Good-bye
Volume;
Hello Valuepresented by
Irving L. Stackpole
Post-Acute Care
Learning Objectives
Define “value” in healthcare and post-acute care
Describe current reasons for high degree of variance in
post-acute care
Identify information & resources that managers can
and should access to establish programs to improve
value
List partners and models to develop and communicate
an effective program
Describe a 7 step process to build cross-continuum
collaborations
1. What is the “value formula”
in healthcare?
1. Value = Lowest Cost × Best
Outcomes
2. Value = Positive Outcomes –
Untoward Outcomes
3. Value = Quality ÷ Payment
(Total Costs)
4. Value = (Outcomes ×
Efficiency) × Patient
Satisfaction
5. Not sure
Audience Question #1
Volume to Value
Volume - Fee for Service
Value
4
Factors driving the shift from
Volume to Value
Healthcare in the US is too expensive
• Poor outcomes
Pressure in society - consumerism
Rising attention by CMS to PAC
• Mandated data analysis to prove effective
and efficient resource use (VALUE)
5
Copyright © 2017 Stackpole & Associates & Ability Network
Pressure for Aging Services
- Federal Debt as Percent GDP
Source: https://en.wikipedia.org/wiki/National_debt_of_the_United_States#/media/File:51129-land-summaryfigure1(1).png
2. Nursing center utilization
among those over 65 has
been increasing.
1. True
2. False
3. Not sure
Audience Question #2
Copyright © 2017 Stackpole & Associates & Ability Network
The Percent of Population 65+ Using / Needing Skilled Nursing Services
5.21% 5.14%
4.71%
4.21%
3.48%3.23%
2.79%
2.35%
0%
1%
2%
3%
4%
5%
6%
1995 2000 2005 2010 2015 2020 2025 2030
Percent of USA Population using SNF age 65+ using a SNF on a daily basis
Copyright © 2017 Stackpole & Associates & Ability Network
USA Historic / Current / Projected People in SNFs
1,751,302
1,795,388
1,724,582
1,703,398
1,663,365
1,824,056
1,840,988
1,744,279
1,550,000
1,600,000
1,650,000
1,700,000
1,750,000
1,800,000
1,850,000
1,900,000
1995 2000 2005 2010 2015 2020 2025 2030
Current and Forecast Number of SNF Pts Served Daily in USA
Copyright © 2017 Stackpole & Associates & Ability Network
Medicare and Medicaid Nursing Home Expenditures
-$40,000
-$20,000
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
Y1
966
Y1
967
Y1
968
Y1
969
Y1
970
Y1
971
Y1
972
Y1
973
Y1
974
Y1
975
Y1
976
Y1
977
Y1
978
Y1
979
Y1
980
Y1
981
Y1
982
Y1
983
Y1
984
Y1
985
Y1
986
Y1
987
Y1
988
Y1
989
Y1
990
Y1
991
Y1
992
Y1
993
Y1
994
Y1
995
Y1
996
Y1
997
Y1
998
Y1
999
Y2
000
Y2
001
Y2
002
Y2
003
Y2
004
Y2
005
Y2
006
Y2
007
Y2
008
Y2
009
Y2
010
Y2
011
Y2
012
Y2
013
Y2
014
Y2
015
Y2
016
Y2
017
Y2
018
Y2
019
Y2
020
Y2
021
Y2
022
Y2
023
Y2
024
Y2
025
Nu
rsin
g H
om
e E
xp
en
dit
ure
s i
n M
illio
ns (
000)
1966 to 2025 Combined Historic and Projected Medicare and Medicaid Nursing Home Expenditures
Can the growth in funds keep pace with the need?
Medicare & Medicaid total nursing center expenditures are expected to decline as a percentage of overall expenditures.
1. True
2. False
3. Not sure
Audience Question #3
Copyright © 2017 Stackpole & Associates & Ability Network
Nursing Home Care % of Health Expenditures
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
Y1
96
6
Y1
96
8
Y1
97
0
Y1
97
2
Y1
97
4
Y1
97
6
Y1
97
8
Y1
98
0
Y1
98
2
Y1
98
4
Y1
98
6
Y1
98
8
Y1
99
0
Y1
99
2
Y1
99
4
Y1
99
6
Y1
99
8
Y2
00
0
Y2
00
2
Y2
00
4
Y2
00
6
Y2
00
8
Y2
01
0
Y2
01
2
Y2
01
4
Y2
01
6
Y2
01
8
Y2
02
0
Y2
02
2
Y2
02
4
1966 to 2025 Medicare/Medicaid Nursing Home Expenditures Percent of Total National Health Expenditures
Nursing Home Care is now and projected to be 2.6% of US Health Expenditures
4. Why are nursing center occupancies low, and declining?
1. Demographics
2. Patient/consumer
preference
3. Regulatory &
intermediary
constraint
4. All of the above
5. Not sure
Audience Question #4
Stackpole & Associates, Inc.14
2020
Born 1934
85 yoa
2017
Born 1931
85 yoa
2030Born 1945
85 yoa
2045Born 1960
85 yoa
Copyright © 2017 Stackpole & Associates & Ability NetworkCopyright © 2017 Stackpole & Associates & Ability Network
Turbulence in action
• Balance innovation
and value
• Race to the
bottom?
• Protect DSO
• Measurement is
easy outside of the
river
Value – Three Principles
First Principle
• PAC - variance in costs & outcomes =
“waste”
Second Principle
• FFS = misaligned incentives
Third Principle
• Simplify to meet Triple Aim
–Too complex and lacks integration
–No one has responsibility for coordination
16
Increase your value
Integrated care and organized paths!
Integration = coordination and alignment of goals
Integrated environments:
• share clinical data,
• agree on plans of care, and
• collaborate - patient-centered outcomes
Foster care coordination among providers, share
data and track outcomes to measure progress
Technology can help better manage, communicate
and use data
Volume to Value
Volume - Fee for Service
Value
18
Volume or
Value?
The Challenges / WHY?
Volume – Value Shift • High Value Providers thrive
Low occupancy
Declining payments
Three Principles – REMEMBER!
First Principle• Decrease variance & efficiency
Second Principle• Align incentives for best outcomes
Third Principle
• Simplify, integrated care & complexity
21
Steps to the dance…
Leadership
Trust
Shared experiences
Early wins
Inclusive
Data, data, data
“Take your partner by the hand…”
The highest levels of “efficiency” produce the best outcomes for society.
1. True
2. False
3. Not sure
Audience Question #5
Stackpole & Associates, Inc.24
Efficiency
Technical, Productive, Allocative
– TechnicalMaximum improvement from resources
– ProductiveBest health outcome for given costs or
reduction in cost for the same outcome
– AllocativeBest outcomes for society
Focus for Clinical Integration
Focus e.g., quality improvement,
Care coordination - SNF, HHA & PAC
referrals,
Favor efficient providers
Target high-risk individuals & populations
• disease management
COLLABORATION
25
What reduces value?
Fragmentation
• Services are delivered across an increasing array
of distinct and often competing providers and
entities, each with different objectives, obligations,
and capabilities (Cebul et al., 2008).
• Providers practicing within the same geographic
area, sometimes caring for the same patients,
often work independently from and not
communicating with one another (Bodenheimer,
2008; Shih et al., 2008).
• As a fragmented health care delivery system we
are not equipped to manage the continuum of
health care for an aging population with complex
needs.26
Drive Value
– How can we respond?
27
Short Cut – New Rules
Defend, protect & fortify
Increase Productivity / Efficiency
Innovate
Differentiate
Engage v. Bunker
COLLABORATION
Where do we start
How can disparate actors move
effectively from vision to the
implementation of cross-continuum
collaboration?
When no one actor has all the answers
or the authority, the usual committee of
working group isn’t adequate to the task.
Steps to the dance…
Leadership
Trust
Shared experiences
Early wins
Inclusive
Data, data, data
Focus on end-users
“Take your partner by the hand…”
Leadership
Leadership
• Visibility
• Support
• Focus &
• Endurance
• Leadership – measures
6. Trust is best developed in cross-continuum collaborations through:
1. Aligning payment
incentives
2. One-on-one, personal
relationships
3. Visible, charismatic
leadership
4. None of the above
Audience Question #6
Trust
One-on-One
• Reliable
• Transparent
• Personal
Shared Experiences
Integration between / among
• “Walk a mile in my shoes…”
• Work-a-Day / Work-a-Week
• Functional v. management
–Trust, personal
–Early “wins”, durable
Early Wins
Focus on 15 – 30 day victories
• delay to start of home care by 12 hours
OR
• Eliminating readmissions
Which is more likely to have “early win”?
Inclusive
Staff the initiative “inclusively”
NOT the usual position-based staff
• Who is likely to have the insight
• Who handles the phone / text / email
Data, data, data
Measure EVERYTHING
• Qualitative
• Quantitative
Buy Excel tutorials for EVERYONE
The end user
Realities
Occupancies are poor• The age qualified markets are declining
• Increased options / choices
• Negative perception (consumerism)
• The economy
• The role of “Intermediaries”
The need for change is URGENT
“Soft” skills are needed
Realities
Continued pressure on payments
Continued pressure on utilization
Efficiencies & productivity are the
keys to effective differentiation
Collaboration is the “new frontier”
QUESTIONS???
Brill, S. America’s Bitter Pill: Money, politics back room deals, and the fight to fix our broken
health care system. New York: Random House 2015
Dent, H. The Demographic Cliff: How to survive and prosper during the great deflation ahead.
New York. Portfolio/Penguin. 2014, 2015
Emanuel, E. Reinventing American Healthcare: How the affordable care act will improve our
terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error -prone
system. New York: Public Affairs. 2014
Hillestad, S & Berkowitz, E. Health Care Marketing Plans: from strategy to action. Gaithersburg:
Aspen. 1999
Moriates, C., Arora, V. & Shah, N. Understanding Value Based Healthcare. New York, McGraw
Hill Education. 2015
Patterson, P. & Spreng, R. “Modeling the relationship between perceived value, satisfaction and
repurchase intentions in a business-to-business, services context: an empirical examination.”
International Journal of Service Industry Management. Vol. 8 No. 5, 1997: 414-434.
Porter, M. “What is Value in Health Care?” New England Journal of Medicine. N Engl J Med
2010; 363: 2477-2481. December 2010
Reichheld, F. The Loyalty Effect: the hidden force behind growth, profits, and lasting value .
Boston: Harvard University Press. 1991
Roth, A. Who Gets What and Why: The new economics of matchmaking and market design.
Boston, Houghton Mifflin Harcourt. 2015
Stackpole. I. & Ziemba, E. Make Your Marketing P-P-P-P-Perfect, Care Management Matters,
April 2008
Stackpole, I. & Ziemba, E. It’s Not What Your Say – It’s What People Hear!, Care Management
Matters, June, 2008
References
Irving Stackpole
Stackpole & Associates, Inc.
1-617-739-5900, Ext. 11
1-617-719-9530
Stackpole & Associates, Inc.
1. What is the “value formula”
in healthcare?
1. Value = Lowest Cost × Best
Outcomes
2. Value = Positive Outcomes –
Untoward Outcomes
3. Value = Quality ÷ Payment
(Total Costs)
4. Value = (Outcomes ×
Efficiency) × Patient
Satisfaction
5. Not sure
Audience Question #1
2. Nursing center utilization
among those over 65 has
been increasing.
1. True
2. False
3. Not sure
Audience Question #2
Medicare & Medicaid total nursing center expenditures are expected to decline as a percentage of overall expenditures.
1. True
2. False
3. Not sure
Audience Question #3
4. Why are nursing center occupancies low, and declining?
1. Demographics
2. Patient/consumer
preference
3. Regulatory &
intermediary
constraint
4. All of the above
5. Not sure
Audience Question #4
The highest levels of “efficiency” produce the best outcomes for society.
1. True
2. False
3. Not sure
Audience Question #5
6. Trust is best developed in cross-continuum collaborations through:
1. Aligning payment
incentives
2. One-on-one, personal
relationships
3. Visible, charismatic
leadership
4. None of the above
Audience Question #6
Access Code
1580