Sharp HealthCare ACO Accountable Care Organizations Implications for Post-Acute Care Thursday, November 8, 2012
Sharp HealthCare Largest health care system in San Diego 2 affiliated medical groups, 7 hospitals, 3 skilled nursing facilities, a health plan, 21 outpatient clinics, 5 urgent care centers, home health, hospice, and home infusion programs Market share leader and only health care system that increased market share each of the past 11 years Largest private employer in San Diego 15,000 employees, 2,600 affiliated physicians, 2,300 volunteers 2
Sharp HealthCare Grew from one hospital in 1955 to an integrated health care delivery system Aligned physician partners Fully integrated information technology systems and infrastructure Centralized system support services Sharp Health Plan, a 65,000 member, Knox Keene licensed commercial health plan Over 25 years experience in managing care under populationbased payment structures 3
Sharp s Population Health Strategy Care coordination and population health management are not new concepts at Sharp 35,000 Senior Enrollees 246,000 Commercial Enrollees 20,000 Commercial ACO Members 32,000 Pioneer ACO Beneficiaries (Medicare) 4
Pioneer ACO Program Offered by the Center for Medicare & Medicaid Innovation ( CMMI ) Designed for health care organizations that are already experienced in coordinating care for patients across care settings Allows these provider groups to move more rapidly from a shared savings payment model to a population-based payment model 5
Goal of CMS ACO Program CMS Shared Savings Program established in the Patient Protection and Affordable Care Act ( PPACA ) with the goal to provide: Three- Part Aim 1. Better care for individuals 2. Better health for populations 3. Lower growth in Medicare expenditures 6
Pioneer ACO Footprint 7
Sharp HealthCare ACO Began January 1, 2012 Collaboration between Sharp HealthCare, SCMG and SRSMG All SRSMG physicians, most SCMG physicians (includes Graybill), and all Sharp hospitals 32,000 aligned beneficiaries 74% with SCMG 26% with SRSMG 8
What Have We Accomplished? Created corporation Named leadership team Developed subcommittee structure Established provider and supplier network Formed governing body, including consumer advocate and patient representative 9
What Have We Learned? Identified Opportunities 63% of 2011 inpatient costs ($78 million) originate from the ED 51% of total Part A claims costs for 2011 ($123 million) are outof-network 150 beneficiaries had 5 or more ED visits in 2011 without a corresponding admit (one beneficiary had 53) 100 beneficiaries had 5 or more hospital admits in 2011 (one beneficiary had 17) 3.5% of beneficiaries generate 21% of Part A paid claims Skilled nursing bed days per 1,000 were 2,608 in 2011 compared to a 5% sample of Medicare fee-for-service beneficiaries in San Diego County of 1,842 (42% higher) 10
Skilled Nursing Internal Audit Calendar 2011 Sharp HealthCare ACO Sharp Medicare Advantage SNF Admits PTMPY SNF Days PTMPY SNF ALOS % of SNF LOS 85+ Days 88 2,608 29.68 4.4% 79 1,439 18.30 0.8% -12% -81% -62% -477% SNF bed days per thousand for the 5% sample of San Diego County Medicare fee-for-service beneficiaries were 1,842 for 2011 11
Skilled Nursing Internal Audit ACO 2011 Claim Analysis* * LOS = 6+ Days Provider Organization Name # Admissions ALOS Frequency Distribution of LOS % 0-45 % 46-60 % 61-84 % 85+ MEK ESCONDIDO, LLC 44 40.23 30% 14% 12% 44% B SPRING VALLEY LLC 57 39.46 29% 26% 29% 17% LIFEHOUSE SAN DIEGO OPERATIONS, LLC 25 39.20 40% 5% 15% 40% GHC OF LA MESA, LLC 87 39.11 36% 14% 24% 26% COUNTRY HILLS HEALTH CARE CENTER 122 39.02 30% 2% 20% 47% B EAST LLC 39 37.67 43% 15% 16% 26% GHC OF NATIONAL CITY II, LLC 72 37.54 40% 28% 22% 10% GHC OF NATIONAL CITY I, LLC 57 35.58 43% 16% 18% 23% MISSION HILLS HEALTH CARE CENTER 14 35.14 49% 0% 31% 20% VILLA RANCHO BERNARDO HEALTH CARE LLC 30 34.20 42% 25% 6% 27% ELM HOLDINGS, LLC 43 33.40 43% 23% 13% 20% PARKWAY MANOR LLC 23 33.39 37% 28% 10% 25% CHASE CARE CENTER 35 33.23 45% 13% 19% 23% WINDSOR HEALTH CARE GOLDEN PALMS LLC 11 32.45 72% 0% 0% 28% GHC OF SANTEE, LLC 58 32.31 59% 20% 10% 11% KOA HOLDINGS, LLC 18 31.83 32% 0% 36% 32% Comparison of Sharp HealthCare ACO ALOS by SNF 12
Skilled Nursing Internal Audit ACO 2011 Claim Analysis* * LOS = 6+ Days Provider Organization Name # Admissions ALOS Frequency Distribution of LOS % 0-45 % 46-60 % 61-84 % 85+ COUNTRY HILLS HEALTH CARE CENTER 122 39.02 30% 2% 20% 47% MEK ESCONDIDO, LLC 44 40.23 30% 14% 12% 44% LIFEHOUSE SAN DIEGO OPERATIONS, LLC 25 39.20 40% 5% 15% 40% KOA HOLDINGS, LLC 18 31.83 32% 0% 36% 32% WINDSOR HEALTH CARE GOLDEN PALMS LLC 11 32.45 72% 0% 0% 28% VILLA RANCHO BERNARDO HEALTH CARE LLC 30 34.20 42% 25% 6% 27% B EAST LLC 39 37.67 43% 15% 16% 26% GHC OF LA MESA, LLC 87 39.11 36% 14% 24% 26% PARKWAY MANOR LLC 23 33.39 37% 28% 10% 25% LEMON GROVE HEALTH ASSOCIATES LLC 78 31.17 43% 19% 15% 23% CHASE CARE CENTER 35 33.23 45% 13% 19% 23% GHC OF NATIONAL CITY I, LLC 57 35.58 43% 16% 18% 23% BIRCH HOLDINGS, LLC 19 23.42 67% 11% 0% 22% Comparison of Sharp HealthCare ACO 85+ ALOS by SNF 13
What Have We Learned? Identified Opportunities Other Pioneer ACOs reported substantial variation in Post-Acute costs Over 1000% Variation for Home Health costs have been reported Large variations in Home Health Cases PTMPY Large variations in Home Health Visits PTMPY Large variations in Home Health Costs reported, by HH Agency Home Health historic baseline utilization and costs were unknown for the Sharp Healthcare ACO 14
Home Health Internal Audit Calendar 2011 Sharp HealthCare ACO Sharp Medicare Advantage HH Cases PTMPY HH Visits PTMPY HH Visits Per Case HH $PBPM 8.5 121 14.3 $16.10 6.3 89 14.1 $11.28-35% -36% -1% -43% HH costs per beneficiary per month have a wide range for Pioneer ACO s 15
Home Health Internal Audit ACO 2011 HHA Claim Analysis - Average Visits per Case, By Agency Home Health Agency Provider Name Average Visits/Case Total Visits Total Cases SHARP MEMORIAL HOSPITAL 13 6,870 539 PALOMAR POMERADO HEALTH 15 5,383 362 MISSION HOME HEALTH OF SAN DIEGO, INC. 13 4,747 362 ADVANTAGE HEALTH SYSTEMS 18 2,956 161 LORIAN HOME SYSTEMS, INC. 16 2,818 174 GENTIVA CERTIFIED HEALTHCARE CORP. 15 2,183 143 NIGHTINGALE HOME CARE, INC. 11 2,119 197 FALLBROOK HOME CARE SERVICES, LLC 22 2,056 92 ACCENTCARE HOME HEALTH OF CALIFORNIA, INC. 12 1,952 166 ALPHA PLUS HOME HEALTH SERVICES 16 1,616 102 WESTERN HEALTH RESOURCES 16 1,121 72 SCRIPPS HEALTH 10 1,037 103 INTEGRITY HEALTHCARE SOLUTIONS, INC. 12 991 82 F&H HEALTH CARE INC. 18 856 48 TENDER LOVING CARE HEALTH CARE SERVICES WESTERN, L 13 851 64 EXCEL HOME HEALTH 12 828 68 SAN DIEGO HOME HEALTH CARE SERVICES, INC 15 827 55 Comparison of Sharp HealthCare ACO Visits/Case by HHA 16
Aim and Primary Drivers Best Health, Best Care, Best Experience Care Delivery Models Care Coordination Patient Engagement Information Technology and Analytics Alignment of Incentives 17
Care Management Programs Program Beneficiaries Touched Hospital Case Management 6,700 21.0% Skilled Nursing Case Management 2,900 9.0% Care Transitions 6,100 19.0% Complex Case Management 480 1.5% Disease Management (CHF) 320 1.0% End-of-Life Care Management 960 3.0% Fully implemented, these programs touch up to 55% of our Sharp HealthCare ACO beneficiaries 18
Post-Acute Care Implications Findings of Pioneer ACOs Reported significant differences in utilization and costs between Medicare Advantage members and Medicare fee-for-service beneficiaries. Between other Pioneer ACOs 1. Home health 2. Skilled nursing 3. Acute rehabilitation 4. Long-term acute care 5. Outpatient Palliative & Hospice Care 19
Post-Acute Care Implications 5 ways healthcare reform affects postacute providers Comparative Effectiveness Expansion of Value-Based Purchasing Incentives for provider collaboration Incentives for non-institutional care Disclosure of financial relationships 20
Post-Acute Care Implications Newly created CMMI Post-Acute Care Action Group Shared expectations and responsibilities between ACOs and post-acute providers Alternative payment systems Demonstration of value by post-acute care providers and capture of part of fund flow Alternative payment arrangements Episode-based management Post-acute care network measures 21
Best Health, Best Care, Best Experience