5/26/2015. January 26, 2015 INCENTIVES AND PENALTIES. Medicare Readmission Penalties. CMS Bundled Payment Providers & ACOs in NE

Transcription

1 Agenda ESTABLISHING SHARED EXPECTATIONS New tool of ACOs, Bundled Payments & Readmission Reduction Update on current market pressures driving a focus on care across settings & over time at lowest cost Description of the different models of shared expectations among referral partners Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies May 20, 2015 Recommendations home care & hospice providers given current realities in the field Objectives Describe why understanding hospital and SNF market pressures are relevant to home care & hospice providers Describe at least 3 domains of shared expectations, based on current examples in the field CMS Strategy: Redesign Care Across Settings, Over Time Understand the benefits & limitations of negotiating shared expectations on an individualistic v. regional basis Care Across Settings, Over Time Care transitions Community- based care transitions program (180 days) Transitional care billing codes (30 days) Bundled payments Hospital + post acute care (30, 60, 90 days) Post acute care (30, 60, 90 days) Care management Accountable Care Organizations (across settings, over time) Patient Centered Medical Home (management over time) Care management billing codes (management over time) Accountable Care- What Does that Mean? 1

2 Accountable: only so many ways to dress it up Lose money for readmissions: Hospital readmission penalties Earn-back withheld money Medicare Value-Based Payment Program, SNF VBP Not lose money Skirt the line of no loss, no gain Receive a small bonus For quality/use/satisfaction targets Share in savings from reducing costs with the payer, for reducing costs while maintaining quality Upside only (small gain), or full risk (bigger gains, potential loss) Who s Accountable, and What Are They Doing? Hospitals Magnitude of the penalty warrants either no investment, or internal shifting of capacity to deploy existing staff to address issue Accountable Care Organizations Big difference in whether Hospital-led ACO or Physician-led ACO Many ACOs to date are focused on capacity development, data Big focus in 2014 has been on networks, expanding population base and post-acute utilization Bundled Payment for Episodes of Care Hospitalization +/or Post-Acute Care + Follow up 30, 60 or 90 day episodes CMS Bundled Payment Providers & ACOs in NE INCENTIVES AND PENALTIES What s here for hospitals, and coming for PAC Medicare Readmission Penalties Year 3: October September Up to 3% reduction in all Medicare payments for hospitals with high 30-day readmissions for AMI, HF, PNA, COPD and hip/knee replacement January 26, 2015 Average penalty DOUBLED this year 2,160 hospitals penalized; $480 MILLION MA, CT, NY are in WORST states for % of hospitals w/ penalty 2

3 High-Value Care: No Looking Back Year % Medicare in Alternative Payment Models % % % Source: Bruce Spurlock, MD, Cynosure Health Quality, Outcomes, Experience..+ Efficiency! Medicare Spending Per Beneficiary New Efficiency Measure for hospitals Medicare Part A + B spending per beneficiary Looks at total 3 days prior to through 30 days post-discharge Adjusted for age and severity of illness Ratio: Hospital Medicare Spending per Beneficiary National Median Spending per Beneficiary Medicare Spending Per Beneficiary Effectively exposes all hospitals into a bundle payment Hospitals must find ways to reduce cost of care overall CMS will provide cost broken down by: 3 days before hospitalization Cost of hospitalization Cost 30-days post discharge Overall by: inpatient, outpatient, home health, SNF, hospice, DME Sheet-MSPB-Spending-Breakdowns-by-Claim-Type-Dec-2014.pdf Hospitals judged by both performance and improvement Potential for efficiency improvements in post acute care utilization.. Conditions for which post acute care accounts for a large percent of episode payments provide hospitals with a stronger incentive to efficiently manage post acute services. SNF Utilization Patterns are Increasingly Visible CMS is developing a SNF 30-day all cause readmission policy Office of the Inspector General s November 2013 report analyzed hospitalizations from SNFs SNF by SNF Area of active research in academics, payers, state/federal agencies Pressure on SNFs, Pressure on Hospitals Pressure on home care and hospice as well CMS technical guidance on MSPB 3

4 ! "#$%&' ' &( ) *+ #,#*- "#.' * 5/26/2015 Effect of Hospital-SNF Referral Linkages on Readmission Return to Acute Care After SNF d/c to Home Stronger hospital-snf linkages were found to reduce readmission rates The greater proportion of discharges a hospital sends to a single SNF, the lower the rate of readmission Specifically lower rates of immediate bounce-backs (days 0-3) Rahman et al, December ,980 Medicare d/c from 694 SNFs 67% d/c to home care after SNF 12,350 (22%) returned to acute care <30d 10% returned to ED 15% readmitted ~50% of returns <30d occurred <10d! High Risks: male, black, history of HU, dual, comorbidities, cancer, respiratory Low Risks: fracture, longer SNF LOS, more LPN hours indicates the need for interventions to improve transition from SNF to home Toles et al JAGS 2014 SNF Readmission Penalties Passed in 2014 All cause unplanned readmissions <30 days of hospital discharge Public reporting of SNF readmissions (October 2017) 2% withhold of SNF payments (October 2018) 50-70% of the withhold will go to incentive payments to SNFs 30-50% of the withhold will go to Medicare for savings Incentive/ penalty goes live (October 2018) 40% of SNFs nationalyl will receive a penalty Estimated to save Medicare $2B over next 10 years! It s Time to Get Serious /.&(.*- "#.' 0*+ #,#*1 2( ) *3 4&54*67,7."*6- */") #8,&"' *9."*: #' "$* "##$!!!!!! "##)! %&' (!!!!! "#' #! %&' *!!!! "#' '! %&' +!!!! "#' "! %&',!!!! "#' (! %&' -!!!! "#' *! %&' $!!!!! "#' +! 7/11-6/12!!!! 7/12-6/13! 7/13-6/14 7/12-6/13 7/13-6/14 7/14-6/15 7/13-6/14 7/14-6/15 7/15-6/16 Spending in MA on LTC/ & HH: 72% higher than US average 4

5 Discharge to HH in MA 74% Higher than US Average RESPONDING TO READMISSION PRESSURES Warm handoffs, provider-provider follow up, comanagement over time SNF Circle Back Warm Handoffs with Follow Up Collaborate Across the Continuum: Mass General 3 day waiver Experience SNF Circle Back Questions (Hospital calls back SNF 3-24h after d/c) 1. Did the patient arrive safely? 2. Did you find admission packet in order? 3. Were the medication orders correct? 4. Does the patient s presentation reflect the information you received? 5. Is patient and/or family satisfied with the transition from the hospital to your facility? 6. Have we provided you everything you need to provide excellent care to the patient? Insights Transitions are a PROCESS (forms are useful, but only a tool to achieve intent) Best done ITERATIVELY with COMMUNICATION Warm follow-up [patient directly admitted to SNF] Process with SNFs: Warm handoff from ED to SNF clinician-clinician; joint decision Support staff were available to facilitate Telephonic card flipping between MGH team & SNF Key lessons: Took a while to develop collaborative rapport v. in-charge No substitute for verbal communication and problem solving Source: Emily Skinner, Carolinas Healthcare System Collaborate Across the Continuum: Emerging Practices from ACOs & Bundles ACO or Bundle clinical coordinator Physical rounds in SNF RN / NP to see patient, discuss plan with SNF staff Respond to changes in clinical status to manage in setting SHARED EXPECTATIONS Virtual care management rounds with SNF Weekly telephonic rounds ACO/bundle coordinator and SNF LOS, progress toward discharge goals, discharge planning Tele-medicine consults in SNF for follow up Tele-evals for change in clinical status Direct admit to SNF from home if need escalated care 5

6 Genesis of Shared Expectations Types of Expectations Providers accountable for care over time need to ensure: Better care across settings (at transitions) Better decision making about levels of care (which settings) Collaborative management of care over time Fluid use of continuum with ability to intensify care outside hospital Response is to narrow list of providers Ok if pilot/ single episode/small market Challenging at scale / across a region Open RFP Query to field: sender requesting demonstration of receiver s willingness to meet expectations Strategic Partnership Alliance preferred provider relationship to develop better processes together in response to a market change Shared Expectations Mutual enumeration of what sender and receiver agree to do in a reliable manner Development of Shared Expectations in MA Story of Co-opetition in health care 5 highly competitive organizations in Eastern MA Boston Pioneer ACOs Realized they all had same move: control PAC spend and care post-hospitalization to reduce readmits Co-Opetition Moment A small set of individuals from the Boston ACOs recognized they were about to work with the same SNFs across a region with 5 sets of detailed expectations, or is there an opportunity to collaborate to issue one common set of expectations? Association leadership seized opportunity to get involved Process: 2012 and Ongoing. 5 Pioneer ACOs met Drafted Common expectations for SNF Providers Without SNFs at the table It was luck this effort was raised in conversation between an ACO leader and leader at MA Senior Care Association Already great relationship She basically invited herself to the next meeting! How was this possible? in Boston? This is actually chapter 4 or 5 in a story that started years before Key relationships formed in Development of a statewide strategic plan for care transitions Care transitions forum relationship, common language for care transitions STAAR Initiative: use of the cross continuum teams It literally brought people out of their silos Met face to face, developed relationships, own aims, work together Collaboration became part of our language: INTERACT became part of shared language Everybody was using it Everyone shared language 6

7 Key Moments Key Domains of Shared Expectations Started with a coalition of the willing (individuals willing to meet) Drafted ideas transparent, inclusive, tracked changes Leadership mattered someone to keep notes, follow up, convene SNF Association got to the table with ACOs They tempered their shock at the first set of expectations It s not about the form, it s about the relationship Association brought expectations to membership This is fine; we are doing this already Principle was to make this easier, standard for everyone s benefit Characteristics of the Facility Turnover, staffing ratios, etc Improving system of care Principles of coordinating between organizations Clinical processes Prior to transition, at transition, after transition, change in condition Measurement Measuring processes, sharing data APPLICATION TO HOME HEALTH SNF to HH and Hospital to HH shared expectations Section 1 Improving Systems of Care 7

8 Section2 Screening & Referral Section 3 Pre Discharge Transitional Planning Section 4 Day of Transfer 8

9 Section 5 Initial Review and Confirmation of Care Plan (Home Health Agency) Section 6 Change in Clinical Status & Transfer of Care (Home Health Agency) 9

10 PREFERRED PROVIDER RELATIONSHIPS Principles are same Define Value in Accountable Providers Terms Data is your best business development tool SHOW what service, for whom Recommendations for PAC providers in 2015 TRACK what happens to your residents TREND improvement over time (LOS, return to ED, readmission) DEMONSTRATE consistency through standard processes DESCRIBE services & outcomes in terms that hospitals recognize Embrace the business of reducing SNF utilization HELP Accountable Care providers make better decisions about who needs SNF and who can receive services at home Describe Value in Accountable Providers Terms Describe services in terms of what creates value for them Fewer emergency room visits Fewer hospitalizations Fewer readmissions Shortened hospital length of stay Reduced skilled nursing facility days Shorter home health episodes [possibly] greater patient satisfaction with hospital or SNF [possibly] greater system loyalty based on positive experience Recommendations Consider your opportunity for co-opetition Is it time to lead development of shared expectations to meet your referral partners needs? In all cases make care across the continuum more reliable Measure what you do and use data as language upon which to build and strengthen partnerships 10

11 THANK YOU Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies Lexington, Massachusetts 11