Transcript Monthly Census Analysis

Impacts of Payment Model Reform
in Hospice and Home Health
Molly Smith, Visiting Nurse Associations of America
Lillian Hummel, Avalere Heath
Patrick Brown, Penn Care at Home
Agenda
•
Welcome & Introductions
•
New Payment Models & the Role of Home Health & Hospice
•
2016 Medicare Payment Reforms for Home Health &
Hospice
•
Discussion: The Future of Payment Reform & Implications for
Home-based Care Providers
•
Audience Q & A
Evolving Payment Reform Models:
Prepared for LeadingAge Annual
Conference
Avalere Health | An Inovalon Company
November 1, 2015
About Avalere Health
Reach and Influence
●
Extensive Fortune 500 client roster
●
Sought-after by national and trade outlets
for our independent voice and analysis
●
Featured speaker at national industry
conferences and webinars
Customer Overview
Informing the Discussion
KAISER HEALTH NEWS
January 14, 2015
Health-Law Test To Cut Readmissions Lacks Early Results
Company Overview
●
Presently 250+ employees
November 28, 2013
Large discrepancies found in Medicare spending on
post-hospital care
●
Singularly focused on healthcare
●
Wholly owned subsidiary of
October 24, 2014
Bulk of Medicaid to be managed care in two years: Avalere
●
Founded in March 2000
5
Momentum Accelerating as HHS Sets Targets Linking
Payments to Performance
NEARLY HALF OF ALL FEE-FOR-SERVICE PAYMENTS WILL BE MADE UNDER
ALTERNATIVE PAYMENT MODELS BY 2018
2018
2016
100%
85%
30%
100%
90%
50%
All
Medicare
FFS
FFS
Linked to
Quality
Alternative
Payment
Models
All
Medicare
FFS
FFS
Linked to
Quality
Alternative
Payment
Models
FFS Tied to Quality: At least a portion of payments vary based on the quality or efficiency of health
care delivery (e.g. Hospital VBP, Physician Value-Based Modifier)
Alternative Payment Models: Some or all payment linked to effective management of a population
or episode of care (e.g. ACOs, medical homes, bundled payment)
6
Why do Policymakers and Hospitals Continue to Focus on
Post-Acute Care?
High degree of variation in
spending
Critical to achieving positive
performance on VPB
measures
(readmissions, MSPB)
Instrumental in improving
bundling performance as
hospital is paid based on set
DRG / opportunity in PAC
(and hospital does not have
to reduce its own revenue)
Substantial dollars in PAC
7
Dramatic Increases in Alternative Payment Model (APM)
Participation
FROM 2009-2015, DRAMATIC INCREASE IN PARTICIPATION IN MEDICARE APMs
2009
2015
Medicare Advantage
~24% of enrollees1
~30% of enrollees and
growing1
Medicare ACOs
None
400+2
Bundled Payments
None
2,000+ organizations
participating in BPCI3
Patient Centered Medical
Homes
Limited
8000+ NCQA accredited
PCMHs4
Duals Demonstrations
None
15 States participating in
Financial Alignment Initiative5
ACO: Accountable Care Organization; APM: Alternative Payment Model; BPCI: Bundled Payments for Care Improvement Initiative
Sources: 1. Congressional Budget Office’s March 2015 Medicare baseline. CBO report. Mar 9, 2015.; 2. Shared savings program. CMS website.
Accessed Jul 7, 2015.; 3. Bundled payments for care improvement (BPCI) initiative: http://innovation.cms.gov/initiatives/BundledPayments/index.html Accessed August 17, 2015. 4. Robeznieks A. Reform update: Medical home adoption growing; evidence of effectiveness
still elusive. Modern Healthcare. Aug 18, 2014. 5. Financial alignment initiative. CMMI website. Accessed Jul 6, 2015
8
Shifting Greater Financial Risk to Providers Core Element of
Payment and Delivery Innovations
PRESENT
PAST
FUTURE?
Full
Capitation
Partial Capitation
Episodic Bundles
Shared Savings
VBP
FFS
● New payment and delivery models seek to shift
risk to providers in an effort to improve quality of
care and decrease healthcare spending
● Many of these models attempt to move away
from FFS to paying for “value over volume”
● Some models continue to pay for services on a
fee-for-service basis
VBP: Value-based payment
FFS: Fee-for-service
9
Value-Based Care Systems Have Direct Implications
on Providers
GREATER MA, APMs, AND VALUE-BASED PURCHASING WILL DRIVE:
Fewer FFS
Patients
Shorter
LOS for Facilities
Fewer
Readmissions
Less Use of
Costly Settings
Payers, Providers, and Patients will Have Higher Expectations for Quality,
Value and Service Delivery
APM: Alternative Payment Model; FFS: Fee-for-Service; LOS: Length of Stay; MA: Medicare Advantage
Sources: 1. Green L, et al. Pioneer ACO evaluation findings from performance years one and two. L&M Policy Research: prepared for
CMS. Mar 10, 2015.; 2. Dummit L, et al. CMS bundled payments for care improvement (BPCI) initiative models 2-4: Year 1 evaluation &
monitoring annual report. LewinGroup: prepared for CMS. Feb 2015.; 3. Congressional Budget Office’s March 2015 Medicare baseline.
CBO report. Mar 9, 2015.
10
Alternative Payment Models are Transforming Relationships
Narrowing Networks
Gainsharing Among
Providers
PAC Providers Pushing
Value & Risk Upstream
Providers being chosen as
preferred partners based on
quality performance and
expectations
Providers sharing gains (and
losses) based on performance
against quality and spending
targets with upstream and
downstream providers
PAC providers are bearing risk
with hospitals, payers and
physician groups to manage
quality and cost of PAC
Demand of Meeting
Quality Expectations
New Players Emerging
Meeting expectations for quality
performance increasingly tied to
referral volume and/or payment
levels by many partners.
Integrators and Conveners are
emerging that bring together
providers to share risk and
reward under new payment
models.
11
Role of Home Health Agency Varies by Market and
Provider
Initial Patient Destinations Following an
Inpatient Hospital Stay,
Medicare Beneficiaries in 2013
Market Dynamics
• Variation in PAC Utilization
• Who Are the Dominant Players
• Degree of Market Movement
towards APMs and Managed Care
100%
80%
13.8%
20.2%
15.2%
National
MA
MI
8.2%
60%
40%
20%
0%
Agency Characteristics
•Ownership
 Independent agencies
 Hospital-based
 Integrated Post-Acute Care
Provider
•Size/Scale/Resources
•Mission
Community
Source: Avalere Health, LLC analysis of Medicare Standard Analytic Files, 2013. See
http://ahhqi.org/images/uploads/AHHQI_2015_Chartbook_FINAL_October.pdf
SNF
HHA
IRF
Death
OR
Other
LTACH
12
What Should Providers Do Now?
PAC PROVIDERS ARE AT DIFFERENT STATES OF READINESS TO ACCEPT RISK; ALL PROVIDERS SHOULD
BEGIN ACQUIRING BASELINE CAPABILITIES; THOSE PARTICIPATING IN APMs SHOULD ACHIEVE “ADVANCED
STAGE” CAPABILITIES
Baseline
Advanced Stage
Health Information
Technology
Transition to all electronic documentation;
Capturing value-driven data metrics in
standardized way
Patient medical information in enterprise-wide
EHR;
Data analytics to identify patients/interventions;
Telehealth for post-discharge monitoring
Clinical Operations
Processes for coordinating transitions between
settings of care;
Interventions that prevent exacerbations of
conditions and/or readmissions
Evidence-based guidelines and clinical
decision support;
Post-discharge follow-up care navigation and
longitudinal care planning & assessment
Business Operations
Integrating cost data into financial systems to
track patient level costs;
Tracking performance of downstream providers
Value-Based Contracts with other public and
private payers;
Provider Scorecards;
Focus on episodic cost and population health
management
Network
Development
Assess providers in the market to identify likely
partners;
Assess market position as a viable network
partner for other upstream providers
Narrow network of physicians, post-acute
partners to manage financial and clinical risk;
Leverage network strength to increase
volumes, negotiate with vendors, improve payer
contracting
13
Questions?
Lilly Hummel
Senior Manager, Avalere Health
[email protected]
202-207-1328
14
PENN WISSAHICKON HOSPICE
2016 MEDICARE PAYMENT ANALYSIS
2015 LeadingAge Annual Meeting
November 1, 2015
2016 Final Payment Rule
 Final Rule estimates a 1.1% increase in Medicare Hospice
payments
 Rule provides for a blended implementation of New Labor
Market Delineations
 Two key implementation dates
• Effective October 1, 2015
– Updated payment rates
– Wage-index adjustment transition
• Effective January 1, 2016
– New routine home care (RHC) rates
– New service intensity add-on (SIA) payment
16
16
Medicare Payment Rates by Level of Care
Level of
Care
Labor
Portion
Non-labor
Portion
Final
Rate*
RHC
$111.23
$50.66
$161.89
Continuous Care (per
hour)
$27.05
$12.32
$39.37
Inpatient respite
$90.64
$76.81
$167.45
General inpatient care
(GIP)
$460.94
$259.17
$720.11
17
17
2016 Final Payment Rule
 Initial (“New”) rate
• Applies to days one through 60 of hospice “episode of care”
– Episode of care considered continuous if 60 days or less between
hospice benefit periods
 Subsequent (“Old”) rate
• Applies to days 61 & after of hospice episode of care
– New episode of care occurs after 60 days from last hospice
service date
 No special claim coding required
 Claim edits will determine applicable payment rate
18
18
Fiscal Year 2016 Modeling
Program created three separate models to
determine impact of new payment methodology:
• Six month analysis to look at overall impact
• Monthly census analysis to look at January impact
• SIA model
19
Six Month Model
Six Month Analysis:
 Reviews patient discharges over a six
month period to determine overall impact of
proposed rule.
 Calculates reimbursement for cumulative
period of time on program.
 Model does not adjust for days where
patient received General Inpatient Care or
Continuous Care
20
Six Month Model Excerpt
Patient Length of Stay, in Days
Daily Weight
1
30
60
61
90
120
150
179
180
181
182
210
240
270
300
365
117.8%
117.8%
117.8%
117.3%
108.9%
104.4%
101.8%
100.1%
100.0%
100.0%
99.9%
98.7%
97.8%
97.0%
96.5%
95.5%
21
Six Month Model: Examples
Agency One Model
Patient Death
Patient Discharge
Total Patient Days
Average Length of Stay
Percentage of
Total Days on
Current
Hospice
Reimbursement
4,152
103.81%
2,671
98.19%
6,823
101.61%
68.23
Agency Two Model
Patient Death
Patient Discharge
Total Patient Days
Average Length of Stay
Percentage of
Total Days on
Current
Hospice
Reimbursement
5,486
100.55%
5,323
97.75%
10,809
99.17%
108.09
22
Monthly Census Analysis
 CMS, in the Final Rule, indicated that:
“we believe that the most appropriate
approach is to calculate the patient's episode
day count based on the total number of days
the patient has been receiving hospice care,
separated by no more than a 60 day gap in
hospice care, regardless of level of care or
whether those days were billable or not. This
calculation would include hospice days that
occurred prior to January 1, 2016.”
23
Monthly Census Analysis:
 Monthly Census model looks at the
Financial Impact if the 2015 census for a
given month was reimbursed under the new
rule.
 Census defines patients as “new” or “old”
based on admission date; patients also
identified as “transitional” if the patient may
transition during the month from days in the
1-60 day period to days in the 61+ period.
24
Notes on Monthly Census Analysis
 Model first determined whether patients with
prior admissions should have the prior
episode days added to the total.
 Model backed out any days for General
Inpatient Care or Continuous Care
25
Monthly Census Analysis
FY 16 Payment
Analysis
Monthly Census
Current Month
Admissions
Prior Month
Admissions (New
Patients)
Prior Admissions
(Transition Patients)
Prior Admissions (Old
Patients)
Number of
Days
Weight
Payment
Days
Percentage Percentage
949
1,112.78
117.26%
20.71%
998
1,170.23
117.26%
21.78%
646
689.18
106.68%
14.10%
1,989
1,832.79
92.15%
43.41%
4,582
4,804.99
104.87%
100.00%
26
Transitional Patient Calculation
Patient Status
Transition Period,
Discharge
Transition Period,
Discharge
Transition Period,
Discharge
Transition Period,
Discharge
Transition Period,
Discharge
Transition Period,
Deceased
Transition Period,
Deceased
Transition Period,
Deceased
Transition Period,
Deceased
Transition Period,
Continuing
Transition Period,
Continuing
Transition Period,
Continuing
Transition Period,
Continuing
Days on
Program
Weight
Total Days
“61 Plus" Days
“1-60" Days
6/4/2015 8/3/2015
2
104.7%
61.00
1.00
1.00
6/24/2015 8/9/2015
8
117.3%
47.00
0.00
8.00
6/16/2015 8/14/2015
13
117.3%
60.00
0.00
13.00
6/10/2015 8/27/2015
26
98.9%
79.00
19.00
7.00
6/9/2015 8/31/2015
30
97.2%
84.00
24.00
6.00
6/23/2015 8/1/2015
1
117.3%
40.00
0.00
1.00
6/26/2015 8/5/2015
5
117.3%
41.00
0.00
5.00
6/10/2015 8/6/2015
6
117.3%
58.00
0.00
6.00
6/19/2015 8/28/2015
28
107.4%
71.00
11.00
17.00
6/24/2015
31
110.0%
69.00
9.00
22.00
6/24/2015
31
110.0%
69.00
9.00
22.00
6/11/2015
31
99.4%
82.00
22.00
9.00
6/29/2015
31
114.0%
64.00
4.00
27.00
Admit
Discharge
27
Service Intensity (SIA) Payment
 Service intensity add-on (SIA) payment
 End of life payment add-on
 Applies only during last seven days of life when patient is
discharged deceased
 Applies only to RHC level of care
 Applies only to visits by registered nurses (RNs) or medical
social workers (MSWs)
• LPN visits do not qualify
• MSW phone calls do not qualify
 Payment equal to the Continuous Care rate, paid in fifteen
minute increments up to four hours per day
28
SIA Analysis
 Payments effective January 1, 2016 incorporate a budget
neutrality factor to offset the anticipated cost of the SIA
adjustment.
 SIA adjustment is calculated for both payment periods:
o Adjustment factor of .9806 (1.94% reduction) for days 1-60
o Adjustment factor of .9957 (0.43% reduction) for days 61+
29
Rate Comparison
FFY 2016
Calculation
Routine Home
Care
Labor Portion
OctoberDecember
January 2016 Rates
RHC Payment Rate
Labor Related Share
New Rate Differential
Budget Neutrality
Factor
Market Basket
Net Labor Rate
Total Amount
99.78% $137.68 99.78%
100.00% $137.68 100.00%
86.40% $137.68 59.80%
$95.28
$95.28
$95.28
$111.23
Non-Labor Rate
Non-Labor Portion
Days 160
Days 61+
$159.34
$159.34
68.71% $109.48 68.71%
$109.48
126.03% $137.98 87.22%
$95.49
$50.66
$161.89
$49.86 31.29%
$49.86
Labor Plus Non-Labor
117.69% $187.54 91.09%
$145.14
SIA Adjustment Factor
98.06% $183.90 99.57%
$144.51
101.60% $186.84 101.60%
$146.83
Hospice Update
Percentage
31.29%
30
SIA Analysis: Budget Neutrality Reduction
 Note the projected financial impact for the monthly model
based on the number of days and the SIA reduction for each
period
FY 16 Payment
Analysis
Monthly Census
New Patients
Old Patients
Total Days
2,321
2,261
4,582
Budget
Neutrality
Factor
$3.64
$0.63
$8,448.44
$1,424.43
$9,872.87
31
SIA Analysis (continued)
 Patient Monthly Census review:
Status
Active
Death
Discharge
Number
135
83
36
Percentage
53.15%
32.68%
14.17%
Grand Total
254
100.00%
32
SIA Calculation
 Penn Wissahickon Hospice estimates that each patient who
died on program will receive 240 minutes of care eligible for
SIA.
 SIA payments are estimated as follows:
SIA Payment
Continuous Care Rate
Fifteen Minute Increment:
SIA Payment per patient
Patients Eligible for SIA
Total SIA Payment
$944.79
$9.84
$157.47
66
$10,392.69
33
Key Points:
 Penn Wissahickon Hospice will benefit from
the revised payment model, in that PWH has
a lower than average percentage of patients
where the LOS exceeds 180 days.
 PWH will not be materially impacted by the
inclusion of prior period days when the new
Payment Model takes effect in January,
2016.
 PWH will marginally benefit from the SIA
analysis. The majority of patients received
visits, with the average number of SIA visits
3.77 per patient.
34
35
Medicare Home Health
Value-Based Purchasing Model
Molly Smith
Vice President, Policy and Innovation
November 1, 2015
Performance
Measurement
• All HHAs in nine states: Arizona, Florida, Iowa, Maryland,
Massachusetts, Nebraska, North Carolina, Tennessee, and Washington
• Only HHAs certified for less than 6 months and with fewer than 20
cases per year exempt
• 24 measures: 6 Process / 15 Outcome / 3 New
• Better of achievement or improvement
• Comparison by state /size cohort (large/small)
Financial
Impact
Applicability
Home Health Value-Based Purchasing Model
• Budget neutral overall
• Between 3 and 8 percent of payments at risk over life of program
• Lower-performing HHAs receive lower payments than what would
have been reimbursed under traditional FFS Medicare
Implementation Timeline
Summer
2017:
First
Quarterly
Performance
Report
Available
Baseline
Performance
Period
Payment
Adjustment
Based on Year
1
Performance
Goes into
Effect
First Draft
Payment
Adjustment
Report
Available; 30
Days to
Submit
Revisions
July 2016:
Jan. – Dec
2015:
Jan. 2018:
(Up to 3%)
Jan. 1, 2016:
Oct. 7, 2016:
Nov. 2017:
Performance
Year 1 Begins
Final Date to
Begin
Reporting on
New
Measures
Final Payment
Adjustment
Report
Available
Why These States?
• Geographic
distribution
• Utilization patterns
• Size of agency
• Proportion of
nonprofit agencies
• Types of
beneficiaries
served, e.g.,
severity, comorbidities, socioeconomic status
Performance
Year
2017
2018
2019
2020
2018
2019
2020
2021
2022
3%
5%
6%
7%
8%
Amount
at Risk
2016
Payment
Year
Incentive / Penalty Range
Example Performance at 5% Range
Source: CMS 2016 Final Home Health Payment Rule
Process
Outcome
1.
Care Management: Types and
Sources of Assistance
2.
Influenza Data Collection Period: 2.
Does this episode of care include 3.
any dates one or between
4.
October 1 and March 31?
5.
Influenza Immunization Received
6.
for Current Flu Season*
3.
1.
New Measures
Improvement in AmbulationLocomotion*
1.
Influenza Vaccination Coverage
for Home Health Care Personnel
Improvement in Bed Transferring*
2.
Herpes Zoster (Shingles)
Vaccination: Has the patient ever
received the shingles
vaccination?
3.
Advanced Care Plan
Improvement in Bathing*
Improvement in Dyspnea*
Discharge to Community
Acute Care Hospitalization*
4.
Pneumococcal Polysaccharide
Vaccine Ever Received
7.
Emergency Department Use Without
Hospitalization
5.
Reason Pneumococcal vaccine
not received
8.
Improvement in Pain Interfering with
Activity*
6.
Drug Education on All
Medications Provided to
Patient/Caregiver during All
Episodes of Care*
9.
Improvement in Management of Oral
Medications
10. Prior Functioning ADL/IADL
11. Care of Patients**
12. Communications Between Providers
and Patients**
* = Quality of Care
Star Rating
13. Specific Care Issues**
14. Overall Rating of Home Health Care**
15. Willingness to Recommend the
Agency**
** = Patient
Experience of Care
Star Rating
Calculating Points:
Improvement vs. Achievement
Achievement:
Median of all
HHAs’
performance
during the
baseline period
Benchmark:
Mean of the top
decile of all
HHAs’
performance
during the
baseline period
Data / Performance Reports
• Quarterly performance reports
• Private
• 30-day review/reconciliation period
• Annual payment adjustment report
• Private
• 30-day review/reconciliation period
• Annual performance report
• Public
To Be Determined…
• HHVBP learning collaborative
• Quality reporting web-portal
Performance
Measurement
• Expansion of program to additional states/HHAs
• Refinement of measure set, especially to align with IMPACT Act
• Recalibration of measure weights to further direct improvement
efforts
Financial
Impact
Applicability
Possible Future Iterations
• Adjusting payments more frequently than annually
Agency Preparations
Knowing and tracking key financial and clinical
performance data points
Continuous learning processes and accountability at
all staff levels
Partnerships with other providers – clinical and nonclinical
Patient / caregiver engagement strategy
VNAA Healthcare Transformation e-Toolkit
Care Delivery &
Payment
Innovations
Home Health
Compare Star
Ratings
Home Health
Value-based
Purchasing
Demonstration
Program
Payment and Delivery
System 101
Evidence-based Clinical
Guidelines
Evidence-based Clinical
Guidelines
Medicaid 101
Readiness Assessments
Performance Tracking &
Management
Performance Tracking &
Management
Care Delivery
Innovations & Case
Studies
Risk Assessments &
Management Strategies
Care Delivery
Innovations & Case
Studies
Communicating Value
to Model Conveners
Special Issues in
Medicaid
Managed Care
Tips & Resources for
Working with States &
MCOs
Appendix:
Changes: Proposed  Final
• Measure Set
Removed
Measures
10 Process/15 Outcome/4 New  6 Process/15 Outcome/3 New
 Timely Initiation of Care
 Depression assessment conducted
 Pressure Ulcer Prevention and Care
 Adverse Event for Improper Medication
Administration and/or Side Effects
 Multifactor Fall Risk Assessment
Conducted for All Patients who can
Ambulate
• Incentive Penalty Range
2018
2019
2020
2021
2022
5%
5%
6%
8%
8%

2018
2019
2020
2021
2022
3%
5%
6%
7%
8%
• Report Review/Reconciliation Period
10  30 Days
Questions?
Thank you
Molly Smith
[email protected]
571-527-1529
Discussion
• How do we see home health and hospice payment evolving in the
future to further advance value-based payment arrangements?
• What can we expect in terms of the evolution of performance
measurement and reporting?
• What do agencies need to do to prepare clinically and operationally?
• Can/should home-based care providers develop capabilities to accept
greater financial risk? What might that look like, and what would it
take?
• What does it mean to be a good partner in new payment models?
Thank you!