Florida Health Care Association 2013 Annual Conference

Transcription

1 Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #51 Navigating Health Care Reform: Creating a Road Map for Success Thursday, August 8 8:15 to 9:45 a.m. Regency 1 Upon completion of this presentation, the learner will be able to: identify five health care reform initiatives affecting the role of the nurse leader in 2013; describe key clinical operational strategies to successfully implement health care reform initiatives; review the use of tools and resources to prevent resident rehospitalizations; and integrate evaluation and monitoring systems for successful health care reform initiative implementation. Seminar Description: As leaders in the long term care profession, it is imperative that we keep abreast of the everchanging dynamics of long term care regulations, health care reform and reimbursement methodology. Knowledge and understanding of the major components of the Patient Protection and Affordable Care Act specific to post-acute care is critical to successful clinical and operational outcomes. Determination of key operational strategies to ready your organization for health care reform initiatives is imperative. During this presentation, you will discover how these changes directly impact you and your organization. Reducing hospital re-admissions has become the focus of Medicare, hospitals and post-acute providers. Presenter Bio(s): Lisa Thomson, Vice President for Pathway Health Services, has over 25 years of experience in the post-acute and long term care setting. She has had extensive experience in the daily operations of numerous health care organizations as a Chief Executive Officer, Vice President, Executive Director, Administrator, Marketing Director and Director of various IDT departments. She has been instrumental in guiding leadership teams (from all levels) through a number of organizational changes to establish regulatory compliance, standards of practice, operational strategies as well as Joint Commission Accreditation. Lisa is skilled in the coordination and leadership of compliance teams that aid facilities in achieving regulatory, clinical and financial turnaround. In addition, she has the ability to interpret regulations and operationalize the process.

2 Navigating Healthcare Reform: Creating a Roadmap for Success! Lisa Thomson Vice President The Journey Begins It is time for CHANGE! 7/24/12 All rights reserved. 3 1

3 Current Healthcare Landscape 4 Preparation for the Journey 2

4 Course Has Been Set Challenges - Post Acute Care Government Unrest Reform of Health Care as we know Reimbursement Changes Increased Costs Regulatory Changes External Oversight Challenges - Post Acute Care 3

5 Challenges - Post Acute Care In the United States, we are spending more of our gross national product on health care than in other developed countries with no better outcomes (measured in terms of life expectancy at birth, which was 78.2 years in 2009). Challenges - Post Acute Care Medicare spending is projected to increase from $555 billion in 2011 to $903 billion in 2020 (CBO, August 2011). Over the next decade, Medicare spending is projected to grow more rapidly for prescription drugs, hospital outpatient services, and skilled nursing facility services than for hospital inpatient care and home health services. Source: Kaiser Foundation 06.pdf Challenges - Post Acute Care 4

6 Challenges - Post Acute Care Source; Government Response Reform Health Care Decrease Costs Decrease Reimbursement Increase Quality Increase Access Government Response Patient Protection and Affordable Care Act (PPACA) Signed into effect March 23, 2010 Reform Private Insurance Reform Public Insurance Improve coverage to those with preexisting conditions Expand access to care Reduce long term costs of health care 5

7 Government Response Accountable Care Act (ACA) Increase access for healthcare Decrease high costs of Medicare and Medicaid Improve efficiency and effectiveness of Medicare and Medicaid Increase HCBS (home care based services) Government Response Accountable Care Act (ACA) Link reimbursement to quality outcomes Move from Fee for Service to Bundled Payment methods Person Centered Care Consumer engagement and access to data Destination: Value and Lower Cost Start 2010 x Arrival

8 Education and Knowledge Accountable Care Act Initiatives Accountable Care Act Initiatives A new engine for revitalizing and sustaining the Medicare, Medicaid and CHIP programs and ultimately to help to improve the healthcare system for all Americans. Flexibility and resources Test innovative care models Test innovative payments models Accountable Care Organizations 7

9 Accountable Care Act Initiatives Accountable Care Act Initiatives CMS is working toward a revamped health care delivery system that will reduce hospital readmissions and, at the same time, create incentives to foster a more person-centered health care approach. CMS envisions health care truly becoming an integrated, collaborative approach as diagnoses, prescriptions, and patient interactions are captured, stored, and immediately available to relevant health care providers. CMS s ultimate goal of eliminating redundancies, needless delays, and unwarranted referrals will be realized, in addition to cost savings, integrated health care, improved processes, and better care. Accountable Care Act Initiatives 8

10 Accountable Care Act Initiatives Initiatives in motion Hospital Readmission Reduction Program Fraud and Abuse QAPI Corporate Compliance Bundle Payment Demonstration Community Based Services Accountable Care Act Initiatives Initiatives in motion Medicare Value Based Purchasing Performance based pay Quality metrics P4P National Dementia Initiative Unnecessary Medications - Antipsychotic Abuse prevention training updates National program for background checks Person Centered Care ICD 10 Internal Review 9

11 Leadership Strategies Develop an internal Interdisciplinary Team task force Leadership involvement Specific initiative leaders Mavericks Quality Mapping Assess Organization Systems Corporate Programs and Outcomes Facility specific protocols Assess need to change Benchmark internal systems for review Current status Industry standards Best practice approach Identify opportunities Leadership Strategies Assess Clinical Readiness Your Role Industry initiatives Market initiatives and expectations Quality Outcomes Payor and External Expectations Consequences Internal competency process Right people and Right Roles Clinical Competencies Integration of Industry Best Practice Standards (i.e.interact) 10

12 Leadership Strategies Develop quality strategy Goals Prioritize Impact Systems and tools needed to change processes Resources applied or needed Time frames Approval/Agreement Leadership Strategies Motivate Change! Great leaders are almost great simplifiers, who can cut through issues or doubt to offer a solution everybody can understand. Colin Powell Statesman, General Retired Leadership Strategies Ownership Acceptance Resistance Denial Time Anxiety Executives Managers Employees 11

13 Three Leadership Options Shape the Future Play a leadership role in establishing how the post acute care industry operates: Innovator Quality Expectations Creating Demand Adapt to the Future Win through speed, agility, and flexibility in recognizing and capturing opportunities in existing markets Reserved Invest sufficiently to stay in the game but avoid premature commitments Source: Harvard Business Review. Strategy Under Uncertainty, December 1997 Quality Outcomes: Data Today and Beyond Quality Outcomes: Data Larson Allen, LLP Health Care Reform 12

14 Quality Outcomes: Data Become informed Outcome data and performance Quality Measures Readmssion Rate MDS 3.0 data Hospital Compare Regulatory data Consumer Satisfaction Industry and Regional Trends Quality Outcomes: Data We are transforming Medicare form a passive payer, to an active purchaser of value Tom Valuck Assistant CMS Administrator Quality Care + Data = Reimbursement Quality Outcomes: Data One thing you can control to some degree is performance! 13

15 Quality Outcomes: Data Quality Outcomes: Data Quality Outcomes: Data Organizational Data: The New Path to Value Determine Quality Profile: Assess Organization Data Review Internal Processes: Optimize Data Establish an Information Agenda for Planning Your data is key to positive outcomes. 14

16 Quality Outcomes: Data Performance Who is measuring your performance? You, the facility State, consumers, press/media How are you measuring your performance? Quality Improvement processes If you were a private pay consumer, how would you rate your performance proof 43 Quality Outcomes: Data Performance QIS Data Utilize data for improvement processes How do you use the data? Leadership involvement in performance improvement Readmission Rate Clinical competency Clinical Readiness Organizational Philosophy 44 Quality Outcomes: Data Performance External monitoring of data Regulators Peers Partners Referral entities Consumers Fraud and Abuse GAO Government Accountability Office OIG Office of Inspector General CMS 45 15

17 Preparedness and Protection Preparedness and Protection Office of the Inspector General (OIG) Questionable billing by SNFs. Conduct a full review of SNF billing by end of FY 2011 and implement plan. Increased diligence on therapy utilization. Increased auditing of supporting documentation. NEW HHS 2014 Budget! CMS and OIG (a new kind of marriage)! Preparedness and Protection Performance External monitoring of data Fraud and Abuse GAO Government Accountability Office OIG Office of Inspector General CMS Legal Entities 16

18 CMS Fraud and Abuse Partners Centers for Medicare & Medicaid Services (CMS) Government agencies partner to fight fraud and abuse, uphold the Medicare Program s integrity, save and recoup taxpayer funds, and maintain health care costs and quality of care. CMS partners with the following entities and law enforcement agencies, among others, to prevent and detect fraud and abuse: Program Safeguard Contractors (PSCs)/Zone Program Integrity Contractors (ZPICs); Medicare Drug Integrity Contractors (MEDICs); State and Federal law enforcement agencies, such as the OIG, Federal Bureau of Investigation (FBI), Department of Justice (DOJ), and State Medicaid Fraud Control Units (MFCUs); 49 Medicare and Medicaid Fraud and Abuse Centers for Medicare & Medicaid Services (CMS) Partners (continued): Medicare beneficiaries and caregivers; Senior Medicare Patrol (SMP) program; Physicians, suppliers, and other providers; Medicare Carriers, Fiscal Intermediaries (FIs), and Medicare Administrative Contractors (MACs) who pay claims and enroll providers and suppliers; Accreditation Organizations (AOs); Recovery Audit Program Recovery Auditors; and Comprehensive Error Rate Testing (CERT) Contractors. 50 Preparedness and Protection 17

19 Preparedness and Protection Audits In Full Swing! RAC Audits MAC Audits ZPIC Audits Preparedness and Protection Healthcare Landscape Focus on Overpayment as well as Fraud and Abuse From: Hooper, Lundy & Bookman, PC 54 18

20 Preparedness and Protection High Risk Areas Sudden changes in billing Spikes in billing Compromised identities (provider/beneficiary) High error rates RUG changes or discrepancies Overpayments/underpayments Preparedness and Protection Negative Outcomes Administrative Actions Suspension of payments Exclusion from participation Criminal action Preparedness and Protection Strategies Internal and External monitoring Education/Knowledge Documentation Policies and Procedures Staffing Right Roles 19

21 Preparedness and Protection The Final Review: Implementation The Final Review: Implementation Facility Strategic Positioning Readiness Benchmark Data Compare Data Nursing Home Compare e Hospital Compare: Home Health Compare: hcompare 20

22 The Final Review: Implementation Facility Manage complex medical care Approach referral entities - strategic relationship Streamline communication Care transitions Successful care management success for acute partner Acute care partners Seeking partners in facing challenges of health care reform Opportunity to educate new partners Become community leaders in health care The Final Review: Implementation Specialty Units Partnerships Adult Day Services Senior Services 21

23 The Final Review: Implementation Industry Response The Final Review: Implementation Preparation Operational Readiness Assessment Services Internal Systems Team composition Increase clinical competencies Validation and benchmark data Excellent outcomes quality and financial Evaluate, reposition, partner and implement 65 22

24 The Final Review: Implementation Facility Overall Goals Increase communication Efficiency and effectiveness Collaboration with partners Reduce redundancy Determine roles and anticipated processes Improve patient outcomes Care Transitions The Journey Begins! 23

25 Preparation for the Journey Preparation for the Journey Execution is the ability to mesh strategy with reality, align people with goals and achieve promised results. Larry Bossidy Author and businessman/ceo Navigating Healthcare Reform: Creating a Roadmap for Success! THANK YOU! Lisa Thomson Lisa.thomson@pathwayhealth.com 24