Using Quality Data to Market to Referral Sources Cindy Mason Change as a Matter of Survival BUSINESS OF HEALTHCARE 2 National Transformation of Healthcare the Affordable Care Act provides CMS the flexibility to implement a wide range of innovations designed to transform the delivery system by paying for value not volume. These innovations include fostering the growth of Accountable Care Organizations, Primary Care Medical Homes, bundled payments for acute and post-acute care, reducing the frequency of readmissions, reducing hospital acquired infections, and reducing fraudulent activity. Source: ASPE Issue Brief Growth In Medicare Spending Per Beneficiary Continues To Hit Historic Lows January 7, 2013 By: Richard Kronick and Rosa Po 3 1
Affordable Care Act The Affordable Care Act is an important factor contributing to slow growth in spending per beneficiary in 2011 and 2012, and is the primary cause of the projections of continued slow growth over the next decade. The Affordable Care Act restrains the rate of growth of payments to Medicare Advantage plans, restrains the rate of growth in unit payments to hospitals and other providers, promotes value-based payment systems, and makes major investments to reduce fraud and abuse. Source: ASPE Issue Brief Growth In Medicare Spending Per Beneficiary Continues To Hit Historic Lows January 7, 2013 By: Richard Kronick and Rosa Po 4 McKnights. www. McKnights.com 5 Collaboration and coordination will be key in remaining a viable participant in the changing health care delivery model. Each level of care must coordinate with the next to prevent fragmented care. Collaboration 6 2
So, what does this mean to us? Hospitals, Managed Care and Accountable Care Organizations are reducing the number of skilled nursing facilities that they partner with 7 What is happening in the industry? Hospitals and accountable care organizations (ACOs) are demanding data driven, statistically based information Hospitals want validated outcomes Facilities that can t provide this info are in Trouble 8 Nursing Homes that can t position themselves as an attractive option to the hospitals in their areas 9 3
Will find themselves on the outside looking in 10 11 What would your organization do if you were no longer given referrals from your main referral hospital? 12 4
QUALITY PARTNERS 13 CMS Innovation Center 14 Triple Aim National Goals Improve Care for Individuals Improve Health for Populations Reduce per capita Costs in healthcare delivery system Copyright Providigm, LLC. 2013 15 5
Service Delivery Models Models must Either reduce spending without reducing the quality of care Or improve the quality of care without increasing spending Not deny or limit the coverage or provision of any benefits CMS.gov, Innovation Models 16 Innovation Model Categories Accountable Care Bundled Payment Primary Care Transformation Initiatives Focused on the Medicaid and CHIP Population 17 Innovation Model Categories Initiatives Focused on the Medicare- Medicaid Enrollees Initiatives to Speed the Adoption of Best Practice Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models 18 6
Accountable Care Organizations Accountable Care Organizations and similar care models are designed to incentivize health care providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality and efficient service delivery. CMS.gov, Innovation Models 19 Accountable Care Organizations ACOs are voluntary groups of physicians, hospitals, and other health care providers that are willing to assume responsibility for the care of a clearly defined population of Medicare beneficiaries attributed to them on the basis of patients' use of primary care services. Source: Making Good on ACOs' Promise The Final Rule for the Medicare Shared Savings Program, Donald M. Berwick, M.D., N Engl J Med 2011; 365:1753-1756, November 10, 2011 20 Medicare Shared Saving Program The Medicare Shared Savings Program, rewards ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. 21 7
Two Risk Sharing Models CMS is implementing both a one-sided model (sharing savings, but not losses, for the entire term of the first agreement) A two-sided model (sharing both savings and losses for the entire term of the agreement), allowing the ACO to opt for one or the other model for their first agreement period. Source: December 21,2012, Accountable Care Organization 2013 Program Analysis Quality Performance Standards Narrative Measure Specifications 22 Two Sided Risk Approach To provide a greater incentive for ACOs to adopt the two-sided approach the maximum sharing percentage based on quality performance is higher for the twosided model. ACOs adopting a two sided model will be eligible for a sharing rate of up to 60 percent, while ACOs in the one-sided model will be eligible for a sharing rate of up to 50 percent. Source: December 21,2012, Accountable Care Organization 2013 Program Analysis Quality Performance Standards Narrative Measure Specifications 23 Will You Win the Race to be a Model Partner? 24 8
Providers of care will be judged by quality metrics. Measurement and decisions based on data and outcomes will become the health care norm. Quality Metrics 25 Like what? Hospital Readmission Rates Customer Satisfaction Data Patient Communication Clinical Outcomes QAPI driven practices 26 SNF Rehospitalization Measure Recommendation Copyright Providigm, LLC. 2013 27 9
SNF Rehospitalization Policy Because a rehospitalization policy would align the incentives of providers across sectors, it represents a stepping stone toward paying for larger bundles of services. Copyright Providigm, LLC. 2013 28 Long phase-in SNF Readmission No financial impact until FY2019 FY 2017 SNF providers given information on performance measure FY2018 measure information public on Nursing Home Compare Data from FY2018 will determine rank AHCA, Congress Passes Doc Fix 29 SNF Readmission 2019 rates cut 2% but money goes into an incentive pool Pool redistributed back based on performance Money not withheld but notice received at the start of the year based on prior performance indicating rate for that year AHCA, Congress Passes Doc Fix 30 10
31 They want the information But how do they want it? 32 33 11
34 How do you summarize your success? Demonstrate outcomes with data Leave them with information they can understand without you there to explain it Keep it as short and as simple as possible 35 HOSPITAL READMISSION RATES 36 12
Hospital Readmission Rates You will need to be able to market yourself to hospitals and managed care partners and show: Your readmission rate What you are doing to track and reduce readmissions That you utilize a comprehensive QA system that helps you monitor all areas of care Copyright Providigm 2012 37 What should you be doing At the very least, know your raw rate of readmissions to the hospital But, realize that risk adjustment is necessary 38 Calculating a Raw Rate of Readmission Numerator Denominator Percentage of Readmissions 39 13
Calculating a Raw Rate of Readmission Numerator: Number of those admissions that returned to the hospital within 30 days of their admission date Denominator: Number of admissions that came to you from a hospital and have had at least 30 days since their admission date 40 Understand that Risk Adjustment is necessary FACILITY A FACILITY B 41 Understand that Risk Adjustment is necessary Rehab Younger Population Low Acuity, Low Risk Long Term Stay Specializes in Cardiac More Elderly, Frail Population High Acuity, High Risk 42 14
Understand that Risk Adjustment is necessary Worse than expected job managing readmissions considering who they care for Their risk adjusted rate would be HIGHER than their actual rate Better than expected job managing readmissions considering who they care for Their risk adjusted rate would be LOWER than their actual rate 43 Understand that Risk Adjustment is necessary Allows benchmarking and comparison in a way that is fair and accurate. Takes into account the types of acuity levels of the residents in a building, as well as their risk for readmission 44 Benchmarks Benchmarking is the comparison of an organization s or individual practitioner s results against a reference point The organization s or practitioner's results remain the same Value can change by comparison to different standards Q Solutions Essential Resousrces for the Healthcare Quality Professional, Information Management, Luc Pelletier and Christy L Beaudin Editor 45 45 15
46 47 CUSTOMER SATISFACTION 48 16
Customer Satisfaction Resident and family satisfaction has always been important. Now, because of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospitals are even more concerned about your satisfaction scores. 49 HCAHPS Hospital s HCAHPS scores began to affect about 30% of their reimbursement in 2013 The HCAHPS measurement reports the quality of care in a hospital as perceived and reported by patients. Because HCAHPS includes questions about transition of care, your satisfaction rating can directly impact your hospital referral partners. 50 51 17
Employee Engagement High rates of employee engagement have been shown to reduce turnover and increase the consistency and quality of care. 52 COMMUNICATION STRATEGY 53 Communication: Patients as Partners Medicare beneficiaries will be partners in care in terms of decision making and health choices. Communication with and education of consumers improves outcomes for consumers and providers. 54 18
Be prepared to discuss communication strategy 55 CLINICAL OUTCOMES 56 Clinical Outcomes Pressure Ulcers Falls Infections UTIs, Vaccinations Community Discharge 57 19
QIs/QMs Fact Sheet of Outcomes Confirmation of data from other measureable data sources 58 59 QAPI 60 20
QAPI Hospitals have been utilizing QAPI practices for years- this is a concept they are familiar with Don t let this opportunity slide- there is a window where you can prove you know more than the rest 61 QAPI: Business Impact Requires collaboration Scientific process of effective change Regulatory compliance Better Quality of Life and Care Better place to live, work and visit Improved Census Copyright Providigm, LLC. 2013 62 QAPI: The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring 21
How do you prove it? What are you measuring against? 64 Where the Rubber Hits the Road Conservative average per patient/ per day reimbursement is $391.78 Source: Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2013. CMS 1446 F. Medicare Program; Prospective payment systems and consolidated billing for skilled nursing facilities for fiscal year 2014. Federal Register 78, no. 151 (August 6): 47936 44978. 65 If providing data to a partner would cause them to refer you even one more patient a quarter $391.78 X 365= $142,999.70 66 22
Let s discuss! What are you doing to become a referral partner? What strategies have worked? What hasn t? What do you have in place to demonstrate your worth in data? 67 For information regarding QIS Education Contact: Cindy Mason, VP Provider Services, Providigm 8055 East Tufts Ave, Suite 1200 Denver, CO 80237 727-403-7423 cmason@providigm.com Copyright Providigm, LLC. 2013 68 For information regarding abaqis Contact: Ellen Sandler, VP Sales and Marketing, Providigm 8055 East Tufts Ave, Suite 1200 Denver, CO 80237 720-240-9920 esandler@providigm.com Copyright Providigm, LLC. 2013 69 23