Trends In ACO s and Managed Care. LeadingAge Iowa Spring Conference Jill Sumner LeadingAge. Overview

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1 Trends In ACO s and Managed Care LeadingAge Iowa Spring Conference 2015 Jill Sumner LeadingAge jsumner@leadingage.org Overview Why are we here? What is this mess? How are providers responding? 1

2 Why are we here? 2

3 What is this mess? Population Health Management Managed Care Medicare Advantage Dual Eligible Special Needs Plans Chronic Disease Special Needs Plans Institutional Special Needs Plans Managed Long Term Services and Supports Accountable Care Organizations Bundled Payments Primary Care Medical Homes Primary Care Case Management Independent Practice Associations Provider Hospital Organization Health Maintenance Organization Preferred Provider Organization Program of All Inclusive Care for the Elderly Continuing Care Retirement Communities Population Health Management the technical field of endeavor which utilizes interventions to help improve the morbidity patterns and the health care use behavior of defined populations. PHM is distinguished from disease management by including more chronic conditions and diseases, by use of "a single point of contact and coordination", and by "predictive modeling across multiple clinical conditions".phm is considered broader than disease management in that it also includes "intensive care management for individuals at the highest level of risk" and "personal health management... for those at lower levels of predicted health risk". Managed Care a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques"), for organizations that use those techniques or provide them as services to other organizations ("managed care organization" or "MCO"), or to describe systems of financing and delivering health care to enrollees organized around managed care techniques and concepts ("managed care delivery systems"). 3

4 Short term skilled care : -traditional medicare -private insurance -medicare advantage What is changing? Long term services and supports : Delivery Reform & Payment Reform -private pay -traditional medicaid -medicaid managed care -long term care insurance Managed Care Models Medicare Advantage (skilled) Medicare Advantage Special Needs Plans (SNPs) (skilled) Dual eligible special needs plans (DSNPs) (skilled) Fully integrated dual eligible special needs plans (FIDE SNP) (skilled and LTSS) Institutional Special Needs Plans Chronic Disease Special Needs Plans Medicare Medicaid Integrated Plans (MMPs) (skilled & LTSS) Medicaid Managed Care Plans (skilled, LTSS, both) Managed Long Term Services and Supports Plans (MLTSS)(LTSS) Specialty Health Plans (behavioral health, pharmacy) (LTSS) 4

5 Managed Care Models Accountable Care Organizations (ACOs) (skilled) Program of All Inclusive Care for the Elderly (PACE) (skilled & LTSS) Independence at Home Demonstration (skilled & LTSS) Bundled Payments (skilled) Care management organizations (skilled & LTSS) CCRCs (lifecare, extended contract, modified contract) 5

6 Spending 4/27/2015 ACOs That Succeed Have Mastered Key Capabilities Health Information Technology Patient Engagement Clinical Operations Business Operations Physician and PAC Network Development EHR: Electronic Health Record; ACO: Accountable Care Organization Sources: 1. Succeeding as an ACO: A 6-step guide for health care organizations. Athenahealth white paper. Jul Forster AJ, et al. Accountable care strategies: Lessons from the Premier Health Care Alliance s Accountable Care Collaborative. Premier Research Institute. Aug To Succeed, ACOs Must Achieve Both Savings and High Quality ACOs Must Achieve Savings Depending on the payment model, ACOs achieve savings by spending less than historical benchmarks, capitated payments, global budgets, or bundle prices Without Sacrificing Quality To be eligible for savings, ACOs must meet performance thresholds for quality measures, which typically focus on several areas: Illustrative Shared Savings Example* Diabetes Patient Experience Respiratory Conditions Preventive Care Time Cardiovascular Conditions Readmission Rates Target spending Historical spending benchmark Pediatric Wellbeing Behavioral Health Payers evaluate ACOs based on their ability to generate savings without compromising quality of care, so ACOs focus on interventions that can both reduce costs and improve patient outcomes. ACO: Accountable Care Organization; FFS: Fee-for-Service *Illustrative for a FFS plus shared savings model. ACOs usually need to meet a minimum savings threshold to be eligible to share in savings. If costs exceed the benchmark, then some ACOs need to repay a portion of the difference. In other payment models the threshold is the capitated per member per month payment or the bundle price. 12 6

7 As of Jan. 2015, 405 MSSP and 19 Pioneer ACOs Are Operating in 48 States, Puerto Rico, and DC CA* (38) OR (4) AK WA (4) NV (6) ID (2) UT (3) AZ* (12) MT (2) WY (2) NM (5) CO (3) HI ND (2) SD (1) NE (3) KS (9) TX (34) OK (8) MN* (7) IA* (9) MO (15) AR (10) LA (6) WI* (12) IL* (27) MS (7) MI* (22) IN* (24) TN (13) AL (6) OH (16) KY (12) WV (7) GA (21) PR - 2 PA* (24) VA (22) NC (19) SC (9) FL (49) VT - 5 NY* (36) ME* (4) NH* - 10 MA* - 24 RI - 4 CT - 15 NJ - 24 DE - 3 MD - 23 D.C. - 8 No ACOs 1-5 ACOs 6-10 ACOs ACOs ACOs ACOs 26+ ACOs ACO: Accountable Care Organization; MSSP: Medicare Shared Savings Program *State has both Pioneer and MSSP ACOs Note: State totals do not sum to 424 since many ACOs operate across several states. Source: Based on the most recent MSSP and Pioneer ACO participant lists available from Data.CMS.Gov, last updated April 2014 and December 2015, respectively, and the list and press release issued by the Centers for Medicare & Medicaid Services in December 2014 for the 89 MSSP ACOs that began participating in January MSSP: Top Ten ACOs by Savings Per Beneficiary Average benchmark spend per beneficiary was $12K ACO Name Total Assigned Beneficiaries Earned Payments Average Savings Per Beneficiary Savings as % of Benchmark RGV ACO (Advanced Payment) (TX) 7,089 $11,900,756 $1,679 14% Winchester Community ACO (MA, NH) 6,068 $5,821,078 $959 19% Accountable Care Options (FL) 6,962 $6,245,631 $897 11% Memorial Hermann ACO (TX) 34,430 $28,338,705 $823 12% Accountable Care of SE WI (WI) 11,701 $8,671,679 $741 7% SEMAC (MI) 17,303 $12,094,617 $699 9% Integral Healthcare (FL) 5,954 $3,704,440 $622 12% National ACO (CA) 5,507 $3,033,551 $551 6% Circle Health Alliance (MA, NH) 11,300 $6,087,568 $539 8% Palm Beach ACO (FL) 36,268 $19,388,729 $535 7% Source: CMS website: Performance year 1 is a 21- or 18-month period for ACOs with 2012 start dates, and a 12 month period for ACOs with 2013 start dates 14 7

8 MSSP: Top Ten ACOs by Total Generated Savings ACO Name (LBN or DBA, if applicable) Total Savings Earned Payments Average Savings Per Beneficiary Memorial Hermann ACO (TX) $57,834,092 $28,338,705 $823 Palm Beach ACO (FL) $39,568,835 $19,388,729 $535 Catholic Medical Partners-Accountable Care IPA (NY) $27,922,572 $13,682,060 $411 SEMAC (MI) $24,682,891 $12,094,617 $699 ProHEALTH Accountable Care Medical Group (NY) $21,913,987 $10,737,854 $375 Nevada Primary Care Network, ACO (NV) $21,691,301 Missed on Quality Triad HealthCare Network (NC) $21,505,622 $10,537,755 $257 RGV ACO Health Providers (TX) $20,239,381 $11,900,756 $1,679 WellStar Health Network (GA) $19,875,274 $9,738,884 $213 MaineHealth ACO (ME) $19,196,823 $9,406,443 $195 Source: CMS website: Performance year 1 is a 21- or 18-month period for ACOs with 2012 start dates, and a 12 month period for ACOs with 2013 start dates 15 Iowa Medicare ACOs Organization Program Provider Affiliation Service Area Assigned Beneficaries Risk Track Shared Savings Trinity Pioneer ACO Pioneer ACO UnityPoint Health Northwest Central Iowa 10,600 One, upside only None in year one Univ of Iowa Affiliated Health Partners Mercy ACO Iowa Health Accountable Care L.C. Genesis Accountable Care Organization Alegant Health Partners Accountable Care Clinical Services MSSP Mercy Medical Center Cedar Rapids, IU Healthcare MSSP, Commerci al Mercy Medical Center Des Moines East Central Iowa 20,262 One, upside only None in year one Greater Des Moines 27,662 One, upside only $4,426,331 MSSP UnityPoint Health Iowa and Illinois 86,134 One, upside only None in year one MSSP, Commerci al Genesis Health System Eastern Iowa and Western Illinois MSSP Alegant Health Iowa and Nebraska MSSP Iowa, California, Connecticut, Massachusetts, Pennsylvania 19,855 One, upside only None in year one 23,852 One, upside only None in year one 19,637 One, upside only $10,526,169 8

9 Iowa Commercial ACOs ACO Program ACO Name Website ACO Type Commercial Commercial Commercial Commercial Commercial Commercial Family Health IPA Care of Siouxland Iowa Clinic McFarland Clinic of Ames Mercy Medical Center-Cedar Rapids & University of Iowa Hospitals IPA om/ IPA linic.com/ IDN org/ Wheaton Franciscan IDN wa.org/ Healthcare Iowa One Care, LLC (Mercy ACO) IDN oines.org/ Source: Avalere Unity ACO Point Listing Commercial Physician led Health Partners org/aco Member Entities Agreement with Wellmark Blue Cross and Blue Shield Agreement with Wellmark Blue Cross and Blue Shield Agreement with Wellmark Blue Cross and Blue Shield Agreement with Wellmark Blue Cross Blue Shield of Iowa Agreement with Wellmark Blue Cross Blue Shield of Iowa Wellmark is collaborating with this ACO and Mercy Health Providers Beneficiaries HQ Location N/A N/A Sioux City, IA IA ,000 West Des Moines, IA N/A N/A Ames, IA IA N/A N/A Iowa City and Cedar Rapids, IA N/A N/A Waterloo, IA IA 402 N/A Des Moines, IA IA Agreement with United Healthcare. 2,500 2,500 independent and 36,000 West Des Moines IA employed physicians. IA Approximate Service Area IA 17 Bundled Payments Acute/PAC Payment 9

10 What is Bundling? Bundling is a single payment for an array of services Bundles are currently used in Medicare to reimburse a single provider for services rendered. o For example, CMS makes a single payment to hospitals for the care provided based on the inpatient MS-DRG Policy makers and payers are now exploring bundled payments that cross provider silos and include a variety of services from different providers. o For example hospital and physician services or all services post hospital discharge (for a specified amount of time) Physician EPISODIC PAYMENT FOR HOSPITAL CARE Hospital HOSPITAL / PAC BUNDLE LTACH IRF Home Health Hospital Readmissions Hospital SNF Other Services* * Hospital outpatient services, Part B drugs, durable medical equipment (DME), clinical laboratory services and independent outpatient therapy services. 19 CMS BPCI Program Includes Four Models Majority of Applicants Opted for Model 3 Model 1 Model 2 Model 3 Model 4 Episode All acute patients, all DRGs Selected DRGs + post-acute period PAC only for selected DRGs Selected DRGs Services included in the bundle All Part-A DRG-based payments All Part A and B services (hospital inpatient, hospital readmissions, physician, LTACH, IRF, SNF, HHA, hospital outpatient, independent outpatient therapy, labs, DME, part B drugs) All Part A and B services (hospital readmissions, physician, LTACH, IRF, SNF, HHA, hospital outpatient, independent outpatient therapy, labs, DME, part B drugs) All hospital Part A and physician Part B services plus readmissions Payment Retrospective Retrospective Retrospective Prospective Episode Duration Inpatient stay only Inpatient hospital plus 30/60/90 days 30, 60, or 90 days Inpatient hospital plus 30 days Discount Amount Up to 2 percent* 2-3 percent** 3 percent percent*** Participants 15 2,068 4, ** 0-0.5% in Year 1, 1% in year 2, and 2% in year 3 ** 3 percent discount for 30 and 60 day episodes, 2 percent discount for a 90 day episode. *** 3.25 percent applies to select cardiac and orthopedic conditions. Source: Number of participants in Phase 1 & 2 as of July 30,

11 BPCI Model 2: Number of Episode Initiators by State (Phases 1 and 2) OR (13) CA (230) WA (80) AK (9) NV (23) ID (22) UT (20) AZ (58) MT (8) WY (4) CO (21) NM (14) HI (7) ND (0) SD (9) NE (11) KS (36) TX (137) OK (18) MN (5) IA (13) MO (32) AR (20) LA (38) WI (7) IL (79) MS (20) MI (40) IN (70) KY (22) TN (189) AL (35) OH (75) GA (32) WV (11) PA (143) SC (34) VA (71) NC (48) FL (195) NY (89) ME (5) NH (8) VT (1) MA (63) RI (5) CT (27) NJ (72) DE (9) MD (1) D.C. (1) BPCI Model 3: Number of Episode Initiators by State (Phases 1 and 2) OR (82) CA (411) WA (111 ) AK (9) NV (21) ID (53) UT (56) AZ (88) MT (21) WY (9) CO (103) NM (29) HI (5) ND (1) SD (6) NE (33) KS (12) TX (489) OK (21) MN (24) IA (20) MO (20) AR (39) LA (43) WI (42) IL (77) MS (12) MI (112) IN (96) KY (125) TN (200) AL (61) OH (267) WV (84) PA (355) VA (77) NC (152) SC (34) GA (130) FL (229) NY (100) ME (33) VT (17) NH (56) MA (201) RI (51) CT (188) NJ (203) DE (21) MD D.C. (96) (1)

12 Iowa Bundled Payment Models 2 & 3 Why Bundle Post-Acute Care? PAC IS SIZEABLE BUT NOT GREATEST SHARE OF PROVIDER PAYMENTS Medicare FFS Spending, % = $358.7 billion Hospital Outpatient 12% Other, 19% Inpatient Hospital 47% IN 2013, SNF & HHA SPENDING REPRESENTED 13% OF MEDICARE FFS SPENDING Post-Acute Care, 13% Physician, 19% Source: 2014 Medicare Trustees Report, Table IV.B6 and IV.A3 PAC includes SNF and Home Health (A+B) Other includes Lab, DME, Hospice 24 12

13 How Much of the Post-Acute Care Industry Participating in BPCI? PAC PROVIDER FACILITIES MAKE UP 58% OF ALL FACILITIES PARTICIPATING IN BPCI 0.5% 2% PAC Providers In BPCI, By Provider Type Provider Type Total # of Facilities # in BPCI % in BPCI 42% TOTAL # OF FACILITIES IN BPCI: 6,637 51% SNF 15,163 3,360 22% IRF 1, % LTCH % HHA 12, % 5% LTCH IRF SNF HHA Non-PAC* * Non-PAC providers defined as STACHs and PGPs Sources: MedPAC June 2014 Data Book. Total number of PAC facilities in 2013 from Chart 8-1: Number of post-acute care providers increased or remained stable in 2013; CMS Bundled Payments for Care Episode Analytic file - Models 1-4 (7/31/14). Link: Info/eza9-qxqp? 25 Large PAC Providers are Self-Convening 75% USE CONVENER TOP SELF-CONVENERS Model 3 Participants by Convener Type No Convener, 26, 1% The Evangelical Lutheran Good Samaritan Society Avamere Health Services Signature Holdings II, LLC Self Convening, 1104, 24% Plum Healthcare Group, LLC Amedisys Holdings Third Party Convener, 3441, 75% HealthSouth Bundling Initiatives Ensign Service, Inc. Liberty Health Partners LLC Genesis Care Innovations LLC CMS Bundled Payments for Care Episode Analytic file - Models 1-4 (7/31/14). Link: Initiative-All-Model-Info/eza9-qxqp? 26 13

14 Which Clinical Conditions Are SNFs Most Interested in Bundling? In Phase 1, 3,360 SNFs selected primarily Orthopedic conditions; in Phase 2* 62 SNFs have selected primarily Medical conditions. Top Five Conditions Selected by SNFs in Phase 1 (Non-Risk Bearing Phase) 1. Major joint replacement of the lower extremity Top Five Conditions Selected by SNFs in Phase 2 (Risk-Bearing Phase) 1. Congestive heart failure 2. Revision of the hip or knee 2. Chronic obstructive pulmonary disease/bronchitis/asthma 3. Hip & femur procedures except major joint 4. Double joint replacement of the lower extremity 3. Simple pneumonia and respiratory infections 4. Urinary tract infection 5. Congestive heart failure 5. Sepsis; Other respiratory 1 Source: CMS Bundled Payments for Care Episode Analytic file - Models 1-4 (7/31/14). Link: Initiative-All-Model-Info/eza9-qxqp? * Does not include participants who entered Phase 2 in January Iowa BPCI Model 2 Participants 12 HOSPITALS OR PHYSICIAN GROUPS PARTICIPATING IN MODEL 2 Organization Name Convener Phase I Phase II Total Alegent Health Mercy Hospital Catholic Health Initiatives Mercy Medical Center - Mason City Remedy BPCI Partners, LLC Mercy Medical Center Dubuque Remedy BPCI Partners, LLC Mercy Medical Center Clinton Remedy BPCI Partners, LLC Iowa Heart Center Catholic Health Initiatives Trinity Medical Center Trinity Medical Center 1 1 Mercy Medical Center - Sioux City Remedy BPCI Partners, LLC Cardiovascular Medicine Remedy BPCI Partners, LLC Cogent Healthcare of Iowa, P.C. Medsolutions, Inc Des Moines Orthopedic Surgeons Signature Medical Group, Inc Hospitalist Medicine Physicians of Iowa, PLC Medsolutions, Inc Ora Orthopedics, P.C. Signature Medical Group, Inc

15 Iowa BPCI Model 3 Participants 12 HOSPITALS OR PHYSICIAN GROUPS PARTICIPATING IN MODEL 3 Organization Name Convener Phase I Phase II Total Gypsum Creek Healthcare, Inc. Ensign Service, Inc.; Remedy BPCI Partners, LLC Good Samaritan Society - Davenport Evangelical Lutheran Good Samaritan Society 8 8 Good Samaritan Society - Ottumwa Evangelical Lutheran Good Samaritan Society 8 8 Riverside Healthcare, Inc. Ensign Service, Inc.; Remedy BPCI Partners, LLC Central Avenue Healthcare, Inc. Ensign Service, Inc.; Remedy BPCI Partners, LLC Cherokee Healthcare, Inc. Ensign Service, Inc.; Remedy BPCI Partners, LLC Lutheran Homes Society Remedy BPCI Partners, LLC Prairie Creek Healthcare, Inc. Ensign Service, Inc Risen Son Christian Village Remedy BPCI Partners, LLC Mercy Home Care, Sioux City CHE Trinity Incorporated Great Plains Healthcare, Inc. Ensign Service, Inc.; Remedy BPCI Partners, LLC Cardiovascular Medicine Pc Remedy BPCI Partners, LLC Managed Care Organizations 15

16 Iowa 14% Iowa NR 16

17 Iowa Proposal Withdrawn Iowa Medicare Medicaid Coordination Initiative 17

18 New Guys: Friend or Foe? 18

19 $ How are providers responding? 19

20 KINDRED'S CLEVELAND INTEGRATED CARE MARKET SERVICES When people leave traditional hospitals they often need continued care to recover completely. That s where we come in. Kindred s expertise across a variety of post-acute care sites of service helps us provide care for patients in the most appropriate setting. We specialize in delivering quality medical interventions and successfully transitioning patients home or to a less intense level of care that meets their needs and enhances their quality of life. In the Cleveland area, Kindred offers services including aggressive care for medically complex patients, intensive care and short-term rehabilitation through two transitional care hospitals, a subacute unit, three nursing and rehabilitation centers, home health and assisted living services. CARE TRANSITIONS PROGRAM We are proud to offer an innovative, new approach to care through our Care Transitions Program. The program is a quality improvement initiative designed for patients with medically complex conditions. We provide patients with Care Transitions Managers, patient advocates and navigators who communicate directly with patients, caregivers and primary care physicians or specialists every step of the way. They facilitate transitions between settings and help fill in communication gaps SUBACUTE UNIT ASSISTED LIVING FACILITIES TRANSITIONAL CARE HOSPITALS TRANSITIONAL CARE AND REHABILITATION CENTERS HOME CARE Signature Communities Signature HealthCARE has a vision to radically change the landscape of healthcare forever. It s more than a corporation it s a revolution. Signature HealthCARE is a healthcare company providing skilled nursing, rehabilitation and other services across the care spectrum with 126 locations in 10 states and nearly 19,000 employees. A growing number of Signature centers are earning five-star ratings from the Centers for Medicare & Medicaid Services. In 2013, the company was named one of Modern Healthcare s Best Places to Work for the third time. Signature s organizational culture is founded on three pillars: Learning, Spirituality, and Intra-preneurship. To learn more about Signature HealthCARE, please visit LTCrevolution.com. 20

21 Patient Placement PruittHealth Care Management starts with Patient Placement. Patient Placement was established to help patients and families navigate the maze of services and options. This program provides a centralized, single-source solution administered by transition nurses who are a primary point of contact for each patient, providing multiple patient services. The professionals within Patient Placement act as care managers for private resources and payment plans, such as commercial insurance, Medicare "replacements" and selfpayment. Transition Support In order to decrease patient hospitalizations, our specially trained caregivers utilize Transition Support, our rehospitalization prevention program. It provides an amplified focus on decreasing patient hospitalizations through an established model of high-quality care. Our proprietary set of procedures that allows patients to better achieve their desired rehabilitation goals without the often traumatic setback of a return hospitalization. Home First PruittHealth Home First is a program designed to help patients receive care in their home, rather than in an institutional setting. Nurse Care Managers coordinate all aspects of patient care to ensure that the patient is able to remain home as long as possible. Services include adult day health, emergency response, home meal delivery, support services and more. Payment options include private pay and the SOURCE (Service Options Using Memory Support Fitness Therapy Balance Program Aquatic Therapy Stroke Rehab Cardiac Care Wound Care Pain Management Repiratory Therapy Life Enrichment Resources in a Community Environment) Medicaid waiver program that is offered in certain areas of Georgia. Skilled Nursing and Rehabilitation Centers Home Health Veteran Services Community Services Assisted Living Centers and Independent Living Communities Hospice CareCentrix offers comprehensive, home health management solutions. Through our network of credentialed, quality providers, we manage care to the home in a coordinated way, helping to ensure that patients receive the care they need, when they need it, for the right cost in the comfort of their home. Successfully managed care for over 2 million* services in the home and prevented over 450 people from being readmitted to the hospital; Delivered client savings, through both utilization and network management, of up to 15% per year; Implemented specific programs to manage care to the home and improve patient outcomes, including: 1. A Wound Management program that reduced patient days on therapy by 19% and decreased nursing days needed to heal wounds by 21%; 2. Sleep Management programs that managed sleep testing and therapy in the lower cost home setting, resulting in more than a 3-1 return on investment for our clients; 3. An Infusion Solutions program that managed infusion in the home, as opposed to more costly outpatient and hospital settings, when clinically appropriate, saving 40-50% per case. This can result in up to $120,000 savings per patient in any given year. 21

22 Your ally for innovative home health solutions. For nearly 20 years, we have acted as agents for smart change, forging holistic relationships with We manage the payors coordination to create a more so seamless you can process, deliver the care. We share your passion improve for helping patients patients outcomes, seamlessly drive transition leading-edge back home. solutions And and we understand offer significant the peace savings. of mind that comes with knowing they will receive the quality and level of care you demand. We support you by coordinating your patients at-home care, leaving you free to focus on the care that you are providing. Join Our Network Than you for your interest in joining the CareCentrix provider network! As a participating provider with us, you will enjoy a number of benefits: Diversify your revenue base by gaining access to patients insured through our national client base Reimbursement at 100% of your contracted rate no chasing member co-pays! Electronic tools to make working with us simple Electronic claims submission Provider Portal for you to submit authorization, re-authorization, and add-on requests, in addition to claim and authorization status lookup features! In order to join the Carecentrix provider network, we ask that you complete the questionnaire below, and upon submission, a member of our Network team will reach out to you for next steps. Questions 22