Redesigning Post-Acute Care: Value Based Payment Models Liz Almeida-Sanborn, MS, PT President Preferred Therapy Solutions This session will address: Discussion of the emergence of voluntary and mandatory bundled programs (BPCI/CJR, Newly proposed mandatory bundles) What PAC Providers (SNFs) can do to prepare Planning successful care transitions Driving Impactful engagement with critical partners in care. Necessary factors for success in a bundled environment 1
ACA/ BPCI/ACO/VBP Response to CMS Triple Aim Value Based Care VALUE = Outcomes Cost 2
Paradigm Shift From Reactive Disease Management Silo-ed Care Fee for Service To Proactive Patient Management Coordinated Care Fee for Value Bundled Payment Care Improvement (BPCI) (Voluntary Program) Launched October 1, 2013 as a CMS demonstration project Moves payments from un-managed FFS model to Episodic Care BPCI involves 179 MS-DRGs (grouped into 48 bundles) Episode begins with hospitalization and (usually) continues for 90 days CMS saves 2-3% per bundle. Participant receives remaining savings estimates 10%-20% 3
BPCI Average Spend Per Bundle - $29,991 SNF, IRF/LTCH, Re-Admission 43% or $13,000 Model 1 Model 2 Model 3 Model 4 Episode All acute patients, all DRGs Selected DRGs, hospital plus post-acute period Selected DRGs, postacute period only Selected DRGs, hospital plus readmissions Services included in the bundle All Part A services paid as part of the MS- DRG payment All non-hospice Part A and B services during the initial inpatient stay, post-acute period & readmissions All nonhospice Part A and B services during the post-acute period & readmissions All non-hospice Part A and B services (including the hospital & physician) during initial inpatient stay & readmissions Payment Retrospective Retrospective Retrospective Prospective 4
High Quality Improved patient outcomes Reduce Costs Re-Hospitalization Length of Stay Preliminary Results of Voluntary Bundles Favorable Answer: Mandatory Bundles 5
Comprehensive Care for Joint Replacement (CJR) Payment Model for Acute Care Hospitals furnishing LE joint replacement services (MANDATORY BUNDLE) CJR Bundled payment model Final Rule published last November, Effective April 1, 2016 67 Geographic Areas (MSA) All related care bundled for 90 days. Mandatory (with very few exceptions) unlike other bundled payment models. 5 year program that applies to ALL acute care hospitals in the selected MSAs. 6
Total Joint Replacements 430,000 TJR (DRG 469 and 470) per year Annual cost of $7 billion 5% of all hospital discharges are TJR Average Medicare expenditure for surgery, hospitalization, and recovery ranges $16,500 - $33,000 depending on geography 7
Summary of Key Provisions (similar to BPCI) CJR puts hospitals at risk for the cost and quality of 90 day episodes of care. Includes procedure, inpatient stay and all post acute services for 90 days. Hospitals and PAC providers paid under the usual payment systems services Year end actual spending compared to hospital specific benchmark. Beneficiaries retain freedom of choice to choose services and providers, but are automatically part of the program. Physicians and hospitals expected to continue to meet current standards required by the Medicare program. Risk bearers cannot be non-medicare providers (Remedy, NaviHealth,etc) Hospital Specific Benchmarks Each year (during the five demonstration years) CMS will set Medicare episode prices for each hospital that includes payment for all related services. (Part A and Part B) Retrospective year end reconciliation Depending on performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending. Upside opportunity for years 1-5; downside risk only for performance years 2-5. Both upside gain and downside risk are limited (stop/loss) Target prices will reflect a blend of regional and individual hospital data Medicare takes 2% discount off the target prices as their savings 8
Target Pricing Key Provisions Hospitals paid a bonus or required to repay Medicare based on quality and efficiency determined by a standard set of quality measures: Complication measure: hospital level complication rate(rscr) Readmission measure: hospital-level 30 day, all-cause Patient experience survey measure: HCAHPS survey 9
CJR is not an expansion of BPCI Hospitals participating in BPCI Models 2 and 4 for LEJR episodes, and acute care hospitals participating in BPCI Model 1 would be excluded from CJR. CMS may move to a nationwide mandatory program versus the voluntary programs that are currently in the testing phase. CMS indicated that they intend to have 1/2 of Medicare payments to go through alternative payment models by 2018. FINANCIAL ARRANGEMENTS CJR Collaborators CJR provisions allow participating hospitals to enter into financial arrangements with providers and suppliers caring for beneficiaries in CJR episodes. Sharing arrangements must be set forth in a written agreement between the hospital and CJR collaborator (referred to as "collaborator agreements"). Eligible providers include: PGPs, physicians, non-physician practitioners, SNFs, HHAs, IRFs, LTCHs, and suppliers of outpatient therapy services. 10
CJR Collaborator Agreements Additional Documentation Required Hospitals Must provide: Documentation of criteria used to select CJR collaborators, and the criteria must include quality of care within CJR episodes. Documentation of methodology used to determine gainsharing amounts, and the methodology must include quality metrics related to care within CJR episodes. Publish on their public websites an accurate and current list of CJR collaborators. Waivers Post-Discharge Home Visits Telehealth Services 3-Day SNF Waiver 11
Beneficiaries Retain the right to obtain care from any qualified Medicare provider, but cannot opt out Hospitals must provide written information about the program Beneficiary exclusions Medicare Advantage members ESRD Medicare is secondary payer What are our referring Hospitals doing to prepare? Determining where they need to focus based on analysis of data. Redesigning care to improve quality, reduce variation and decrease cost across the entire continuum. Aligning providers by creating the right formal/informal agreements that drive impactful engagements to improve care and reduce cost under the bundle. 12
What else are Hospitals doing? Enhancing pre-op programs Better Educating their Patients Looking at long term patient satisfaction Correctly Identify the Patient Care Re- Design Gainsharing Quality Measures Understand the Program VBP Data Analysis 13
Why is this important to us in Post Acute Care? Hospitals are looking for Partners to help them succeed! Building Relationships with Hospitals and Physicians No Patients No Revenue 14
Consider: Patient Volume Quality Management Systems Collaboration across the Continuum Aligning Care with Improvement Opportunities Compare: Facilities, Physicians, Outcomes Care Improvement Opportunities Coordinated Care Standardized care pathways Care transition 15
What Should We Be Doing? Meet with Hospitals: What s their approach to CJR and BPCI? Analyze your data to see trends and opportunities for improvement Clinical integration and transition of care programs (home care relationships, etc) Outcomes measurement and management What should we be looking at? Current market dynamics and your position in the marketplace Current potential opportunity this presents based on hospital size and volume in joint replacements and their diagnosis bundles Your key metrics (Medicare LOS, readmit %, 5-star score, average SNF episode cost) Hospital/Physician point of view Competition Partnership potential 16
Rehabilitation It s all about Care Redesign and training Ensure all licensed clinicians are well educated to manage the patient population targeted by CJR or an ACO or in a bundled project. Formulate fast track therapy programs and schedules to meet the needs of the patient, CJR Hospital, ACO or bundle Discuss barriers to discharge with every department responsible to address their identified issues. Establish IDT plan of care covering entire episode within 48 hours and formally share with all team members and resident Establish functional Care Paths with milestones for each patient Ensure documentation for nursing and therapy occur according to standards and reflect actual resident status What is a Care Pathway? Care pathways establish clear steps for clinicians to guide patient care and to assist in discharge planning Provide expected clinical course that the patient will follow throughout the sub-acute stay Focus on functional progress to guide treatment Use objective standards to facilitate safe discharges and communicate with IDT, patient and family on needs at discharge 17
Remember. You will be rewarded for delivering high-quality, low-cost care and penalized for not. Fiscal performance does not HAVE to suffer with VBP, but will if it is not embraced. Leverage your data and use an opportunity to INNOVATE as a team. Begin to eliminate SILOS! Start NOW: early success = continued cycle of payoff You re in a race to build the highest value care continuum! GO! Questions? Email: lalmeida-sanborn@preftherapy.com Tel # 860-610-0400 18