Bundled Payments in Post Acute Care: Put on Your Crash Helmets or Fasten Your Seatbelts

Transcription

1 Bundled Payments in Post Acute Care: Put on Your Crash Helmets or Fasten Your Seatbelts Presented by: Rodney Farley, Vice President of Post Acute Services 5925 Stevenson Avenue Suite G Harrisburg, PA

2 Bundled Payment Overview $300B of Medicare will be spent in alternative payment models by 2018 Current Initiatives Bundled Payment for Care Improvement (BPCI) CMS Participants include SNFs, hospitals, hospitalists, ortho groups and home health agencies $8-10B of healthcare spend

3 Bundled Payment Overview CCJR Program announced in October 2015 and started April hospital participants $3B in healthcare spend Oncology Care Model Participants include oncology groups and hospitals with cancer programs $2B in healthcare spend

4 Provider as Healthcare General Contractor Bundled payment programs create unique new opportunities for specialists and acute care providers to benefit from improved care transition and coordination efforts. Providers responsible for the full episode of care Episode prices established up front Meet episode-specific quality metrics

5 Bundled Patient Continuum

6 Provider Strategic Benefits Increase Net Revenue Significantly increase net revenue per Major Joint Case Enhance Physician Alignment Opportunity to enhance physician alignment & loyalty Low Risk Low-risk way to prepare for other alternative payment initiatives Network Development Facilitates development of a network of preferred post-acute providers Increase Patient Satisfaction Enhances long-term relationship with patients

7 6 Keys to Bundled Payment Success 1 Opportunity Assessment 2 Preferred Provider Network Development 3 Simple Care Management Process 4 Real Time Patient Tracking 5 Claims Data Analytics 6 Integrated Performance Dashboard

8 Keys to Successful Management of Bundles Infrastructure Clinical Operations Transitional Care Visits Post-SNF Discharge Post-SNF Discharge Ancillary Relationships

9 Bundled Payments: Post Acute Setting CURRENT POSSIBLE FUTURE BPCI- Model 3 BPCI- Model 3 Post Acute Episodic Bundle

10 Bundled Payments: Hospital Setting (Upstream) CURRENT DEFINITE FUTURE BPCI- Model 2 Mandated CJR Cardiac More Mandated Bundles Cancer? CHF? COPD? Stroke?

11 Mandated Hospital Bundles: Negative Impact on SNFs

12 Mandated Hospital Bundles: Positive Impact on HH

13 Practical Suggestions for Succeeding in a Bundled Payment Environment Structure the ability to track the patient s health status throughout the 90 day bundle this will take a lot of thought and work operationally. Identify partners that are high-quality providers must obtain and compile data to identify those partners. Understand the importance of data analysis, tracking and execution

14 Practical Suggestions for Succeeding in a Bundled Payment Environment Know your market and make sure you have a seat at the table with those who are participating in bundled payments. Who is involved with BPCI? Which model and bundle selections? Are they developing a network of preferred post acute providers? What are the criteria they are using for selection? What care protocols are they using for BPCI patients? Track and trend key metrics (such as admissions within 24 hours for HH.

15 Church Bulletins Next Sunday Mrs. Vinson will be soloist for the morning service. The pastor will then speak on It s a Terrible Experience.

16 The eighth-graders will be presenting Shakespeare s Hamlet in the church basement on Friday at 7 p.m. The congregation is invited to attend this tragedy.

17 Let us join David and Lisa in the celebration of their wedding and bring their happiness to a conclusion.

18 Mandated Cardiac Bundles: Comparison to Comprehensive Joint Replacement Program CJR Cardiac Lower Extremity Joint Replacements (469 and 470) AMI (280, 281, 282) and CABG (1231, 232, 233, 234, 235, 236) Conditions (MS-DRGs) Effective Date April 1, 2016 July 1, 2018 Risk Period Effective Date January 1, 2017 January 1, 2018 End Date December 31, 2020 December 31, 2021 Episode Length 90 Days 90 Days Locations (MSAs) Mandated Participants Acute Care Hospitals Only Acute Care Hospitals Only Convener Role No No

19 Mandated Cardiac Bundles: Comparison to Comprehensive Joint Replacement Program CJR Cardiac Participation by other provider Maximum 50% shared risk / 25% maximum per provider Maximum 50% shared risk / 25% maximum per provider BPCI Precedence ACO Precedence Next Gen ACO Precedence BPCI Major Joint Replacement of Lower Extremity Bundle has precedence over CJR CJR has Precedence over ACO Next Generation ACO has precedence (proposed) BPCI Model 3 AMI and CABG bundles do not have precedence over Mandated Cardiac Bundles Cardiac bundles have Precedence over ACO Next Generation ACO has precedence

20 Mandated Cardiac Bundles: Comparison to Comprehensive Joint Replacement Program CJR Cardiac Pricing Methodology 2 years at 2/3 Historical, 3rd year at 2/3 Regional, 4th and 5th year at Regional 2 years at 2/3 Historical, 3rd year at 2/3 Regional, 4th and 5th year at Regional Reconciliation Frequency Annual Annual Major Cost Mitigation Opportunity SNF avoidance when appropriate Readmission reduction

21 What is CMS Doing? CMS s strategic direction for Medicare payments Category 1 Fee-for-Service No link to Quality and Value Category 2 Fee-for-Service Link to Quality and Value A Foundational payment for Infrastructure and Operations B Pay for Reporting C Rewards for Performance D Rewards and Penalties for Performance Category 3 APMs Built on Fee-for-Service Architecture A APMs with Upside Gainsharing B APMs with Upside Gainsharing / Downside Risk Category 4 Population-Based Payment A Condition-Specific Population-Based Payment B Comprehensive Population-Based Payment

22 What is CMS Doing? BPCI extends to CJR Which expands to another orthopedic bundle And a heart attack bundle And a bypass surgery bundle And very likely a second round of BPCI Unless superseded by something sexier And certainly a full move to episode models in the future

23 What is CMS Doing? All of these intermediate steps To set the stage for a later complete transition to population health models (i.e., a capitated system) At Federal HHS level, this has full dedicated staff support

24 What is CMS Doing? Added CJR (hip/knee replacements) in April 2016 In July 2017 Adding SHFFT (hip/femur fractures w/o joint replacement) to traditional CJR in the original 67 markets Adding new bundles. AMI (heart attacks) and CABG (bypass surgery) in one third (98) of 294 proposed markets

25 What is CMS Doing Specific to PA? Of PA s 36 CBSAs: 11 cardiac (pre-selected) 4 orthopedic and cardiac (pre-selected) PA currently has 709 SNFs, 537 (76%) of which are in the list of 294 MSAs

26 How Will CJR/EPMs Impact PA SNFs? If you receive a CJR, SHFFT, AMI or CABG case from a hospital in one of these markets Many PA markets in the policy >25% of PA SNFs likely have revenue exposed to the policy Bigger factor is: Hospital behavior

27 PA s SNF Total FY2014 Medicare A Revenue Within the EPMs: AMI, CABG, CJR or SHFFT

28 PA SNFs Most Exposed Markets (>1% of FY2014 SNF-PPS revenue)

29 Exactly How Do EPMs Work? Two orthopedic episodes, and two cardiac episodes CMS has chosen 67 markets for orthopedic, and Will choose 98 of 294 markets cardiac Mandatory participation for hospitals within these markets

30 Exactly How Do EPMs Work? Medicare Part A acute hospitalization in chosen markets for CJR/SHFFT/AMI/CABG Target prices are them calculated based on historical Medicare claims

31 Exactly How Do EPMs Work? Hospitals can waive 3-day stay requirement if they send patient to SNF > 3 stars for 7 of last 12 months SNFs will still get reimbursed on Fee-for-Service, however, not meeting the hospital s cost requirements under episodic payments will deny patient referral to the facility

32 What Will Hospitals Read Into the Data? You need to know and understand your data Some hospitals will analyze your data and make anything of it Your job is to become familiar with your data

33 SNF % of Total Episode Costs with Episode Complexity Not Transfer Case Transfer Case w/o CC/MCC w/cc w/mcc w/o CC/MCC w/cc w/mcc AMI/PCI Episodes AMI, discharged alive 11% 16% 18% 7% 11% 11% PCI w/drug-eluting stent 2% n/a 6% 5% n/a 7% PCI w/non-drug-eluting stent 5% n/a 9% 9% n/a 7% PCI w/o stent 4% n/a 7% n/a n/a n/a AMI transferring to CABG w/ptca n/a n/a n/a n/a n/a n/a AMI transferring to CABG w/cardiac catheter n/a n/a n/a n/a n/a n/a AMI transferring to CABG w/o cardiac catheter n/a n/a n/a n/a n/a n/a CABG Episdes CABG w/ptca 3% n/a 5% n/a n/a n/a CABG w/cardiac catheter 4% n/a 6% n/a n/a n/a CABG w/o cardiac catheter 4% n/a 6% n/a n/a n/a CJR Episodes LEJR w/hip fracture 13% n/a 44% n/a n/a n/a LEJR w/o hip fracture 8% n/a 63% n/a n/a n/a SHFFT Episodes Hip/Femur fracture w/o replacement 39% 42% 38% n/a n/a n/a

34 Percent of Episodes First Referred to SNFs And how did hospitals refer to SNFs for different complexities of case? Not Transfer Case Transfer Case w/o CC/MCC w/cc w/mcc w/o CC/MCC w/cc w/mcc AMI/PCI Episodes AMI, discharged alive 8% 15% 25% 17% 19% 27% PCI w/drug-eluting stent 3% n/a 12% 8% n/a 18% PCI w/non-drug-eluting stent 6% n/a 19% 13% n/a 18% PCI w/o stent 5% n/a 15% 12% n/a 21% AMI transferring to CABG w/ptca n/a n/a n/a n/a n/a n/a AMI transferring to CABG w/cardiac catheter n/a n/a n/a 24% n/a 46% AMI transferring to CABG w/o cardiac catheter n/a n/a n/a 24% n/a 35% CABG Episdes CABG w/ptca 15% n/a 26% n/a n/a n/a CABG w/cardiac catheter 17% n/a 27% n/a n/a n/a CABG w/o cardiac catheter 14% n/a 23% n/a n/a n/a CJR Episodes LEJR w/hip fracture 66% n/a 70% n/a n/a n/a LEJR w/o hip fracture 33% n/a 49% n/a n/a n/a SHFFT Episodes Hip/Femur fracture w/o replacement 60% 69% 72% n/a n/a n/a

35 Percent of Episodes First Referred to SNFs Traditional business lines: orthopedic rehabilitation But also increasing focus on complex rehab of cardiac recovery cases

36 Episodes Referred to Home Health Do you see how the Home Health referral patterns from the episodes differ? Not Transfer Case Transfer Case w/o CC/MCC w/cc w/mcc w/o CC/MCC w/cc w/mcc AMI/PCI Episodes AMI, discharged alive 13% 17% 23% 23% 28% 34% PCI w/drug-eluting stent 8% n/a 18% 16% n/a 32% PCI w/non-drug-eluting stent 11% n/a 20% 23% n/a 38% PCI w/o stent 8% n/a 20% 23% n/a 38% AMI transferring to CABG w/ptca n/a n/a n/a n/a n/a n/a AMI transferring to CABG w/cardiac catheter n/a n/a n/a 52% n/a 37% AMI transferring to CABG w/o cardiac catheter n/a n/a n/a 45% n/a 42% CABG Episdes CABG w/ptca 44% n/a 30% n/a n/a n/a CABG w/cardiac catheter 41% n/a 34% n/a n/a n/a CABG w/o cardiac catheter 40% n/a 35% n/a n/a n/a CJR Episodes LEJR w/hip fracture 7% n/a 4% n/a n/a n/a LEJR w/o hip fracture 44% n/a 25% n/a n/a n/a SHFFT Episodes Hip/Femur fracture w/o replacement 12% 6% 4% n/a n/a n/a

37 More Church Bulletins Diana and Don request your presents at their wedding.

38 The choir invites any member of the congregation who enjoys sinning to join the choir.

39 Hymn: I Love Thee My Ford.

40 Women s Luncheon: Each member bring a sandwich. Polly Phillips will give the medication.

41 Financially Broke, Time for Something New CJR, EPMs, BPCS, ACOs, all forms of Alternative Payments (APMs) attempt to: Decrease Medicare spending while increasing quality

42 Preparing for Change In order for hospitals to be in an upside gain position under CJR/EPMs, they need to reduce costs while improving quality

43 Incentives to Changes Increased volume of admissions through Preferred Provider Networks (PPN) partnerships, as well as 3- day stay waiver Opportunity to receive gain sharing incentives from acute care providers

44 Strategies Six key elements in the portfolio: SNF length of stay SNF re-hospitalization rate Keep your Five Star rating > 3 stars for 7 of last 12 months Manage the hospital s CJR/EPM quality measures Be the competent care coordinator Leverage participation in Model 3 BPCI

45 #1 Manage Hospital Requirements for Shorter LOS Educate Hospital to stop telling patients SNF will get patient back to baseline level of functioning as this should be the task of the HHA ACUTE MYOCARDIAL INFARCTION The DRGs Acute Myocardial Infarction Disease Discharged Alive w/mcc (280) Acute Myocardial Infarction Disease Discharged Alive w/cc (281) Acute Myocardial Infarction Disease Discharged Alive w/o CC/MCC (282) Goal ELOS Days * Discharge Planning Goals Home Health Evaluation Social Work Referral PT Evaluation Functional Goals Patient will be able to ambulate and transfer without Chest Pain or Shortness of Breath

46 #2 - Minimize Your Hospitalization Rates main measure of cost paired with quality #3 Manage Your Five Star Rating Survey readiness throughout the year Comprehensive QAPI

47 #4 Manage the Hospital s Quality Measures Hospital target prices are higher for better quality and almost all of them can be affected by a SNF stay Program and Quality Measure CJR Complications following electrive hip/knee replacement: 1. Mechanical complications - 90 days 2. Wound infection/periprosthetic joint infection (PJI) - 90 days 3. Surgical site bleeding - 30 days 4. Pulmonary embolism - 30 days 5. Death - 30 days 6. AMI - 7 days 7. Pneumonia - 7 days 8. Sepsis/septicemia/shock - 7 days Customer satisfaction about hospital stay (all discharges) SHFFT Same as CJR, plus Hip/knee replacement reported outcomes AMI Mortality Rate (AMI Only) Excess days in ed, readmissions, and observations (AMI only) Customer satisfaction about hospital stay (all discharges) CABG Mortality Rate (CABG Only) Customer satisfaction about hospital stay (all discharges) Reference Period 90 days post hospitalization 90 days post hospitalization 30 days post hospitalization 30 days post hospitalization 30 days post hospitalization 7 days post hospitalization 7 days post hospitalization 7 days post hospitalization Hospitalization 9-12 months post hospitalization 30 days post hospitalization 30 days post hospitalization Hospitalization 30 days post hospitalization Hospitalization SNF Opportunity Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No

48 #5 Be the Competent Care Coordinator Manage the patient within the SNF stay and post SNF discharge

49 #6 Leverage Participation in Model 3 BPCI BPCI Models 2 and 3 take precedence over CJR and EPMs Creating a strategic opportunity for SNF providers participating in BPCI

50 Drive Change Don t Just Change Take relentless aggressive action to preserving and increasing post acute admissions Go to the hospital and demonstrate how you can bring value to their financial success with CJR - Don t wait for the hospital to come see you

51 More Church Bulletins Announcement in the church bulletin for a National PRAYER & FASTING conference: The cost for attending the Fasting and Prayer conference includes meals.

52 Weight Watchers will meet at 7 p.m. Please use large double door at the side entrance.

53 For those of you who have children and don't know it, we have a nursery down stairs.

54 Pastor is on vacation. Massages can be given to church secretary.

55 Mandatory Payment Models Pose Risks Letter submitted to Deputy Administrator Patrick Conway and Acting Administrator Andy Slavitt on September 29, 2016 House lawmakers urge CMS to stop making payment models mandatory Source: gov/files/assets/september%2029%2c% %20CMMI%20Letter.pdf

56 Last of the Church Bulletins Eight new choir robes are currently needed, due to the addition of several new members and to the deterioration of some older ones.

57 Rodney Farley Vice President of Post Acute Services LW Consulting, Inc Stevenson Avenue Second Floor Harrisburg, PA Stevenson Avenue Suite G Harrisburg, PA