How to Survive in Value-Based Purchasing: Making the Case for Quality

Transcription

1 How to Survive in Value-Based Purchasing: Making the Case for Quality September 13, 2017 PACAH - Pennsylvania Coalition of Affiliated Healthcare & Living Communities 2017 Fall Conference Pittsburgh, PA Gina Zimmermann Executive Director, Nursing Care Center Services The Joint Commission

2 Outline Quality Measures for Nursing Facilities Existing Models for Value-Based Purchasing Improving Your 5-Star Making the Business Case for Quality 2

3 The Joint Commission The leader in standards development promoting quality and safety in health care organizations for more than 60 years Currently the nation s largest and only full continuum accreditor; with more than 20,000 accredited health care organizations Currently accredits over 80% of the nation s hospitals and the industry leader in the accreditation of home health agencies and home care-related services Began accrediting nursing homes, including skilled nursing facilities, in 1966 Our experience and expertise has propelled Joint Commission accreditation to become the most widely recognized quality and safety distinction across the continuum, among managed care contractors, liability insurers and other key stakeholders 3

4 Leaders in Patient Safety and Quality Improvement Accreditation and Certification Evidence-based solutions and coaching Practical and effective solutions International accreditation, certification and consulting Nationally recognized standards Targeted Solutions Tool Education and publications Leadership and innovative solutions Performance measures Oro 2.0 Consulting Evidence-based advisory services National Patient Safety Goals Software tools 4

5 5 Copyright, The Joint Commission

6 The Joint Commission Mission Statement To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value 6

7 There is a business case for quality improvement programs primarily because QUALITY, COST, VALUE, SPEED and TRUST are intrinsically interlocked and tightly coupled. Denham CR. J Patient Saf. 2009;5:43. 7

8 Improve Quality = Reduce Waste PROCESS INEFFICIENCY Three primary forms of provider-related health care waste OVERUSE As much as 40% of health care dollars spent is waste PREVENTABLE HARM WASTE Swensen SJ, Meyer GS, Clancy CM, N Engl J Med. 2010;362:e12, February 4,

9 Shift in Motivation for Accreditation Most health care organizations support quality work - - only to the extent required by an external reporting agency Shift to value-based models based on outcomes is changing this perspective 9

10 Business Case for Quality Objective Make the case that pursuit of a framework for optimal quality and improved patient outcomes have a direct impact on core nursing home quality outcomes, health care business management and fiscal well-being S. Swenson, Journal of Patient Safety, March

11 Quality Measures for Nursing Homes Copyright, The Joint Commission

12 Typical Requests for Information (RFI)/Credentialing of Post Acute Partners Provider statistics Hospital readmissions Length of stay Admissions/discharges Cost of stay Nursing Home Compare/5-Star Ratings CMS/State Certification Survey results 12

13 Existing Models for Value-Based Purchasing Copyright, The Joint Commission

14 Existing Models for Value-Based Purchasing Shared Savings Payers Narrowing networks Preferred provider relationships ACOs Bundled payments Hospital/Health System Partnerships 14

15 Arizona Long Term Care System (ALTCS) Value-Based Payment Target AZ Medicaid program contracts with MCOs to provide coverage for LTC services for senior and individuals with disabilities Program provides acute care, behavioral health services, case management and long-term services and supports (LTSS) including home and community-based services ALTCS plans and SNPs have a min. of 25% of their total payments to providers in value-based models for contract year 2016; and 35% in contract year

16 Arizona Long Term Care System (ALTCS) Copyright, The Joint Commission Value-Based Payment Target (cont d) Plans must meet the value-based payment target in order to access any portion of a 1% capitation rate that the state withholds Plans can earn back the withhold for performance on the following measures: Emergency department utilization Readmissions within 30 days of discharge HbA1c testing LDL-C screening; and Flu shots for adults 18 years and older 16

17 Florida - Medicaid Prospective Payment System (PPS) Converts Medicaid payments for nursing facility services from a cost-based reimbursement methodology to a prospective payment system in a budget neutral manner promoting value for Florida Medicaid Prospective = Predictability Seeks to balance financial incentive for high quality care with incentive for efficiency 17

18 Florida - Medicaid Prospective Payment System (PPS) (cont d) Governor signed budget funding program (June 2017) Impacts reimbursement beginning October 2018 Providers who earn the quality payment will gain on average an additional $15.14 per Medicaid day (includes accreditation awards) Five-year transition period with a rebasing of rates in year three of the five-year transition 18

19 Florida - Medicaid Prospective Payment System (PPS) (cont d) Process Measures Outcomes Measures Structural Measures Flu Vaccine UTIs Pressure Ulcers Staffing 5-Star Rating Antipsychotic Use Falls Florida Governor s Gold Seal Award Incontinence Joint Commission Accreditation Restraint Use Decline in ADLs American Health Care Association (AHCA) Quality Award (Silver or Gold) 19

20 Minnesota Integrated Care System Partnerships MN requires health plans serving seniors and individuals with disabilities to enter into value-based contracts with primary care, longterm, and/or behavioral health providers MN DHS seeks to improve service delivery integration, care coordination, and health outcomes through payment reforms with explicit links to quality Outcomes include Fewer hospital stays Fewer emergency department visits More visits with primary care providers Increased utilization of hospice 20

21 Minnesota Integrated Care System Partnerships (cont d) ICSP initiative encouraged plans and providers to try new payment arrangements and may have accelerated the integration of quality performance into payment arrangements New revenue potential (shared savings, performance-based bonuses) led to investments in delivery system changes Funding for community health workers Investments in care coordination Strengthened working relationships between providers and plans 21

22 Tennessee Quality Improvement in Long- Term Services and Supports (QuILTSS) TennCare (Medicaid) enrollees are enrolled in the TN s CHOICES Managed Long-Term Services and Supports program State sets rate of reimbursement for nursing facility and home & community-based services and directs payments, including performance-based incentive payments, through its risk-bearing MCOs QuILTSS has provided more than $18 million in bonus payments to nursing facilities for PI activities since implementation in Aug

23 Tennessee Quality Improvement in Long- Term Services and Supports (QuILTSS) (cont d) Providers must meet min. standards of performance in order to be eligible to receive any portion of quality incentive payments Quality framework and scoring methodology Satisfaction (member, family and staff) 35 points Culture change/quality of life (i.e., respectful treatment, member choice, member/family input, meaningful activities) 30 points Staffing and staff competency 25 points Clinical performance (antipsychotic medication and urinary tract infection rates) 10 points 23

24 Tennessee Quality Improvement in Long- Term Services and Supports (QuILTSS) (cont d) TN nursing facility scores on quality improved each quarter and the number of nursing facilities with higher scores was reported to have continued to increase in the first year of implementation 24

25 Blue Cross Blue Shield of Massachusetts BCBS of MA requires all network SNFs to be accredited Approximately 50% of all Massachusetts nursing homes are Joint Commission-accredited 25

26 Blue Cross Blue Shield of Illinois Implemented in Chicago s Cook County and the 5 collar counties in 2013 BCBS of IL required all network SNFs to be accredited (Joint Commission or CARF) within 1 year Providers were allowed to show evidence of intent to seek accreditation by submitting an application for accreditation Accreditation requirement is now expanded to all of Illinois 26

27 Anthem Pay-for-Value (PFV) Program Anthem has used a targeted approach in selected markets to gather scorecard data on skilled nursing facilities providers Scorecards query performance on a number of standard criteria plus 4 Bonus Measures accreditation infection prevention patient satisfaction skin care 27

28 Anthem Pay-for-Value (PFV) Program The distribution of scores and other factors (access, funding available, etc.) are reviewed and a single cut-point in the distribution is established Scores above the cutpoint get an enhanced fee schedule, those below don t 28

29 Shared Savings Bundled Payments Align hospitals with post-acute providers Bundled payment for episode of care Mandatory CJR comprehensive joint replacements in 67 MSAs Strong preference for 3-star+ facilities CMS would like to expand to acute myocardial infarction model coronary artery bypass graft model surgical hip and femur fracture cardiac rehabilitation incentive payment model 29

30 Six Common Criteria Hospitals Use in Forming Post Acute Networks by Dr. Josh Luke 1. CMS Star rating: While very few people sing the praises of the 5 star system, it is the chosen system of the regulatory body so it is essential it be included in your list of criteria. 2. Long-term community presence: Hospitals are not as concerned about the newest, biggest or best provider, but more so that provider that has successfully served its community for many years. 3. Joint Commission Accreditation for skilled nursing providers. While TJC accreditation is not required in SNF's, TJC is the Gold Standard for accreditation industry-wide and those SNF's who have chosen to seek TJC accreditation have shown a willingness to go above and beyond to exceed all quality and customer service initiatives. 4. Survey history. This one is a no brainer. 5. Physician alignment: By aligning with SNF's that active hospital doctors already frequent, the likelihood of disruption and resistance when the narrow network of SNF's is implemented is drastically reduced. 6. Case manager/discharge planner preference: Hospital discharge planners should know which SNF's are providing the highest quality care and communicating best with the hospital to ensure timely, safe and fluent discharge. Case managers will be a lot more willing to support this drastic change in their daily routine if one or two of the SNF's they prefer are included in the narrow network of SNFs. 30

31 Improving Your 5-Star Copyright, The Joint Commission

32 Pennsylvania Overall 5-Star Ratings as of September 2017 Count % % % Nearly 40% of Pennsylvania s nursing homes can t qualify for Value-Based Purchasing initiatives! % % % Total 697 Source: 32

33 33 Copyright, The Joint Commission

34 Study Methodology Data set from CMS Nursing Home Compare website, April 2015 Accreditation status was identified by matching facilities in the Nursing Home Compare data set and facilities in The Joint Commission database by CMS Certification Number (CCN) CMS Nursing Home Compare data set included records for 15,637 facilities 711 (5%) of the facilities were identified as accredited by The Joint Commission 34

35 Study Results: 5-Star Ratings Joint Commission accredited organizations had statistically higher ratings than non-accredited nursing homes on the overall five-star rating, as well as each of the component subscales (Health Inspections, Quality Rating, Staff Rating and RN Staff Rating) Accredited nursing homes with Post- Acute Care Certification out-performed accredited organizations without Certification 35

36 Study Results: 5-Star Ratings Overall 5-Star Rating: Accredited with Post-Acute Care Certification Accredited Non TJC Accredited 3.63* 3.33* Comparison of Accreditation and Certification Status by Star-Rating Component * 3.469* * * 3.88* Health Inspection Quality Rating Staff Rating RN Staff Rating Accredited with PAC Certification Accredited Non TJC Accredited n = 86 n = 641 n = * Statistical significance P<0.05 Comparison of accredited organizations versus non-tjc accredited organizations after adjusting for facility size and ownership type As a general rule, smaller non-profit organizations also tended to do statistically better than larger for-profit or government owned facilities 36

37 Study Results: 5-Star Ratings Joint Commission accredited nursing centers score higher on Overall Star Rating Williams PsyD, Morton PhD, Braun PhD, Longo RN MBA MSN, Baker MD MPH; Journal of American Medical Directors Association (JAMDA)

38 Study Results: Quality Measures Joint Commission accredited facilities performed consistently better on all five of the short term stay measures (short term stay defined as < 100 days). Patients in accredited facilities: 1) Were less likely to report severe to moderate pain 2) Were less likely to acquire new or worsened pressure ulcers 3) Were less likely to be prescribed antipsychotic medications 4) Were more likely to receive pneumococcal and influenza vaccinations 38

39 Study Results: Quality Measures Joint Commission accredited nursing homes performed better than nonaccredited facilities on key quality measures that focus on nursing home residents who are in the facility for greater than 100 days. Residents in accredited facilities: 1) Needed less help with late-loss activities of daily living (ADLs) (selfperformance bed mobility, selfperformance transfer, self-performance eating, and self-performance toileting) 2) Were less likely to experience moderate to severe pain 3) Were less likely to experience a fall resulting in a major injury 4) Were less likely to be prescribed antipsychotic medication 39

40 Study Results: Scope & Severity Ratings Joint Commission accredited facilities were more likely to have lower-level (Dlevel) deficiency findings associated with an isolated incident with no actual harm, but with the potential for more than minimal harm that is NOT immediate jeopardy Non-accredited organizations had more severe (J-K-L immediate jeopardy) deficiencies than accredited organizations Non-accredited facilities were more likely to have more J-K-L immediate jeopardy deficiencies along with other deficiencies that caused direct harm and were part of a pattern (H) or widespread (I), or had the potential for harm but were widespread (F) 40

41 Study Results: Financial Impact On average, annual fines associated with accredited organizations were nearly $7,000 less than fines associated with nonaccredited facilities Accredited organizations were 50% less likely to have payment denials than were non-accredited facilities 41

42 The Evidence Joint Commission accredited nursing homes have fewer survey deficiency citations on their annual certification surveys than nonaccredited facilities SOURCE: Impact of Voluntary Accreditation on Deficiency Citations in U.S. Nursing Homes, The Gerontologist, March 5,

43 The Evidence Joint Commission accredited nursing homes have better resident outcomes which continue to improve over time SOURCE: Joint Commission Accreditation and Quality Measures in U.S. Nursing Homes, Policy, Politics & Nursing Practice, April 25,

44 Making the Business Case for Quality Copyright, The Joint Commission

45 Making the Business Case for Quality Why a business case? Justification for a proposed business change or plan Outlines allocation of capital and resources required Impetus for moving forward with a new or revised plan of action Unified vision for future business and operations 45

46 Describe the Need for Change SITUATION An new opportunity that generates revenue, cuts costs, or delivers some other benefit A mandatory change something that needs to be complied with APPROACH State what the business case is proposing Describe why it is being considered why now? Describe current state the world today Describe future state how the world will when the proposed change is implemented Correcting/fixing a problem Describe the current situation and explain what the adverse impact is financial or otherwise 46

47 List Project Alternatives List alternatives Include benefits, costs, and risk assessment How do the alternatives align with corporate or business unit strategy? 47

48 Describe Current vs. Future State Use measureable objectives Financial outcomes (revenue, cost, operating margin, etc.) Clinical outcomes (MDS outcomes, etc.) Quality outcomes (5-star, etc.) Customer satisfaction 48

49 Metric Targets Big Y $1,375,751 Achieve Break-Even Operating Margin B 2012F 2013F 2014F ($137,020) Sub-Y s or X s ($1,111,020) OM$ 31 1, % 84.9% 93.0% 76.7% % 84.0% % 87.4% 80.0% $3,455 $3,231 $3, B 2012F 2013F 2014F B 2012F 2013F 2014F B 2012F 2013F 2014F ABC DEF ABC DEF GHI Attract New Customers Retain Existing Customers Increase Average Revenue 49

50 Project: Enhance the Value and Relevance of Accreditation Objective: Ensure value and relevance of the XXXX Accreditation Program, enabling organizations to use accreditation as an operations monitoring system. o o o o Key Components Renew XXXX standards to be customized and relevant to the practice setting Renew XXXX standards to be customized and relevant to the practice setting NEW! Identify linkages between key XXXXX performance measures and XXXX accreditation to demonstrate the value of accreditation NEW! Modify pricing Implement price adjustments in targeted segments to improve survey profitability Moved to Project 6: Revise pricing model to be relevant and drive an appropriate assessment of fees for the XXXX Program Outcome CEO Likelihood to 67.0%* 68.0% 69.0% 70.0% Recommend NPS Accreditation Value NS 47.0%* 48.0% 49.0% 50.0% Operating Margin of Project ($) -$47K $186K $323K $471K Total Revenue - $314K $454K $694K *Aug 2016 YTD Required Resources & Focus DSSM 0.45, 0.68, 0.09 FTE FOR 17, 18 & 19 $47K $71K $9K - New Surveyor Education - $6K $20K $17K 0.03 FTE ACO - $3K $3K $3K Expert Panels - $10K $350 - Pilot Tests/Learning Visits - $9K - - TOTAL $47K $98K $32K $20K ~Payback 4 years (2020) 4 year ROI = 472% 50

51 Implementation Timeline Gather a cross-functional team to define the timeline Start with a high-level view Detail out later 51

52 Project 9: Automated Service Support Model # Task / Action Step Owner Resources Required Due Date Status 1.0 Develop automated processes delivering key content via the web for potential customers Badon Marketing/BD Q In progress 1.1 Vendor Selection Badon Marketing Feb 2011 Completed 1.2 Develop script and Storyboard Badon/Labson Marketing/BD Q Filming Badon Marketing Q Editing /Post Production Badon Marketing /BD Q Launch video modules Badon/Labson Marketing/BD Communications Q

53 Summary Quality Measures for Nursing Facilities Existing Models for Value-Based Purchasing Improving Your 5-Star Making the Business Case for Quality 53

54 Questions? Gina Zimmermann Executive Director, Nursing Care Center Services The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL