Date post: | 30-Dec-2015 |
Category: |
Documents |
Upload: | caitlin-kerwick |
View: | 20 times |
Download: | 0 times |
The Future Impact of the Patient Protection and Affordable Care Act on Post Acute and Long Term Care
VAMDA – 2014Verna Sellers, MD, Medical DirectorGeriatric Services and Centra PACE
Lynchburg, Virginia
Speaker Disclosures:
Dr. Sellers has disclosed that she has no relevant financial relationship(s).
Learning Objectives
• Explain the essential components of the 9 titles in the PPACA
• Discuss the goals of PPACA and the implications for Long Term Care
• Identify strategies for medical directors, physicians and other long term care professionals to navigate new wave of healthcare reform utilizing lessons learned from capitated programs
• Describe the Medical Director’s role in maintaining the financial solvency of the nursing Facility.
Drivers for Change: Healthcare Delivery System Reaches Financial Tipping Point
[The HI fund fails the test of short-range financial adequacy, as projected assets drop below one year’s projected expenditures early in 2011]
[The fund also continues to fail the long-range test of close actuarial balance. Medicare’s HI Trust Fund is expected to pay out more in hospital benefits and other expenditures than it receives in income in all future years. The projected date of HI Trust Fund exhaustion is 2024, five years earlier than estimated in last year’s report]
From 2011 Social Security & Medicare Board of Trustees Annual Report…
Source: http://www.ssa.gov/oact/TRSUM/index.html
MedicareMedicare & Social Security Income & Cost Rates
As a % of taxable payroll
The majority of our healthcare dollars are spent on healing as opposed to prevention
The Patient Protection & Affordable Care ActQuality, Affordable Healthcare for All Americans * Health insurance coverage, Federal & State exchanges
The Role of Public Programs * Medicaid Expansion
Improving the Quality & Efficiency of Healthcare * Value-based purchasing, Physician Quality Reporting Initiative, CMS Innovation Center - ACOs, Bundled Payments, Readmission Penalties
Prevention of Chronic Disease & Improving Public Health * Creates Intra-agency Council w/ Specific Funding, School-based Health Clinics, Improved Access for Preventive Care
Healthcare Workforce * Creates Workforce Commission, State Grants for Workforce Development, RN/MD Student Loan Enhancements
Transparency & Integrity Program * Fraud & Abuse
Improving Access to Innovative Medical Therapies * Biologics changes and Enhanced 340B Drug Pricing Access
Community Living Assistance Services & Supports * Establishes an Affordable Federal Long Term Care Insurance Plan
Revenue Provisions * Cadillac Health Plan Tax, New Industry-Specific Federal Fees (taxes), New Taxes on Medical Devices & Cosmetic Proc.
1
2
3
4
5
6
7
8
9
Innovate
Necessity is the Mother of Invention: Time for Innovation
Next 5 – 10 Years
What is Accountable Care? A New Delivery Model?
Patient Centered
Preventive Emphasis
Coordinated Care
Chronic Disease Focused
Major Risk Shift from Payor to
Provider
Capitated Payments
Predictive Modeling
Information Systems: H.I.E.
9
• 1970 New model• 1983 PMPM• 1986 Replication?• 1990 Waivers• 1994 11 PO in 9 states• 1997 BBA • 2000 PACE Expansion• 2006 Rural Expansion• 2007 42 PO in 22 states• 2013 98 PO in 31 states
http://www.chqpr.org/accountablecareorganizations.html
Major Investments in Information Technology:Investing in the exchange of health information and
targeted care management
Health Coaches or Care Managers monitor near
time patient data
Accesses various care levels for more
immediate preventive care
Home & Ambulatory
Care
Transitional Care
Inpatient Care
A New Set of Core Competencies Will Be Required for Provider
Success
Financial Strength and Capital Capacity
Payer Relationship Management
Risk Management
Market Essentiality
Physician Integration
Care Coordination/ Management Infrastructure
Information Technology
Sophistication
Service Delivery System
Rationalization
Cost Effectiveness
Post Acute-LTC
12
VHA Inc. Confidential Information 13
Integration Attributes Key Characteristics of the Best Prepared
Physician/ Hospital Integration
A highly aligned medical staff characterized by shared goals, outcomes-based contractual arrangements, significant planning input, and adequately represented in organizational governance
Care Coordination/ Management Capability
Use of care coordination tools and processes by an empowered and integrated workforce to meet performance goals that are regularly measured and reported
Information Systems Sophistication
An IT platform that supports clinical decision making, information management, facile communications, and access by all stakeholders (physicians, patients, administration) to proper treatment and strategic decision making
Service Distribution System Effectiveness
A rational service distribution system that has accessible primary care and easy access (both physically and through referrals) across the care continuum, delivered in contemporary facilities with contemporary equipment
Cost Structure Management
A right-sized organization-wide cost structure, highlighted by appropriate levels of staffing, capital spending, overhead support, and supply chain costs; constantly reviewed based on comparative peer group studies and benchmarks
Scale and Market Essentiality
Sufficient scale to attract competitive clinical and administrative talent, realize economies, drive marketplace innovation, and be an essential provider to health plans and patients
Brand Identification Well recognized and respected, associated with high quality and service excellence
Payer Relationships/ Contracts
Maintaining strong relationships with payers and the ability to negotiate support for “new era” business practices
Financial Strength/ Capital Capacity
Strong appeal to capital markets through sustained operations, revenue growth, and balance sheet strength
A New Set of Core Competencies Will Be Required for Provider Success
Medicare's bundled payment program overtakes its ACO models
“More than 450 health care organizations in February joined four CMS bundled payment initiatives, seeking to determine whether paying lump sums for episodes of care will lower health care costs without harming care.”
Medicare Bundled PaymentsFrom The Advisory Board, December 23, 2013
Rep. Diane Black (R-Tenn.) and Rep. Richard Neal (D-Mass.) proposed legislation that would expand bundled payments within the Medicare program.
450 Bundled Payment
Plans
62 Hospitals Participating in CMS' Advanced Bundled Payment Model
In Model 4, hospitals agree to an upfront price on the specific DRGs, and CMS pays that specific bundled price to the hospital, which then pays other physicians and caretakers. In essence, Model 4 is the epitome of what bundled payments are to be in the future.
From Becker’s Hospital Review, January 6, 2014Becker’s Hospital Review, December 20, 2013
CINs are a way for hospitals and physicians to work together in managing the health of a population of patients. They are networks of hospitals or health systems and providers that collaborate to develop and sustain clinical initiatives within the CIN. Participants use evidence-based guidelines and share data and patient information in order to coordinate and manage care efficiently. Additionally, the ability to contract as one network with a payer is important for CINs.
Clinically Integrated NetworksFrom Becker’s Hospital Review,
September 13, 2013
Becker’s Hospital Review Article Link:http://www.beckershospitalreview.com/hospital-physician-relationships/9-keys-for-hospitals-building-effective-clinically-integrated-networks.html
Care Transformation -Financing & Care Delivery Must Evolve Together
Global Capitation
Episodic or Bundled
Payments
Basic Fee-for-Services
Am
ou
nt
of
Paym
en
t A
t R
isk
Care Delivery Transformation – System Maturity
Pay For Performance
Arrangements
Care Delivery Transformation
FutureEmergence of the Triple
Aim1. Improve the health of the overall population2. Focus on the experience of
care: * Safe * Effective * Timely * * Efficient * Patient Centered * * Equitable3. At the lowest per-capita cost
Care Navigators
Community-based delivery systems
Information Techology
PASTMaximize Utilization –
Fee For ServiceFragmented care delivery
Limited electronic patient data
Competing financial incentives between providers
Financial rewards for higher utilization
Focus on sick care (recovery)
Right Place at the Right Time?
A Focus on Preventive Medicine and Acute Care AvoidanceAc
uity
Cost of Care
Home monitoring
& Home Care
Patient Centered Medical Home
Urgent Care
Emergency Care
Transitional Care
Centra - A regional not for profit integrated health system serving communities in central Virginia
Acute Care• 3 acute care facilities• 650 licensed beds• 125,000 annual ER visits• 160 employed physicians• 450 active medical staff• 7,000 employees• Level 2 trauma center• Clinical leadership in all major service lines
Post Acute Care
Long Term Acute Care Hsptl
Inpatient Rehab Facility
Palliative Care &
Inpatient Hospice
Free Standing
Skilled Nursing Facilities
Home Health & Hospice Services
P.A.C.E.
Senior Living
Facilities
Emergency Mental Health
InpatientChild/Adol
AdultGeriatric
Residential Treatment:Child/Adol
Chemical Dep
Rivermont Schools
Outpatient Psychiatric
Services
Moving to Value Based Care
Centra’s 2013 Capitated or At-Risk Populations
• Centra Employees & Dependents
• Medicare 30-Day Readmission Penalties: CHF, MI, Pneumonia
• CMMI Bundle II: CHF, Elective Hip/Knee Replacement
• PCHP Medicare Advantage Plan
• Inpatient Medicaid & Indigent Patients
• Commercial payor P$P models
• P.A.C.E. – Lynchburg & Farmville
• Hospice – Lynchburg & Farmville
Self Insured - $30 Mill - 8,500 lives
Penalty Avoidance - $600k – 1,500 lives
Modified Capitation – 900 lives
Modified Capitation – 900/2700 lives
Cost Avoidance – 3,000 lives
Shared Savings
Full Capitation – 200 lives
Modified Capitation – 350 lives
Financial Mechanisms
Episode Cost by Setting by DRG
Hospital = Lynchburg General Hospital
Episode Start Range = 01JUL2008 to 30JUN2009
Exclusions = Partners
Episode Length = 90 Days
Participants = Hospital Only
Condition = Heart Failure
Condition = Heart Failure Setting
Item Statistic TotalIndexHosp.
AcuteHosp.
Readm.RehabHosp.
LongTermHosp. SNF
HomeHealth Other
Total 1. Mean Cost ($) 16,378 6,357 3,443 30 273 3,597 1,161 1,517
Bundled Payments
CMS Initiative 2011Quality Assurance and Process Improvement (QAPI)
• The Patient Protection and Affordable Care Act (ACA) • Many provisions for which CMS is responsible for
implementing.• Survey and Certification Group – Section 6102• Establishment of standards relating to quality assurance
and process improvement.• Purpose of program is to strengthen current
requirements and promote accountability for resident care and safety by nursing facilities.
Multiple Payment Reform Initiatives Point Towards…
Health Systems are building functionality that will reduce acute care admissions
• NCQA Patient Centered Medical Homes• Chronic Disease Clinics• System Care Navigators• Home monitoring
New payment models incentivize hospitals to reduce patient utilization in higher cost settings
Acute Care
LTACH
Inpatient Rehab
Skilled Nursing Fac
Home Health
Assisted Living
Primary Care
$ COST $
PA-LTC Implications
• Who’s patient is it? Multiple providers with differing patient agendas…CIN or hospital-based care management may interfere with SNF medical director.
• SNFs need to take patients directly from ED, earlier from inpatient hospital, keep them a shorter time in SNF, while reducing readmission %.
• MD/SNF contracting with local CIN and/or hospital for triple aim based care models
• SNF MD…how to touch more patients?
What are the Potential SNF Plays?
30-90 DayAvoidable
Readmissions
• Understand your own 30-90 day readmission history • Meet with your health system(s) to understand their readmission issues• Consider co-developing clinical pathways with both referring health systems and quality home care providers• Expand your scope of knowledge beyond SNF discharge• Consider opening a second front door
SNF Avoidance or Shorter SNF
LOS
Increased Transition
ManagementPotentially Avoidable
Admissions
#1 SNF
Hospital Admissions
Non-Acute Admissions
References
1. The Patient Protection and Affordable Care Act, 2012 Accessed at http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
2. McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29:982–990
3. Helton MR, Cohen LW, Zimmerman S, van der Steen JT. Reply to the Letter to the Editor by Bellelli JAMDA - June 2011 (Vol. 12, Issue 5, Page 388, DOI: 10.1016/j.jamda.2011.03.003)
Thank you