PHCA Webinar January 30, 2014 Latsha Davis & McKenna, P.C. Kimber L. Latsha, Esq. 1
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Intended to: Encourage the development of ACOs in Medicare Promotes accountability for a patient population and coordinates items and services under Parts A & B Encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery Shared savings program Goals implemented through ACOs: 1. better care for individuals (safety & patient-centered care) 2. better health for populations (preventive services & education) 3. lower growth in expenditures 3
Groups of professionals (both providers of services and suppliers) who collaborate to manage and coordinate care for Medicare feefor-service beneficiaries ACOs that meet certain quality performance standards qualify to receive shared savings payments. The MSSP aims to reward quality of work rather than quantity of patients, by aligning payment incentives with successes in efficiency and cost control mechanisms through innovative integrated healthcare. 4
Under PPACA 3022(2), eligible ACOs must: be accountable for the quality, cost, and care of its assigned patients. participate in the program for a minimum of three years. have a formal legal structure that facilitates the receipt and distribution of shared service payments to applicable recipients. have sufficient primary care professionals to care for its assigned Medicare fee-for-service beneficiaries which will number at least 5,000. continually provide requested information to the Secretary. have a leadership and management structure that includes clinical and administrative systems. promote evidence-based medicine and patient engagement, coordinate care, and report on quality and cost measures. demonstrate satisfaction of patient-centeredness criteria. 5
Individual FFS claims Awarded fixed percentage of shared savings ACOs determine allocation of savings among participants Cannot screen at-risk beneficiaries to minimize cost 6
Benchmarking Monitoring and Reporting Performance Improvement Tools EHR Performance Based Compensation Productivity, quality and improvement 7
Establish, implement and periodically update its processes and infrastructure for its ACO participants and ACO providers/suppliers to report on quality and cost metrics to enable the ACO to monitor, provide feedback and evaluate ACO participants and providers/suppliers performance so as to improve care and service over time 8
Must define care coordination processes across and among primary care physicians, specialists, and acute and post-acute providers, and define methods to mange care throughout an episode of care and during transitions 9
Must meet both quality and savings requirements Achieve savings compared to the expenditure benchmark that exceed minimum savings rate One-sided risk model No pay-back risk for first term of Agreement Share 50% of savings up to 10% of benchmark Limit loss risk to 10% of benchmark expenditures in subsequent years 10
Assume risk of loss phased in over 3 years to a cap of 10% of benchmark Share in 60% of savings up to 15% of benchmark expenditures 11
REDUCING RE-HOSPITALIZATIONS 12
CMS believes re-hospitalizations are expensive, disruptive and disorienting for frail elders and people with disabilities. Nursing facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between nursing facilities and hospitals, including medication errors and hospital-acquired infections. CMS research on Medicare-Medicaid enrollees in nursing facilities found that approximately 45% of hospital admissions among those receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005. 13
CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: CMS demonstration program that rewards providers for preventing re-hospitalizations CMS will partner with, and support, enhanced care and coordination providers (non-nursing facility organizations) that implement evidence-based interventions that improve care and lower cost by avoiding preventable hospitalization. Applicants/Participants must partner with SNF/NFs LOIs from Medicare- and Medicaid-certified SNF/NFs agreeing to participate At least 15 SNF/NFs in the same state with an average census of 100 residents or more 14
CMS chose 7 organizations to participate in the demonstration program: Alabama Quality Assurance Foundation Alabama Alegent Health Nebraska HealthInsight of Nevada Indiana University Indiana The Curators of the University of Missouri Missouri The Greater New York Hospital Foundation, Inc. New York City UPMC Community Provider Services - Pennsylvania 15
CMS is not prescribing a specific clinical model. However, all interventions must include the following activities: Hire staff who maintain a physical presence at NF and partner with NF staff to implement preventive services; Work in cooperation with existing providers; Facilitate residents transitions to and from inpatient hospitals and NFs; Provide support for improved communication and coordination among existing providers; Coordinate and improve management and monitoring of prescription drugs, including psychotropic drugs; Demonstrate a strong evidence base; Demonstrate strong potential for replication and sustainability in other communities and institutions; Supplement (rather than replace) existing care provided by NF staff; Allow for participation by NF residents without any need for residents or their families to change providers or enroll in a health plan. 16
Hospital reimbursement will be adjusted based on re-hospitalizations Participants will partner with SNFs that can help them achieve goals Interventions will be evaluated for their effectiveness in meeting the objectives and providing residents with a better care experience. This initiative is expected to last for four years from August 2012 to August 2016. 17
Hospital Readmissions Reduction Program (HRRP) began in FY 2013 (October 2012) Rule applies only to patients with Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) In FY 2014, CMS added (October 2013) Coronary Artery Bypass Graphs (CABG) Chronic Obstructive Pulmonary Disease (COPD) 18
Hospital Readmissions Reduction Program (HRRP) An inpatient admission by a general acute care hospital ( ACH ) of a patient discharged from the same or different ACH within 30 days preceding the readmission may result in a reduction of Medicare payments to the ACH that initially treated the patient Complex formula to determine the amount of the payment reduction to the original ACH for readmissions exceeding a hospital-specific, riskadjusted ratio based on each applicable condition. Readmissions exceeding the ratio are excess readmissions. HRRP will downwardly adjust Medicare payment to ACHs who have excessive readmissions 19
INTERACT (Interventions to Reduce Acute Care Transfers Quality improvement program designed to reduce SNF/NF to hospital transfers Developed under contract with CMS Four primary objectives: Early detection of signs and symptoms STOP AND WATCH tool Communication with primary care providers Early management of clinical conditions Discussions with families about hospitalizations Free online tools to achieve objectives available at http://interact2.net/tools.html 20
BUNDLED PAYMENT INITIATIVES 21
CMS demonstration program that links payment for multiple services received by patient for an episode of care Providers decide which episodes of care and which services are bundled Retrospective Payment Types Model 1: Acute Care Hospital Stay only Model 2: Acute Care Hospital and Post-Acute Stay Model 3: Post-Acute Care Stay only Prospective Payment Types Model 4: Acute Care Hospital Stay only 22
Retrospective Payment Bundling, in general CMS and providers set a target payment amount for a defined episode of care Applicants/Participants propose the target price, which is set by applying a discount to total costs for a similar episode of care based on historical data Participants paid for services under original Medicare FFS system, but at a negotiated discount At the end of the episode, total payments are compared with the target price Participating providers may then be able to share in those savings 23
Model 2 Acute Care Hospital and Post-Acute Stay Episode of care includes inpatient stay and post-acute care Provider has choice of ending at a minimum of either 30, 60 or 90 days after discharge CMS requires minimum discount of 3% for 30-89 days post-discharge episode and 2% for 90 days or longer episode 24
Model 3: Post-Acute Care Stay only Episode of care begins at discharge from inpatient stay Ends no sooner than 30 days after discharge 25
In both Model 2 and Model 3 Bundle would include physicians services, care by a post-acute provider, related readmissions, and other services proposed in episode definition, such as lab services, DMEPOS, and Part B drugs Target price discounted from an amount based on historical FFS payments for the episode CMS will provide to applicants the historical medical data Payments made at usual FFS payment rates, after which aggregate Medicare payment for the episode is reconciled against the target price Any reduction in expenditures beyond the discount reflected in the target price is paid to participants 26
LTC PARTICIPATION IN HEALTH CARE REFORM 27
How Can Post-Acute Providers Participate in the Health Care Reform Movement by Integrating Their Operations with Hospitals and ACOs Develop preferred discharge provider status relationship with Hospital Contract as an ACO provider Contract with third party payors (e.g. Medicare Advantage Plans) 28
Regulatory and Clinical Requirements/Expectations for Post- Acute Participation in ACOs and Integration with Acute Care Providers and Third Party Payors (e.g. Medicare Advantage Plans) Licensing Reimbursement Credentialing Greater integration with physicians and utilization of physician extenders 29
Getting Paid for Participation in Health Care Reform and Integration with Acute Care Costs of integration Payment Shared savings & MSSP Preservation of Medicare revenue 30
Fraud and Abuse Compliance Difference between FFS and risk sharing incentives ACO waivers for participants for Stark, AKS and Gainsharing Structuring contractual relations for compliance 31
Risk Management In Avoiding Unnecessary Re-hospitalizations and Achieving Shared Savings Clinical and regulatory requirements for meeting higher acuity resident care needs Response of nursing staff and attending physicians to change in condition and/or end-of-life condition Education of staff Education of resident and resident families/representatives Use of physician extenders Role of Advanced Directives Role of Hospice providers Staffing requirements to meet resident care needs Evidence-based medicine, clinical documentation and measurement of meeting the resident s needs When is re-hospitalization necessary? 32
Kimber L. Latsha, Esq. Latsha Davis & McKenna, P.C. 1700 Bent Creek Blvd., Suite 140 Mechanicsburg, PA 17050 717-620-2424 Fax - 717-620-2444 klatsha@ldylaw.com 33
Long-Term Care & Acute Care: An Essential Partnership Geoffrey W. Eddowes SVP Post Acute Care gweddowe@lghealth.org February 25, 2014 1
Setting the Stage for Healthcare Reform Unsustainable Cost of Care Overall Economic Conditions Public Shift on Healthcare 2
Healthcare Reform Because Health Care is No Longer Affordable Healthcare represents 18% of GDP today Projected to grow to 25% by 2025 2007 health care expenditures reached $2.2 trillion 2018 projection is $4.4 trillion Cost Shifting is out of balance The question is no longer whether we need health care reform but how to design and implement it to produce improved and intentional outcomes. 3
Spending Increases 4
Move Toward Accountable Care Environments The confluence of these factors will drive fundamental changes in the way healthcare is delivered and the economics supporting it. 5
Accountable Care Implementation Creating the Framework Establishing the Governance Structure -- Administrative Leader -- Medical Director -- Board of Directors Establishing Effective Partnerships -- Participants -- Suppliers 6
Lancaster General Health Accountable Care Framework 7
ACO Partnership Criteria How do we create objective criteria for an optimal partnership Creating an assessment tool JAMDA Article (11/12) - Partner Prioritization Variable Additional criteria to assess compatibility 8
Partner Prioritization Variable 1. Annual discharge volume. - Volume of patients reflects current patient / physician preferences and relationships. 2. 30-day all-cause readmissions rate. - Reflects SNF s ability to care for patients post discharge. A measure of quality of care and comfort /aptitude of staff. 3. Medicare nursing home compare overall 5-star rating. - Public information available related to inspections, staffing and quality of care. * must be a priority in your organization 9
Partner Prioritization Variable 4. Affiliation of SNF s medical director. - Network alignment or employment reflects ability of Network to influence clinical quality. 5. Level of network s employed physician presence at SNF. - Network panel size and patient management by Network physicians reflects ability to develop programs and extend partnerships. 6. SNF s current participation in network-sponsored programs and meetings. - Indicator of SNF s interest and engagement in mutual topics. 10
Additional Partnership Criteria Compatibility with Payers / Open Access Are you open to multiple payor sources Access / Bed Availability Are beds available beyond the needs of your own residents IT Integration Access and connectivity to the patient record 11
Additional Partnership Criteria Cultural Fit / Alignment with Mission and Vision Do we share a common mission and vision for the community Patient Experience / Reputation in Community Are patients and families pleased with care provided 12
Additional Partnership Criteria Geographic Location Strategic locations to support patient needs Multiple Levels of Care Availability of specialized care and therapies 13
Additional Partnership Criteria Minimize Length of Stay Fewer acute care days Fewer in-patient skilled nursing days Seek opportunities for home-based services Value Proposition / Cost of Care Know and manage cost of care 14