Partners in the Continuum of Care: Hospitals and Post-Acute Care Providers Presented to the Wisconsin Association for Home Health Care November 3, 2017 By: Laura Rose WHA Vice President, Policy Development
WHA s Expanding Focus Wisconsin has a strong presence of vertically integrated hospital and health systems, aligning towards a common goal better outcomes. Wisconsin hospitals/health systems care about quality care for patients before, during, and after hospitalization. 3
WHA s Work Beyond the Hospital Walls Reimbursement and Payment Reform o Medicare/Medicaid targeted improvements o Hospital, Physician, Advanced Practice Clinician o MACRA - Medicare Access and CHIP Reauthorization Act Behavioral Health (including Heroin and Opioid Abuse) Workforce Physicians and Practitioners Clinical Performance Improvement Transparency, Information and Analytics Integration of Medical and Dental Care Post-Acute/Discharge Care 4
Example: Post-Acute Care Why are we involved? o Greater integration of hospitals with post-acute care providers is necessary as hospitals become increasingly responsible for outcomes over an episode of care. WHA s Post-Acute Work Group: o Developing policy initiatives aimed at improving the ability of hospitals and health systems to provide or locate postacute care for their patients. 5
Wisconsin Post-Acute Providers LTCH: 5 hospitals; 255 beds IRF: 3 facilities; 121 beds SNF: 372 facilities; 32,854 beds HHA: Approximately 154 agencies Swing bed hospitals: 58 hospitals
Post-Acute Discharges In 2013, 22.3% of all inpatient hospital discharges nationally (7.96 million) were to a post-acute setting. Patients whose payer is Medicare have, by far, the greatest percentage of discharges to post-acute care o Medicare: 41.7% of discharges are to P-AC o Private insurance: 11.7% o Medicaid: 8.1% o Uninsured: 4.8% *AHRQ Healthcare Cost and Utilization Project, Statistical Brief #205, An All-Payer View of Hospital Discharge to Post-Acute Care, 2013, May 2016
MedPAC on Post-Acute Care Medicare payments to P-AC providers are too generous. System encourages providers to increase payments by making certain patient care decisions. Biases in payments systems make certain patients and services provided to them more profitable than others. Despite increased costs, quality of care had not improved. The need for P-AC is not well defined. Medicare per capita spending on P-AC varies more than any other covered services. High Medicare margins relative to other settings. MedPAC Report to Congress, March 2015, ch.7.
Medicare Spending on Post-Acute Care P-AC is fastest growing major Medicare spending category. P-AC Medicare spending grew from $29 billion in 2001 to $59 billion in 2013. In 2013, 50% of P-AC services were provided by home health agencies; 41% by SNFs, and the rest by IRFs or LTACHs. MedPAC Report to the Congress, Ch. 7, March 2015
Wisconsin Medicaid Spending FY 2015 expenditures, Medicaid FFS, all funds, o Nursing homes: $608,800,000* o Home health AND personal care: $966,312,508** Source: *Wisconsin Legislative Fiscal Bureau, Informational Paper #41, Medical Assistance and Related Programs, January 2017. **Kaiser Family Foundation, State Health Facts: Distribution of Fee-for-Service Medicaid Spending on Long Term Care, published 12/2106.
Regulatory Issues LTCHs: 25 day average length of stay rule; reduced payment for certain patients transferred to an LTCH from a particular general acute care hospital. IRFs: 3 hours of therapy/5 days a week minimum; 60% rule SNFs: SNF 3 day stay requirement HHAs: Requirement that patients be homebound in order to qualify for services
Bundled Payments Initiatives Important for P-AC because the expressed goals of bundled approaches to payment are to improve coordination across the providers engaged in caring for a patient during an episode of care and, in turn, improve cost efficiencies or savings. Important for P-AC because payment to providers is based on predetermined expected costs for a group of related health care services, including P- AC.
Bundled Payments for Care Improvement (BPCI) Voluntary, three-year initiative links payments for services related to an episode of care that is triggered by a hospitalization. BPCI allows participants to choose from 48 episodes of care under four different models that provided a mix of episode structures (inpatient only, inpatient plus post-acute care, post-acute care only, etc.). BPCI also provided a mix of payment models. Conditions tested: o Acute Myocardial Infarction (AMI) Model; o Coronary Artery Bypass Graft (CABG) Model; o Surgical Hip and Femur Fracture Treatment (SHFFT) Model; and o Cardiac Rehabilitation (CR) Incentive Payment Model
Comprehensive Care for Joint Replacement (CJR) CJR is mandatory, and tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements (the most common surgeries for Medicare beneficiaries) to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. CMS has implemented the CJR model in 67 geographic areas across the U.S. Wisconsin mandatory participants (except for certain BPCI participants): o Madison, WI: Columbia, Dane, Green, Iowa Counties o Milwaukee-Waukesha-West Allis, WI: Milwaukee, Ozaukee, Washington, Waukesha Counties
Wisconsin CJR Example: Before CJR: 30% of joint replacement patients going home Within 1 year of implementation: Ambulated nearly all patients the day of surgery and sent 80% of patients home. Saw proportional decreases in referral to subacute rehab facilities and the rehab hospital affiliated with PHC. Before CJR: Average length of stay for TKAs was 2.16 days. Within 1 year of implementation: Average length of stay for TKAs was 1.4 days. Complication rates dropped significantly, as did readmission rates. Total costs for TKA dropped significantly. Participation in the CJR bundle drove collaboration between primary care, anesthesiology, and orthopedic surgery to develop protocols for management. We optimized the medical condition of patients prior to surgery. We improved perioperative pain management with a multi-modal approach which markedly decreased the use of opioids.
Next Gen Accountable Care Organizations Goal: To test whether strong financial incentives for ACOs (Accountable Care Organization) can improve health outcomes and lower expenditures in healthcare. Prepares health systems to move more quickly through the corridor from fee-for-service to pay for performance, and be able to take on total risk with certainty.
Wisconsin s Health Systems at the Forefront Two Next Gen ACOs in Wisconsin are working to improve quality, reduce costs and work at managing population health in their service areas. 17
Positive ACO Results Eleven of 18 Next Gen ACOs saw Medicare Shared Savings in 2016: 1. Baroma Health Partners (Miami) $12,254,176 2. Triad HealthCare Network (Greensboro, N.C.) $10,735,910 3. Iowa Health Accountable Care (West Des Moines) $10,527,767 4. Trinity Health ACO (Livonia, Mich.) $6,529,274 5. Deaconess Care Integration (Evansville, Ind.) $5,719,530 6. Pioneer Valley Accountable Care (Springfield, Mass.) $4,683,960 7. Henry Ford Physician ACO (Detroit) $3,938,137 8. Bellin Health Partners (Green Bay, Wis.) $1,400,147 9. ThedaCare ACO (Appleton, Wis.) $1,348,292 10. Prospect ACO (Los Angeles) $938,839 11. Steward Integrated Care Network (Boston) $272,139
Things are changing.. Dr. Tom Price, former Secretary of the Department of Health and Human Services, has been a vocal opponent of mandatory CMS bundled payment programs. CMS issued a proposed rule in August which, among other things: Makes CJR optional in half of the currently participating geographic regions (including Wisconsin) Cancels the Cardiac Rehab Incentive Payment Model and the Episode Payment Models Since the proposed rule was issued, Secretary Price has resigned. Now What?
WHA Responds to CMS Proposal
Opportunities in Post-Acute Care Under a bundled payment or shared savings program, health systems have strong financial incentives not to refer patients to high-intensity post-acute care settings that they don t need. For patients hospitalized with congestive heart failure in 2008, Medicare paid: o $2500 in the 30 days after discharge for each patient who received home health care. o $10,700 for those admitted to a SNF o $15,000 for those admitted to an IRF
Opportunities in Post-Acute Care
WHA s Post-Acute Work Group Goal: To develop a package of achievable policy initiatives aimed at improving the ability of hospitals and health systems to provide or locate post-acute care for their patients. Work Group convened in January, 2017 5 meetings held, to date; next meeting later this fall. Hope to finalize recommendations by year s end.
Issues discussed: Access to Post-Acute Care: Challenges of locating P-AC for complex patients Uneven distribution of P-AC services statewide Swing bed usage Scarcity of P-AC for pediatric patients Workforce issues: All levels Decline in private duty nurse availability Reimbursement: P-AC provider reimbursement rates Durable medical equipment reimbursement issues Impact of bundled payments Creating preferred provider relationships
Issues discussed: Hospital coordination with P-AC providers: Exchange of health information between hospital and P-AC providers Options for using telemedicine in P-AC Transitions of care: best practices End-of-life care planning Transportation to P-AC Regulatory environment Population health: Avoiding hospitalizations in the first place Social determinants of health
Potential recommendations could include: Access to Post-Acute Care: Increase complex patient incentive payments Increase ventilator facility capacity Workforce: Supporting increased reimbursement for P-AC direct care providers: Nursing homes Home health agencies Independent nurses Others Reimbursement: Medicaid reimbursement for P-AC case management, advanced care planning Examine Medicaid program performance in DME reimbursement and availability See Workforce recommendations, above
Potential recommendations could include: Hospital coordination with P-AC providers: Uniform transitions of care planning tool Tools to facilitate exchange of health information Regulatory: Advocate for regulatory changes at state and federal levels Education: Providing educational programming around P-AC: Webinar, toolkit?
Home Health Care Issues and P-AC Pediatric patient with extended hospital length of stay of 90 days. Patient is on a ventilator and private duty nursing cannot be located. Adult patient is ready for discharge from the hospital. She exhibits challenging behaviors, has no family support, and needs intravenous nutrition therapy. She has been waiting in the hospital for 5 months for an appropriate skilled nursing facility placement. 29
Home Health Care Issues and P-AC Private duty nursing: Trend in P-AC is discharge to home, often with home health care, rather than to P-AC facility. Big cost savings with home nursing care vs. a delayed hospital discharge, or discharge to a P-AC facility. But: home nurse pay differential is significant, making recruitment difficult.
Home Health Care Issues and P-AC Personal Care Workers: Decrease in hours authorized by DHS for home care. Personal care reimbursement rate frozen for 10 years; Act 59 provided 2% increase. Will it have an impact?
The Puzzle: How do we create financial and other incentives for for post-acute providers who provide care for complex patients?
Your ideas?