Survival in the Rapidly Changing Health Care Industry LeadingAge Iowa Board Meeting September 20, 2016 The Landscape is Changing The Affordable Care Act Medicaid Expansion Balancing Incentive Program Center for Medicare and Medicaid Innovation CMMI Medicare ACOs Medicare Value based Purchasing Medicare Bundled Payment Program 1
The Changing Landscape: Iowa Medicaid Expansion 1115 waiver 138% FPL IA Health Link Balancing Incentive Program 1915 waiver for HCBS Federal Health Insurance Exchange Money Follows the Person Challenges for Providers in New Care and Payment Models Assessing the current service delivery model and how it fits with the value based systems of ACOs, Bundled Payments, PCMH, etc. What outcomes are being achieved? Where are the areas for improvement? What is the core business and what can be done through partnerships? 2
The Triple Aim 3
How Health Care will be Delivered Regional Approach Fewer hospital systems Affiliations and partnerships Risk Sharing becomes important Producing data and outcomes is imperative What does this mean for Health Care Providers? Payment reforms will challenge service delivery reform. Reducing readmissions and length of stay imperative! Reduced hospital and nursing stays, more home care P4P, Bundled payments, capitation PCMH If I keep doing what I m doing I ll be fine This mindset will not work and you may find yourself out of business. 4
Payors will Change Too Quality verses Efficiency Paying for outcomes Providers must take advantage of opportunities to engage with payors to determine what those outcomes are and how they will be paid. Don t assume payors know your business, be ready and willing to educate them how you deliver services and the outcomes you are trying to achieve. It s All About Data Collecting and analyzing data will be imperative for providers. Presenting that data in a meaningful format for your partners whether they be hospitals or payors shows your value to them. Readmissions and Length of Stay the low hanging fruit. 5
The Benefits of a Network Greater visibility and attention by government and commercial payors. We are their priority. Access to state government Medicaid. Ability to identify key quality measures, collect data on those measures, aggregate information and present it in a meaningful way to payors and partners. Network Development Separate LLC each member of the network is an equal partner of the network. The network develops the parameters as to membership. Committees: Finance, Contracting, Quality and Membership Requirements for data collection of quality measures. Dues structure can be based on a variety of factors; unduplicated client numbers, size and type of services, etc. 6
Leading Age Ohio Facilitates Managed Care Networks LeadingAge Ohio had a managed care task force that worked over two years to explore the feasibility of long term care managed care networks to negotiate contracts with payors for commercial, Medicaid, Medicare and ICDS contracts. Ohio Aging Services Network: The first year, OASN had 37 members and about 71 facilities. Currently, Ohio Aging Services Network is made up of 62 LAO members representing 131 facilities across Ohio. OASN Has contracts with all MyCare Ohio plan providers, Medicaid only contracts and contracts with many commercial plans. The network has developed a quality program collecting data on 21 quality measures. Each member reports their data through cpmt so data can be aggregated. OASN has a contract with Discern Health to develop dashboards for each member showing their quality. 7
OASN Budget First Year Total = $200,000 Expenses: Network Administration $84,000 D&O Insurance $ 3,500 Data Collection (cpmt) $55,000 Quality program $20,000 Estimated Taxes $ 3,500 Marketing $ 5,000 Board Meetings $ 3,000 Website $10,000 TOTAL $184,000 OASN Dues Structure Based on type and size of facility. SNF = $1,000 per facility + $35.00/bed AL = No facility fee + $7.00/bed Medicare Certified Home Health Program = $1,000 Adult Day Program = $7.00/licensed capacity 8
OASN Dues Structure Ohio Aging Services Network Membership Fee Calculator Facility Name: Service Type Number Facility Fee Bed Fee Do you have a skilled nursing facility? If yes, enter the number of facilities in Column B If no, enter 0 1 $1,000.00 How many SNF beds do you have? Enter number of beds for all in Column B 100 $ 3,500 Do you have Assisted Living? If yes, enter the number of beds in Column B 50 $ 350 Do you have a Medicare Certified Home Health program? If yes, enter 1,000 in Column C. If not, enter 0 in Column C $1,000.00 Do you have an Adult Daycare Center? If yes, enter the licensed capacity for each facility in Column B If not, enter 0 0 $0.00 TOTAL Annual Fee for OASN Membership > $5,850.00 OASN Value Survey of members after three years showed three consistent values of OASN by the members: Access to payors they could never get to previously. Increase in reimbursement with payors already under contract with (one payor $15/bed day increase). Increase in revenue. One member share that due to getting a payor contract they had never been able to get yielded over $100,000 in new revenue. More than covered their dues of around $10,000/year. 9
Size and Scope of a Network There is no required size of a network. A network should have adequate market presence in major population areas to ensure access of payors members to facilities and services. OASN has good market presence in the Cincinnati, Columbus, Cleveland, Toledo, Dayton, Akron/Canton, Youngstown markets which are the seven major metropolitan markets in Ohio. OASN has members outside of these areas as well. The Indiana Health Services Network has good representation in the Indianapolis, Fort Wayne, South Bend, Evansville and Terra Haute. OASN Quality Program 30 day unplanned readmissions Observation stays ER Visits Return to Community Pressure Ulcers UTIs Falls with Major Injury Flu and Pneumonia vaccines Staffing hours 10
Who are Your Partners? You will do business with others that you never thought you d do business with in the past.just to survive. Faith based communities Social Service Agencies DME Agencies Hospitals Nursing Homes Tear down the silos!! Find those partners who recognize the right time to start care right care, right place, right time. This may take some education 11
Achieving Success Know your costs not your charges!! Know your quality collect data and analyze it. Identifying those services you do best and find partners for other services you don t have to own it all. Know who your partners are and the value the bring to you. Looking Ahead We need to continue challenging ourselves to assess the way we are providing services so we can improve overall health and collect data that is meaningful to our patients and payors. Identify our partners who can help us achieve desired outcomes and develop those relationships. Data, data, data.. 12
Questions?? 13