A Value Based World: Multiple Perspectives Healthcare Association of New York State (HANYS) Courtney Burke Senior Vice President and Chief Strategy Officer Albany Medical Center November 2, 2015
Part I: The Ideal Vision (my old perspective) Healthier New Yorkers (population health) Lower costs Engaged consumers i.e., the Triple Aim Systems, programs, financing, policies that support and value these goals
The Acronyms ACA Affordable Care Act ACO Accountable Care Organizations APC Advanced Primary Care APD All Payer Database BIP Balancing Incentives Program DISCO Developmental Disability Individualized Supports & Care Coordination Organization DSRIP Delivery System Reform Incentive Payment Program FIDA Fully Integrated Dual Advantage HARPS Health and Recovery Plans HH Health Homes (HH) MLTC Managed Long Term Care MRT Medicaid Redesign Team NYSOH New York State of Health PA Prevention Agenda PCMH Patient Centered Medical Home PHIP Population Health Improvement Program PPS Performing Provider System SHINY NY Statewide Health Information Network for New York Systems SHIP New York State Health Innovation Plan SIM State Innovation Model VAP Vital Access Provider VAPAP Vital Access Provider Assistance Program VBP Value Based Payment
The Ingredients Vision ACA/SHIP/PA Resources/incentives DSRIP/VBP Tools/technology/mechanics SHIN NY/APD/NYSOH Organization PPS/ACO/HH/HARP/DISCO/PCMH/MLTC Grass roots buy in PHIP/APC/MRT Time and assistance for transition VAP/Capital/VAPAP
The Overlap ACA ACOs PCMH HH FIDA Prevention Care Coordination Primary Care & Population Health Collaboration, Cooperation Shared Accountability Attention to Behavioral Health Value Based Payment MRT HARP, DISCO Prevention Agenda NYSOH APD SHIN NY SHIP DSRIP (PPS) PHIP
The Source of Funds (SHIP/DSRIP) Strong, expert, coordinated state leadership can create value over the next four years DSRIP Advanced Primary Care Capital Restructuring Prevention Agenda Common Scorecard Rate Review NY State of Health SHIN-NY Currently funded SIM funding Multi payer funding NY SHIP value-based purchasing SIM Testing Grant Statewide leadership Stakeholder alignment Multi-payer business design and support Workforce strategy APD PHIPs
Part II: The New Perspective
Overview of Albany Medical Center
Overview of Albany Medical Center
Albany Medical Center Operating Financial Statistics Comparison to US Teaching Hospitals (N=147) Q4 2014 Albany Medical Center Hospital Median All Hospitals AMC Mean Last 4 Quarters Avg Median All Hospitals Last 4 Quarters Total Margin 0.07 0.07 0.07 0.07 Operating Margin 0.06 0.06 0.06 0.06 Inpatient Revenue as a Percent of Total Revenue 0.69 0.57 0.69 0.57 Total Hospital Discharges 8,425 7,462 8,360 7,316 Total Patient Days 53,684 41,223 52,240 40,664 Average Length of Stay 6.37 5.68 6.25 5.66 Total CMI 1.78 1.75 1.79 1.71 Occupancy Rate 84% 78% 82% 77% Expense per Adjusted Discharge $16,237 $16,477 $15,686 $16,387 CMI Adjusted Expense per Adjusted Discharge $9,113 $9,651 $8,777 $9,640 Hospital Full Time Equivalents 5,697 4,994 5,576 4,881 Hospital Full Time Equivalents per Adjusted Occupied Bed 6.68 5.95 6.69 6.01 CMI Adjusted Hospital Full Time Equivalents per Adjusted Occupied Bed 3.75 3.43 3.74 3.5 Charity Care Cost Share 0.01 0.01 0.01 0.02 Bad Debt $1,097,000 $8,330,665 $2,888,632 $8,169,346
The Financial Reality for Hospitals Source: Financial Challenges Top Healthcare CEO Concerns John Commins, for HealthLeaders Media, January 14, 2014 Among financial concerns, for example, government funding cuts ranked highest, led by inadequate reimbursements for Medicare and Medicaid, followed by an anticipated increase in bad debt due to high deductible health plans, decreasing patient volumes, staffing costs, competition from other providers, and inadequate funding for capital improvements.
Switching Perspective (Reality) The world is actually changing out here A new financial reality Many new financial penalties have come and are coming New financial opportunities exist as the world changes Some provider are thriving, most are struggling We have an old regulatory system, but some opportunity to waive old regulations Timelines are constantly changing, but change is real Systems are still siloed, but providers/organizations are talking Markets are changing, rapidly and geographically
Mergers, partnerships, and changing markets Trinity Trinity University of Vermont Health Network URMC Auburn St. Joseph s { Bassett IHANY St. Peter s Health Partners Greater Hudson Valley Health System Health Quest Montefiore Westchester Medical Center 13
Albany Medical Center Columbia Memorial Health Patient Care Albany Medical Center Columbia Memorial Health Total Licensed Beds 734 192 926 Skilled Nursing Home Beds * 120 Patient Admissions 35,151 5,988 41,139 Patient Days 212,666 31,630 244,296 Observation Cases 3,070 2,271 5,341 Average Length of Stay 6.1 5.3 Average Daily Census 593 87
Albany Medical Center Columbia Memorial Health Patient Care Albany Medical Center Columbia Memorial Health Total Surgical Cases 29,352 3,745 33,097 Case Mix: All Payer 2.39 1.15 Medicare 2.00 1.29 Emergency Dept Visits 72,980 31,047 104,027 Outpatient Visits 771,436 407,573 1,179,009
Albany Medical Center Columbia Memorial Health Workforce Albany Medical Center Columbia Memorial Health Total Full time Equivalent Employees 7,635 1,270 8,905 Employed Physicians 465 68 533 Voluntary Physicians 600 210 810 Basic Science Faculty 113 N/A 113 Residents 433 N/A 433 College Albany Medical Center Columbia Memorial Health Total Graduate Students 191 N/A 191 Medical Students 545 N/A 545 Research Funding $16.0m N/A $16.0m
Albany Medical Center Columbia Memorial Health Financial Statistics Albany Medical Center Columbia Memorial Health Total Unrestricted Revenues $1.107.9m $144.9m $1,252.8m Unrestricted Expenses $1,067.5m $144.1m $1,211.6m
Albany Medical Center and Columbia Memorial Health Main Campuses and off site locations
Albany Medical Center and Saratoga Hospital Main Campuses and off site locations
Albany Medical Center, Columbia Memorial Health and Saratoga Hospital Main Campuses and off site locations
The World of Value Based Care
Changing Payment is Real Source: Healthcare Association of New York State (HANYS)
PART III: How to Survive the New Reality
Understand the World of Population Health Management Population Health Management
Do a Gap Assessment Level of alignment among hospital, physician, clinicians and others Utilization of evidence based practices for quality Financial management, efficiency & productivity Integrated information systems Other: PCP relations, staff development, new contracts quality, VBP
Figure out Where You Fit
Figure How You Fill the Gaps Build Buy Collaborate/Partner 40/60 (Westchester Bon Secours Active parent Clinical affiliation Management Services Organization
Identify Opportunities (behavioral health examples) Source: Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental Illness by Martha Gerrity The Reforming States Group & The Milbank Memorial, 12/14. Individuals with SMI or substance use disorder have higher rates of acute and chronic medical conditions, shorter life expectancies (by an average of 25 years), and worse quality of life than the general medical population. Modifiable risk factors for medical conditions (e.g., smoking, obesity, lack of exercise) and social conditions (e.g., homelessness, poverty, exposure to violence) account for some of the increased risk, but fragmented care increases overall health disparities in these populations. People with SMI and/or substance use disorder frequently have limited access to primary care, due to stigma and environmental factors, and are often underdiagnosed and undertreated. Poor medication management contributes to inappropriate polypharmacy, inadequate medication trials, and inconsistent monitoring of metabolic and other side effects. Individuals with SMI or substance use disorder also have higher utilization of emergency and inpatient resources.
Initially Focus on your Expertise, with an Eye to Expansion / Growth Opportunities Albany Med s expertise Secondary Prevention and Acute care Opportunities for expansion Primary prevention, home care and sub acute Opportunities for growth Palliative and long term care Birth Source: Dr. Ferdinand Venditti Albany Medical Center Death 29
Identify Opportunities (by population) RISK CONTINUUM High Risk Populations (MSSP) 2015 (MSSP Payors) Payor readiness FFS FFS & Incentives (up only) (up/down) Shared Savings (up side only) Bundled payments Shared Savings (up and Down) Partial Capitation Full Capitation (PMPM fee) Insurance Risk (PMPM medical risk, plus insurance company) Pain Management Asthma Mental Health/ Substance Abuse Injury Prevention People Process Technology Regulatory Partnerships Owner
Identify Opportunities (by department) RISK CONTINUUM Urology 2015 (MSSP) (MSSP Payors) Payor readiness FFS FFS & Incentives (up only) (up/down) Shared Savings (up side only) Bundled payments Shared Savings (up and Down) Partial Capitation Full Capitation (PMPM fee) Insurance Risk (PMPM medical risk, plus insurance company) Radical Prostatectomy Partial Nephrectomy Total Cystectomy Nephrectomy People Process Technology Regulatory Partnerships Owner
Use Data to Inform Decisions Source: Healthcare Association of New York State (HANYS) DataGen Administrative Data Payer Data Internal Data Community Health Data Mandatory Statecollected data Medicaid/Medicare EMR System Census/Inter census Survey Agency for Healthcare Quality Research H CUP Direct from Payer Billing System Public Health Data CDC, etc. APCD RHIO/HIE Claims Aggregators Self insured Program Consulting Firms
Decide How Much Risk You Can Absorb Source: Healthcare Association of NYS (HANYS) Type Financial Requirement Who Conducts Review? Interaction with DSRIP VBP Insurance License Escrow Deposit 5% of annual projected medical expenses Contingent Reserve Requirement 7.25% of premium income DFS and DOH Prepaid Capitation Downside Risk Upside Risk Pay for Performance Financial Security Deposit (FSD) of 12.5%* DFS Level 3 If withhold is more than 25% of total payments: Positive Net Worth No FSD DOH Level 2 Negative Net Worth 12.5% FSD* If bonus is more than 25% of total payments: Positive Net Worth No FSD DOH Level 1 Negative Net Worth 12.5 % FSD* Nothing required DOH Level 0
Decide How to Capture the Value Source: Healthcare Association of NYS (HANYS) Splitting the premium Earning the whole premium More than the premium Plan partnership Insurance license New disruptors
Pick a Collaborative Care Management Intervention Model (Organized by the Chronic Care Model) Components of the Chronic Specific Features of the Interventions Care Model Delivery System Redesign Care/case management* or integrated practices Medical care, mental health, or CD enhancement (on site or off site by appropriate specialists) to provide Supervision of care managers Direct patient care when needed Education and consultation Screening Patient Self Management Support (often delivered by care managers) Decision Support Clinical Information Systems Educational programs (e.g., Life Goals Program) and materials Goal setting Motivational interviewing Systematic follow up of symptoms and adherence to treatment Links to community resources (e.g., travel, housing) Treatment algorithms and guidelines Expert advice from specialists Patient registry Refill monitoring through pharmacy databases to assure adherence Care manager functions include coordination and communication among health care providers, systematic follow up with structured monitoring of symptoms and treatment adherence, patient education and self management support including motivational interviewing. Source: http://nyshealthfoundation.org/uploads/resources/integrating primary care behavioral health settings milbank memorial fund.pdf
Decide Which Programs Are the Best Fit for Your Organization (Medicare) Bundled payments for care improvement initiatives Comprehensive primary care initiatives Federally qualified health center advanced primary care practice demonstration Pioneer ACO (or other ACO) Medicare Shared Savings Program Medicare Advantage (arrangement with private health plans)
Know WHY Your Organization is Making These Changes (as learned from attending the Kaufman Hall Conference in Chicago on 10/22 23/15) Don t be Blockbuster when you could be Netflix Know the value proposition What will happen if Uber comes to healthcare? Maybe it is already here. Why would someone invest millions to build a new health facility in the Grand Caymans? Doesn t the Patient deserve better care and better value?
Additional Recommendations Know your strengths, and others shortcomings Know your limits Know your market and its trends Don t just understand the new lingo/acronyms: DRGs, APGs, risk corridors, VBP, IDS, CIN, etc. figure out how to make them a reality Use DSRIP to begin to build an infrastructure Figure out whether to build, buy, or partner because Use your expertise (e.g., care management, insurance, specialties) Build an organizational structure that supports your work Develop a plan to integrate advanced primary care and providers that support the social determinants of health
It Can Work: The Maryland Example Source: National Public Radio story 10/23/15 The pilot worked, and in January 2014, after 18 months of negotiations between Maryland and the federal authorities, global budgeting went statewide. It was voluntary for hospitals, but within six months every hospital in the state had signed up. Now, nearly two years into the five year agreement, the Centers for Medicare and Medicaid Services says that hospitals are well on track to hit targets. Under the deal, Maryland has to save $330 million for Medicare over five years and reduce hospital readmission rates all while improving the overall health of residents. The Maryland Hospital Association says in the first year alone, cost savings topped more than $100 million, and hospital readmissions were down at a rate faster than the national average.
What Will it Be? Seize the RIGHT moment.or
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CONTACT INFORMATION Courtney Burke Senior Vice President and Chief Strategy Officer Albany Medical Center 43 New Scotland Avenue (518) 262 9590