Sharp HealthCare ACO. Accountable Care Organizations Implications for Post-Acute Care. Thursday, November 8, 2012

Transcription

1 Sharp HealthCare ACO Accountable Care Organizations Implications for Post-Acute Care Thursday, November 8, 2012

2 Sharp HealthCare Largest health care system in San Diego 2 affiliated medical groups, 7 hospitals, 3 skilled nursing facilities, a health plan, 21 outpatient clinics, 5 urgent care centers, home health, hospice, and home infusion programs Market share leader and only health care system that increased market share each of the past 11 years Largest private employer in San Diego 15,000 employees, 2,600 affiliated physicians, 2,300 volunteers 2

3 Sharp HealthCare Grew from one hospital in 1955 to an integrated health care delivery system Aligned physician partners Fully integrated information technology systems and infrastructure Centralized system support services Sharp Health Plan, a 65,000 member, Knox Keene licensed commercial health plan Over 25 years experience in managing care under populationbased payment structures 3

4 Sharp s Population Health Strategy Care coordination and population health management are not new concepts at Sharp 35,000 Senior Enrollees 246,000 Commercial Enrollees 20,000 Commercial ACO Members 32,000 Pioneer ACO Beneficiaries (Medicare) 4

5 Pioneer ACO Program Offered by the Center for Medicare & Medicaid Innovation ( CMMI ) Designed for health care organizations that are already experienced in coordinating care for patients across care settings Allows these provider groups to move more rapidly from a shared savings payment model to a population-based payment model 5

6 Goal of CMS ACO Program CMS Shared Savings Program established in the Patient Protection and Affordable Care Act ( PPACA ) with the goal to provide: Three- Part Aim 1. Better care for individuals 2. Better health for populations 3. Lower growth in Medicare expenditures 6

7 Pioneer ACO Footprint 7

8 Sharp HealthCare ACO Began January 1, 2012 Collaboration between Sharp HealthCare, SCMG and SRSMG All SRSMG physicians, most SCMG physicians (includes Graybill), and all Sharp hospitals 32,000 aligned beneficiaries 74% with SCMG 26% with SRSMG 8

9 What Have We Accomplished? Created corporation Named leadership team Developed subcommittee structure Established provider and supplier network Formed governing body, including consumer advocate and patient representative 9

10 What Have We Learned? Identified Opportunities 63% of 2011 inpatient costs ($78 million) originate from the ED 51% of total Part A claims costs for 2011 ($123 million) are outof-network 150 beneficiaries had 5 or more ED visits in 2011 without a corresponding admit (one beneficiary had 53) 100 beneficiaries had 5 or more hospital admits in 2011 (one beneficiary had 17) 3.5% of beneficiaries generate 21% of Part A paid claims Skilled nursing bed days per 1,000 were 2,608 in 2011 compared to a 5% sample of Medicare fee-for-service beneficiaries in San Diego County of 1,842 (42% higher) 10

11 Skilled Nursing Internal Audit Calendar 2011 Sharp HealthCare ACO Sharp Medicare Advantage SNF Admits PTMPY SNF Days PTMPY SNF ALOS % of SNF LOS 85+ Days 88 2, % 79 1, % -12% -81% -62% -477% SNF bed days per thousand for the 5% sample of San Diego County Medicare fee-for-service beneficiaries were 1,842 for

12 Skilled Nursing Internal Audit ACO 2011 Claim Analysis* * LOS = 6+ Days Provider Organization Name # Admissions ALOS Frequency Distribution of LOS % 0-45 % % % 85+ MEK ESCONDIDO, LLC % 14% 12% 44% B SPRING VALLEY LLC % 26% 29% 17% LIFEHOUSE SAN DIEGO OPERATIONS, LLC % 5% 15% 40% GHC OF LA MESA, LLC % 14% 24% 26% COUNTRY HILLS HEALTH CARE CENTER % 2% 20% 47% B EAST LLC % 15% 16% 26% GHC OF NATIONAL CITY II, LLC % 28% 22% 10% GHC OF NATIONAL CITY I, LLC % 16% 18% 23% MISSION HILLS HEALTH CARE CENTER % 0% 31% 20% VILLA RANCHO BERNARDO HEALTH CARE LLC % 25% 6% 27% ELM HOLDINGS, LLC % 23% 13% 20% PARKWAY MANOR LLC % 28% 10% 25% CHASE CARE CENTER % 13% 19% 23% WINDSOR HEALTH CARE GOLDEN PALMS LLC % 0% 0% 28% GHC OF SANTEE, LLC % 20% 10% 11% KOA HOLDINGS, LLC % 0% 36% 32% Comparison of Sharp HealthCare ACO ALOS by SNF 12

13 Skilled Nursing Internal Audit ACO 2011 Claim Analysis* * LOS = 6+ Days Provider Organization Name # Admissions ALOS Frequency Distribution of LOS % 0-45 % % % 85+ COUNTRY HILLS HEALTH CARE CENTER % 2% 20% 47% MEK ESCONDIDO, LLC % 14% 12% 44% LIFEHOUSE SAN DIEGO OPERATIONS, LLC % 5% 15% 40% KOA HOLDINGS, LLC % 0% 36% 32% WINDSOR HEALTH CARE GOLDEN PALMS LLC % 0% 0% 28% VILLA RANCHO BERNARDO HEALTH CARE LLC % 25% 6% 27% B EAST LLC % 15% 16% 26% GHC OF LA MESA, LLC % 14% 24% 26% PARKWAY MANOR LLC % 28% 10% 25% LEMON GROVE HEALTH ASSOCIATES LLC % 19% 15% 23% CHASE CARE CENTER % 13% 19% 23% GHC OF NATIONAL CITY I, LLC % 16% 18% 23% BIRCH HOLDINGS, LLC % 11% 0% 22% Comparison of Sharp HealthCare ACO 85+ ALOS by SNF 13

14 What Have We Learned? Identified Opportunities Other Pioneer ACOs reported substantial variation in Post-Acute costs Over 1000% Variation for Home Health costs have been reported Large variations in Home Health Cases PTMPY Large variations in Home Health Visits PTMPY Large variations in Home Health Costs reported, by HH Agency Home Health historic baseline utilization and costs were unknown for the Sharp Healthcare ACO 14

15 Home Health Internal Audit Calendar 2011 Sharp HealthCare ACO Sharp Medicare Advantage HH Cases PTMPY HH Visits PTMPY HH Visits Per Case HH $PBPM $ $ % -36% -1% -43% HH costs per beneficiary per month have a wide range for Pioneer ACO s 15

16 Home Health Internal Audit ACO 2011 HHA Claim Analysis - Average Visits per Case, By Agency Home Health Agency Provider Name Average Visits/Case Total Visits Total Cases SHARP MEMORIAL HOSPITAL 13 6, PALOMAR POMERADO HEALTH 15 5, MISSION HOME HEALTH OF SAN DIEGO, INC. 13 4, ADVANTAGE HEALTH SYSTEMS 18 2, LORIAN HOME SYSTEMS, INC. 16 2, GENTIVA CERTIFIED HEALTHCARE CORP. 15 2, NIGHTINGALE HOME CARE, INC. 11 2, FALLBROOK HOME CARE SERVICES, LLC 22 2, ACCENTCARE HOME HEALTH OF CALIFORNIA, INC. 12 1, ALPHA PLUS HOME HEALTH SERVICES 16 1, WESTERN HEALTH RESOURCES 16 1, SCRIPPS HEALTH 10 1, INTEGRITY HEALTHCARE SOLUTIONS, INC F&H HEALTH CARE INC TENDER LOVING CARE HEALTH CARE SERVICES WESTERN, L EXCEL HOME HEALTH SAN DIEGO HOME HEALTH CARE SERVICES, INC Comparison of Sharp HealthCare ACO Visits/Case by HHA 16

17 Aim and Primary Drivers Best Health, Best Care, Best Experience Care Delivery Models Care Coordination Patient Engagement Information Technology and Analytics Alignment of Incentives 17

18 Care Management Programs Program Beneficiaries Touched Hospital Case Management 6, % Skilled Nursing Case Management 2, % Care Transitions 6, % Complex Case Management % Disease Management (CHF) % End-of-Life Care Management % Fully implemented, these programs touch up to 55% of our Sharp HealthCare ACO beneficiaries 18

19 Post-Acute Care Implications Findings of Pioneer ACOs Reported significant differences in utilization and costs between Medicare Advantage members and Medicare fee-for-service beneficiaries. Between other Pioneer ACOs 1. Home health 2. Skilled nursing 3. Acute rehabilitation 4. Long-term acute care 5. Outpatient Palliative & Hospice Care 19

20 Post-Acute Care Implications 5 ways healthcare reform affects postacute providers Comparative Effectiveness Expansion of Value-Based Purchasing Incentives for provider collaboration Incentives for non-institutional care Disclosure of financial relationships 20

21 Post-Acute Care Implications Newly created CMMI Post-Acute Care Action Group Shared expectations and responsibilities between ACOs and post-acute providers Alternative payment systems Demonstration of value by post-acute care providers and capture of part of fund flow Alternative payment arrangements Episode-based management Post-acute care network measures 21

22 Best Health, Best Care, Best Experience