Forces of Change- Seeing Stepping Stones Not Potholes

Transcription

1 May 19, 2014 Forces of Change- Seeing Stepping Stones Not Potholes

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5 Overview Demographics Long Term Care Financing Challenges Broad Health System Challenges Payment Reform Delivery System Reform Where Do We Need to Go? 5

6 DEMOGRAPHICS 6

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9 Long Term Care Workforce Challenges Caregiver Support Ratio* 2010 = 7 potential caregivers for each person over 80 yrs of age 2030 = 4 potential caregivers for each person over 80 years of age Demand for direct care workers to increase 48% over same timeframe * Source: Redfoot,D., L. Feinberg, and A. Houser The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers. AARP Public Policy Institute, August,

10 LONG TERM CARE FINANCING CHALLENGES 10

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13 Medicaid Spending Continues to Increase as a Share of State Budgets Now 1/4 of total State Spending 1/6 of State GF Spending: U.S. Averages U.S. Source: HMA, based on NASBO, State Expenditure Report, 2013 and earlier years. 13

14 State Spending on Medicaid and K 12 Education as % of Total Spending Fifty States % Medicaid 23.7% 24.4% 20.5% K-12 Education 20.0% 19.9% Source: HMA, based on data in: NASBO, State Expenditure Report, 2013 and Earlier Years. 14

15 BROADER HEALTH CARE SYSTEM CHALLENGES 15

16 U.S. Health Spending is Larger Than Total GDP of Most Nations Notes: Data from 2011, adjusted for differences in cost of living Source: D. Blumenthal and R. Osborn, In Pursuit of Better Care at Lower Costs: The Value of Cross-National Learning, (New York: The Commonwealth Fund Blog, April 2013). 16

17 U.S. Ranks Last in Mortality Amenable to Health Care Deaths per 100,000 population* * Countries age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S. Source: Adapted from E. Nolte and M. McKee, Variations in Amenable Mortality Trends in 16 High-Income Nations, Health Policy, published online Sept. 12,

18 Michigan: Avoidable Hospital Use MEASURE 2009 STATE RANK* 2014 STATE RANK* Hospital admissions: Medicare beneficiaries for ambulatory care sensitive conditions, ages Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries Short-stay nursing home residents readmitted within 30 days of hospital discharge to nursing home Potentially avoidable emergency department visits among Medicare beneficiaries N/A 43 Total Medicare (Parts A & B) reimbursements per enrollee *Commonwealth Fund Scorecard on State Performance: Data supporting 2009 or 2014 report may be from prior years.

19 Cost Transparency 19

20 Cost Control is Job 1 We can t approach our health system problems until we get costs under control We can t control costs until we have everyone covered. 20

21 COST $Billions in unnecessary and wasteful spending Overuse puts patients at risk, drains resources, and makes healthcare less accessible and less effective QUALITY Despite rapid advances, thousands of patients die each year from medical error A BROKEN SYSTEM COVERAGE 50 million uninsured; many more underinsured 21

22 PAYMENT AND DELIVERY SYSTEM REFORM 22

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24 MEDICARE 24

25 Traditional FFS Medicare Reimbursement Process Separate payments to providers for each of the individual services they provide to beneficiaries for a single illness or course of treatment. Results in fragmented care with minimal coordination across providers and health care settings. Payment rewards quantity of services instead of quality of care. Traditional FFS Medicare Payment Process (fragmented and uncoordinated) Inpatient Care CMS Post-Acute Care (PAC) CMS Physician Charges Readmissions SNF/RF Initial Hospital Stay Home Care DME Charges Outpatient Long-term Care Hospital Source: CMS BPCI Background Documents 25

26 Medicare Changes New quality standards for providers Hospital payment reforms Post Acute Payment and Delivery Reform Medicare Care Choices Model (Hospice) Bundled Payment for Care Initiative (BPCI) Pioneer and Shared Savings Accountable Care Organizations 26

27 Four BPCI Models CMMI invited participants to apply to test and develop four different models of bundled payments. Applications were due to CMMI in June Model 1: Retrospective Acute Care Hospital Stay Only Model 2: Retrospective Acute Care Hospital plus Post-Acute Care Model 3: Retrospective Post- Acute Care Only Model 4: Acute Care Hospital Stay Only Bundles payment for both inpatient hospital and physician services. Providers are paid Medicare fee-for-service throughout the episode. Total payment for the episode is retrospectively reconciled against a predetermined target price. Bundles payment for both inpatient and post-acute care for 30, 60 or 90 days. Providers are paid Medicare fee-for-service throughout the episode. Total payment for the episode is retrospectively reconciled against a predetermined target price. Bundles payment for post-acute care only for 30, 60 or 90 days. Providers are paid Medicare fee-for-service throughout the episode. Total payment for the episode is retrospectively reconciled against a predetermined target price. Bundles payment only for acute inpatient care and related readmissions for 30 days. Participants are paid a prospective bundled payment amount. Slide prepared by: Mike Fazio, Health Management Associates Source: CMS BPCI Background Documents 27

28 Medicare Pioneer Shared Savings ACOs in Michigan Shared Savings Partners in Care Physician Organization of Michigan ACO Northwest Ohio ACO (Ohio and Michigan) CHA ACO, LLC (Indiana & Michigan) Franciscan Select Health Network ACO, LLC (Indiana & Michigan GGC ACO,LLC National Rural ACO (California, Indiana, Michigan, Oklahoma) Northern Michigan Health Network PMC ACO Reliance ACO, LLC South Bend Clinic Accountable Care ( Indiana & Michigan) The Accountable Care Organization, Ltd. Southeast Michigan Accountable Care (SEMAC) Pioneer Michigan Pioneer ACO Genesys PHO 28

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30 In significant ways is a time of historic change, perhaps the most consequential time in the history of Medicaid. 30

31 Factors Shaping Medicaid Today Affordable Care Act Medicaid Expansion, Conversion to MAGI, Enrollment Systems, Coordination with Marketplaces Delivery and Payment System Reform Managed Care, Care Coordination, Quality, Balancing LTSS, Duals Medicaid Economic Conditions Unemployment, State Revenues, Federal Deficit Reduction Efforts Cost Containment / Program Improvements /Administration Provider Rates, Benefits, Prescription Drug Policy, Cost Sharing, Program Integrity, Program Administration 31

32 Medicaid Managed Long Term Supports and Services (MLTSS) Status As of March 31, 2014 Established, Stable MLTSS Expanding/Implementing Medicaid MLTSS Anticipated Implementation Within 3 Years Dual Eligible Demonstration State States to Watch

33 CMS State Innovation Model (SIM): $300 million to transform health care systems through development and testing of state-based, multi-payer models of care delivery and payment transformation. CMMI SIM Planning and Testing Priorities: Achieve triple aim: Involve multiple payers Move the delivery system to buy value Integrate community health strategies Address primary care and health care workforce capacity; Result in organized health care networks Accelerate broad health system transformation Have the potential to be scaled 33

34 2013 SIM Awards 25 states received awards: 6 Model Testing: AR, MA, MN, ME, OR, VT 3 Model Pre-Testing: CO, NY, WA 16 Model design and planning: CA, CT, DE, HI, ID, IA, IL, MD, MI, NH, OH, PA, RI, TN, TX, UT Each developed a State Health Care Innovation Plan to improve care, raise community health, reduce long-term health risks, and reduce costs for Medicare, Medicaid, and CHIP. 34

35 Michigan Model Elements Element Michigan s Patient Centered Medical Home Model Accountable Systems of Care Community Health Innovation Regions Payment Systems Health Information and Process Improvement Infrastructure Building on MiPCT program and safety net primary care improvements Existing health systems, provider networks, and safetynet infrastructure Existing community coalitions and councils Public and private payment initiatives Existing local, state and federal initiatives 35

36 WHERE DO WE NEED TO GO? 36

37 Health Care Industry Megatrends 1. Consumers Take Charge 2. More w/less: From Volume to Value 3. Healthcare Everywhere 4. Mega Health Systems 5. Centrality of the States 6. Value through Data 7. Predict, Prevent, Personalize 8. Employers Recalibrate 9. The New Aging 10. Healthcare goes Global Source: Manatt, Phelps & Phillips, LLP 37

38 Going Beyond Today s Demonstrations Changes that need to become mainstream Team based care Transition programs Cross continuum care management interventions Increased patient and family engagement Communication protocols for providers across settings Sharing of data using interoperable health information technology Focused investments in clinical care in post acute settings (telemedicine, transitional medical teams) Source: Ackerly, D. Clay M.D., David Grabowski, Ph.D.; Post Acute Care Reform Beyond the ACA ; NEJM, February 20,

39 Commission on Long Term Care- Report to Congress- Sept., 2013 Vision Statement: A more responsive, integrated person centered and fiscally sustainable Long Term Services and Supports delivery system that ensures people can access quality services in settings they choose 39

40 Commission on Long Term Care Principles Comprehensive array of person and family centered, high quality, financially sustainable medical and social services and supports that meet the heterogenic needs, preferences and values of individuals with cognitive and functional limitations Easy to access information and help for persons and families to navigate the delivery system 40

41 Commission on Long Term Care Principles Choice of settings and providers; active involvement of patients and families in making decisions, delivery of services and supports in the least restrictive setting consistent with their preference Integration of LTSS with medical and health care, including effective transitions Affordable, more efficient coordinated health care and LTSS that aligns payments with quality of care and quality of life outcomes. 41

42 Dancing to the Music The only way to make sense out of change is to plunge into it, move with it and join the dance -Alan Watts Possible Dance Partners: Health Plans Hospital and Health Systems ACOs Other PAC and LTSS providers 42

43 Get Ready for a Wild Ride! 43