgical Hip and Femur Fracture Treatment (SHFFT) Models And many other innovation programs

9 CMS Innovation Models

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11 Medicare Advantage Penetration United States = 25.51% Pennsylvania = 38.73% New York = 37.56% Ohio = 32.36% New Jersey = 19.96% Maryland = 7.90% Source: Medicare Advantage/Part D Contract and Enrollment Data Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/ MA-State-County-Penetration-Items/MA-State-County-Penetration html? DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending

12 Medicare Advantage Penetration Top 16 Counties in the United States State Name County Name Penetration 1Minnesota Red Lake 72.14% 2Minnesota Meeker 66.66% 3Minnesota Todd 66.47% 4Minnesota Roseau 65.83% 5Florida Miami-Dade 65.43% 6Minnesota McLeod 64.77% 7Pennsylvania Beaver 64.75% 8New York Monroe 64.73% 9Pennsylvania Westmoreland 64.38% 10Minnesota Douglas 63.88% 11Minnesota Wright 63.27% 12Minnesota Carver 63.26% 14Minnesota Washington 62.67% 15Pennsylvania Allegheny 62.60% 16Pennsylvania Armstrong 62.60%

13 Medicare Advantage Penetration Highest in PA Beaver County = 64.75% Westmoreland County = 64.38% Real-Life Example Facility Location Lowest in PA Pike County = 14.23% Wayne County = 18.5% Carbon County = 21.05%

14 Result of Market Changes High Medicare Advantage Market Behavior High ACO Market Behavior High BPCI Market Behavior How Competition drives the market Who is in or out of networks Do we care about Medicare FFS? 3 Star Rating to participate?

15 Pennsylvania

16 Today s Topic & Agenda Review: The Part A Benefit period in a nursing facility Snapshot Where are we now? Managed Care Organizations Marching in Real-Life Impact of a facility s transition Strategies Learned

17 Real Life Scenario 155-Bed SNF 120-bed Traditional Long-Term Care 25-bed Short-Term Rehab/Recovery 10-bed Pulmonary Care/Ventilator-Dependent Care 118-Bed Personal Care (Assisted Living)/ Independent Living 108-bed Personal Care 10-bed independent living facility

18 Real Life Scenario Total Average Daily Census (Capacity 155) Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

19 Real Life Scenario 60 Skilled Average Daily Census Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Medicare A FFS Medicare Advantage

20 Real Life Scenario Skilled Medicaid Private Other Census Mix 1 44 M 2 = 30.6%

21 Today s Topic & Agenda Review: The Part A Benefit period in a nursing facility Snapshot Where are we now? Managed Care Organizations Marching in Real-Life Impact of a facility s transition Strategies Learned

22 Real Life Scenario Total Average Daily Census (Capacity 155) navihealth Started Service with Highmark

23 Real Life Scenario Skilled Average Daily Census navihealth Started Service with Highmark Medicare A FFS Medicare Advantage

24 Real Life Scenario FY 2014 FY2014 FY 2015 FY 2016 YTD PrenaviHealtnaviHealth Post- Full Year YTD ALOS - Medicare Advantage Medicare Advantage Revenue PPD $ $ $ $ RU 58% 18% 28% 29% RV 41% 79% 68% 67% RH 1% 2% 2% 2% RM 0% 1% 1% 2% RL 0% 0% 1% 0%

25 Real Life Scenario Admits/Month

26 What happened? Referrals declined: Re-Directed to Home or Home with Home Health vs. SNF Admissions stayed less time RUG s dropped from RU to RV Revenue PPD dropped as a result of lower RUG s

27 Today s Topic & Agenda Review: The Part A Benefit period in a nursing facility Snapshot Where are we now? Managed Care Organizations Marching in Real-Life Impact of a facility s transition Strategies Learned

28 Real Life Impact ($1,804,326) (12.6%) Annualized Op Revenue $ 11,704,712 $ 14,336,514 $ 13,432,381 $ 12,532,188 Op Expense $ 10,304,999 $ 12,449,120 $ 12,149,215 $ 11,521,188 EBITDA $ 1,399,713 $ 1,887,394 $ 1,283,166 $ 1,011,000 EBITDA % 12.0% 13.2% 9.6% 8.1%

29 Why? Insurer: Freedom Blue Security Blue Provider: Allegheny Health Network Convener: Post-Acute Savings Strategy Effective 8/1/2014

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31 navihealth at a Glance navihealth manages post-acute care on behalf of health plans and risk-bearing health systems Current Partners 15 years of experience managing post-acute care 1.8M >50k Medicare Advantage members under management for post-acute care annual episodes under management as one of the largest participants in CMS s BPCI program OPERATIONS IN >20 STATES >$6B annual post-acute medical spend impacted by navihealth navihealth presence 31

32 Best in Class Post-Acute Technology LiveSafe : the key differentiator versus other PAC solutions Generates individualized patient centered care plan based on outcomes database containing ~800,000 patient records Patient function is key variable LiveSafe projects: PAC setting Length of Stay Therapy intensity Expected functional improvement Risk of readmission Common language across all PAC settings, ability to integrate with existing platforms LiveSafe enables navihealth, discharge planners and physicians to drive appropriate PAC placement and regimens Risk adjusted reporting to plan on the network of PAC providers 32

33 LiveSafeOPT Outcome Predictor Tool Likelihood of Hospital Readmit in < 30 Days 33

34 navihealth DASHBOARD Episodic Length of Stay (elos) Discharge Score LiveSafeOPT Score at Discharge (Functional Ability) Therapy Hours per Day Readmission Rates % Discharge to Community

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36 Highmark Narrowing Network Using navihealth Dashboard Scores Reducing Skilled Provider contracts to 183 Lose contract, no Medicare Advantage admissions from Highmark beneficiaries Keep contract, skilled admissions from Highmark beneficiaries should INCREASE due to fewer providers Process started 8/1/2014 Cuts effective 1/1/ ½ years to live with reduced income to survive into the new system

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38 XYZ Skilled Nursing Center Facility Rank = 91 Oct 2014 Jul 2015 #183 #91 #137 #45 #1 Weak Performers Strong Performers Top 3 Opportunities For Improvement 1. Length of Stay 2. Patient Function at Discharge Day Readmit Rate Overall Quality

39 Today s Topic & Agenda Review: The Part A Benefit period in a nursing facility Snapshot Where are we now? Managed Care Organizations Marching in Real-Life Impact of a facility s transition Strategies Learned

40 Strategies Learned Prepare your facility to look attractive to the Managed Care Organization: Low Rehospitalization Rate Good therapy outcomes (Efficient) Highest Gains in Abilities Lowest Cost Strong Star Rating Good CMS Quality Measures Infection Control Quality Data Low nosocomial rates Strong Clinical Capabilities Inventory

41 Strategies Learned Know Your Data! InterACT Tools; Hospital Readmissions Therapy Outcomes Therapy Management Consider Initial Home Assessment What are the physical barriers to discharge? Share with the MCO Authorization functional goals Aggressive care pathways Steps day 1 of care? Physician/Extender coverage Simple collaterals aimed at medical professionals

42 einteract

43 Strategies Learned Narrow YOUR network D/C from SNF at day Handoff to Home Health day Any Hospitalization counts against SNF -> paid by Hospital How well are your home health providers performing? 30-day hospital re-admit rate? Star Rating?

44 Home Health Compare (Medicare.gov)

45 Strategies Learned Educate your Residents Why are you cutting therapy early? (Perception of family) Clarify role of MCO in determining care vs. facility Residents and Families talk yet their experience may differ by their chosen MCO Be cautious with Appeals Data impact may be held against facility Communicate Care Plan in Day 2-3? How frequent are family updates? Consider total length of stay target = 12 Days Discharge plan on Day 1?

46 Strategies Learned Prepare for transition Cash reserves Expect downturn in financial performance DURING transition Expense control Prepare for staff variability during transition Reduced hours during census downturn Increased hours during census upswing Hold on for the Ride!

47 UPDATE!!! 42 M2 145 Total Census

48 Thank You Any questions?