Rehabilitation in a Transforming Health Care Environment Panel Discussion Mike Billings, Donna Mueller, Jake Arrastia, Patty Scheets Infinity Rehab Symposium 2016 Landmark Legislation Patient Protection and Affordable Care Act (PPACA) 1
PPACA: Provider Sponsored Risk CMS Innovation Center Most disruptive change brought by ACA is transfer of financial risk to providers Providers incentivized for safety, outcomes, efficiency, and patient experience 2012 Medicare Shared Savings Program (Accountable Care Organizations) Bundled Payments for Care Improvement (BPCI) Comprehensive Primary Care Initiative Hospital Readmissions Reduction Program Hospital Value Based Purchasing 2014 Hospital Acquired Condition 2016 Next Generation ACO Comprehensive Care for Joint Replacement (CJR) CJR 67 Metropolitan Statistical Areas (MSAs) DRGs 469 & 470: Major joint replacement or reattachment of lower extremity Episodic costs 90 days post discharge from hospital April 1, 2016 start date CJR 2
Protecting Access to Medicare Act (PAMA) of 2014 Skilled Nursing Facility Value Based Purchasing Program (VBP) Links SNF re hospitalization to SNF Medicare Part A payments 2% withhold of SNF Part A payments, which SNFs can earn back with re hospitalization score Measurement period likely to begin July 2016 Improving Medicare Post Acute Care Transformation (IMPACT) Act of 2014 Requires Standardized Patient Assessment Data for: Assessment and Quality Measures Quality care and improved outcomes Discharge Planning Interoperability Care coordination IMPACT Act of 2014 Standardization of Data Elements OASIS C HCBS CARE IRF PAI MDS 3.0 Data Elements LTCH CARE Data Set 3
Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 Two physician payment pathways MIPS Physician Quality Reporting System (PQRS) Value Based Modifier Program Meaningful Use APMs Accountable Care Organizations (ACOs) Episodic based Payments Patient Centered Medical Homes (PCMHs) THE ROAD TO ACCOUNTABLE CARE 4
Health Care Reform Brings New Focus on Post Acute Care Tremendous Variation in PAC Spending Provides Opportunity for Value Creation PAC Only, 73% Diagnostic Tests, 14% Procedures, 14% Drugs, 9% Acute Care Only, 27% If regional variation in PAC spending did not exist, Medicare spending variation would fall by 73% Source: Variation in Health Care Spending, Institute of Medicine, October 2013 Four Models of BPCI Types of Services Included in Bundle Model 1 Acute Hospital Stay Only Model 2 Acute Hospital + Post-Acute Model 3 Post-Acute Care Only Model 4 Acute Hospital Stay + Readmissions Inpatient hospital and physician services Related post acute care services Post acute care services Related readmissions Other services defined in the bundle (Part A & Part B) Awardees as of January 2016 11 409/288 700/100/ 9 9 5
Target Price: SNF as episode initiator (Sample Case Study) 21.2% 90 day readmission rate 50.5% received HH at $3,203/episode 34 days LOS at $527/day Historic bundled Price = Mandatory 3% savings = Projected target price = $25,144 $754 $24,390 OR less Orthopedics Example: Bundling Changes Use of Acute and Post Acute BPCI vs. CCJR: key differences 6
Today s Medicare ACO s Value Based Purchasing MSPB: Medicare Spending Per Beneficiary 7
BUNDLED PAYMENTS: WHAT HAVE WE LEARNED? By : Jake Arrastia VP Strategy Development jrarrastia@4signatureservice.com 609 356 3915 The Triple Aim. Conundrum Patient Experience Quality of Care Cost of Care Population Health Financial Episodic Care Clinical The Link Between Clinical & Financial SNF Stay HHA Episode (22 days at $550/day) (34 days at $3400) MD Visits (~$2100 in charges) ED or Readmit SNF Stay #2 (3 days at $550/day) Out Patient SNF Home Health Day 1 Day 90 i. MD Visits ii. Labs iii. Out patient procedures iv. DME i. MD Visits ii. Infusions iii. Labs iv. Out patient procedures v. DME i. Labs ii. Out patient procedures iii. DME Other costs 8
Readmissions: Acute and Post acute blindside Based on our own data, 30 day % readmission is in the low teens Actual claims data paint a vastly different story 58% of all readmissions occurred after patient was DC from SNF provider Food for thought. 1. How can therapy truly prepare a patient to make sure they thrive after discharge BPCI: manage frequent fliers Only 5% of all SNF patients will have more than 1 readmission. But they account for 41% of readmission cost and 26% of the total cost of care Food for thought. 1. Conventional skilled care does not work for these patients. What is the appropriate level of care for these patients? 2. How do you identify these patients? BPCI: creating LOS tracks To achieve the triple aim, there are incentives for managing LOS The longer we keep a patient in the SNF. The lower the readmission rate becomes. The higher the total cost of care gets Food for thought. 1. When forced to manage LOS, which therapy deliver model achieves the highest functional gain for the lowest cost of care? 9
BPCI: non skilled care 21% of all SNF patients will die within the 90 day episode of care period and only 40% of these patients received end of life care 100% of these patients received skilled rehab care to restore and/or improve function Food for thought. 1. What should the treatment strategy have been for the patients?... Remediation vs. compensation? 2. How do you identify these patients? Food for thought Is the framework for healthcare delivery shifting / changing / evolving? Will there be a shift in how we deliver rehabilitation? To remain viable, what kind of delivery model should rehab. evolve to? CLINICAL APPLICATION 10
But What About Quality? Quality Front and Center Implement Evidence- Based Interventions Reduce Variability Remove Waste Maximize Outcome Measure Outcomes Consistent data on all patients Means to stratify data based on important characteristics Study interventions 11
Implement Evidence Based Interventions Knowledge To Action CJR Knowledge To Action Guiding Principles Patients who do not return to symmetrical movement and weight bearing have worse outcomes in the long run Emphasizes interventions to promote muscle activation weight bearing normalize gait kinematics Short term compensatory strategies to expedite discharge to home 12
Interventions to Promote Muscle Activation and Strength Interventions to Promote Weight Bearing and Normal Gait Kinematics Interventions for Other Mobility 13
Reduce Variability Remove Waste Maximize Outcome 14