Transcript Altarum PowerPoint Template 102013

Transition from Volume to
Value Reimbursement,
& MediCaring Communities!
Joanne Lynn, MD
Director, Center for Elder Care & Advanced Illness
April 1, 2016
[email protected]
Altarum Institute integrates independent research and client-centered consulting to
deliver comprehensive, systems-based solutions that improve health and health care.
A nonprofit, Altarum serves clients in both the public and private sectors.
For more information, visit www.altarum.org
The Problem(s)
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Health care costs are distorting the
economy, becoming unsustainable
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Patients and families do not trust the care
system – are often frustrated, fearful, and
angry
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Clinicians are also frustrated, fearful, and
angry
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My Mother’s Broken Back
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“The Cost of a Collapsed Vertebra in Medicare”
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Why?
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Incentives for procedures, more volume
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Disincentives to deal with behavioral and
supportive services
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The American disinclination to accept
disability and death
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PRICES
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What’s been tried – and what’s gone wrong
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Skin in the game – for patients/families (cut high value as much
as low value)
Reducing prices – (hurts current good providers, forces
consolidation, encourages concierge)
Sharing in savings
 Providers (too little, too late, and often out of their control)
 Investors (substantial funds going to investors, not services)
Quality incentives (wrong metrics, small gains and losses)
Now –
Medicare/Medicaid to be value-based payment
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What matters to costly patients in Medicare… elders living with
illness and disability?
Relationships – family, friends, spirituality
 Control, finances, dignity, respect
 Familiarity, meaningfulness, significance
 Comfort
 Confidence
 Survival time
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What do we measure?
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What do we measure in nursing homes?
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Moderate to severe pain
New or worsened pressure ulcers; any pressure ulcers
Flu and pneumococcal vaccine
New anti-psychotic medication; any antipsychotic medication
Increasing need for ADL help
Weight loss
Losing control of bowel or bladder
Urinary catheters
UTIs
Depression
Restraints
Falls with injury
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What more do we measure in home care?
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Improved mobility
Improved bathing
Improved breathing
Improved wounds
Improved understanding of medications
How often the home care team checked on various things
How often – hospitalization, ER use, readmissions
Patient rating of overall care, professionalism, communication
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What’s missing?
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Most of what matters most!
 Customization to patient/family priorities
 Meaningfulness
 Comfort beyond serious pain
 Independence and control
 Finances
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AND a public health perspective – the well-being of frail
elders living in a particular community
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Why?
What should be done?
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The coming of MACRA
MIPS and APMs…for FFS Medicare (probably does not affect
managed care unless tied to FFS)
4 components to the MIPS score –
Quality
Cost
IT
QI
All gains for someone are matched by losses to someone else.
Every clinician wants out of MIPS – APMs give a reliable 5% bonus.
What counts?
 Some Patient-Centered Medical Homes (criteria not clear)
 Some ACOs (maybe requiring downside risk?)
 Some bundles (only with downside risk?)
 And…..?
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Questions to shape the future
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What counts as value-based purchasing??
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What counts as an Alternative Payment
Model?
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Does it matter?
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A winning strategy
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Build a high-reliability model and estimate new expenditures,
avoided expenditures and net savings
Find a way to make it sustainable
Align incentives, including pride in work and by community
For frail elderly people – specifically
 Integrate long-term supportive services and end of life care
 Work within the available funds
 Take responsibility for a geographic community
 Monitor and improve – build a learning organization
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The MediCaring Community Model: Core Elements
1. Frail elders enrolled in a geographic community
2. Longitudinal, person-driven care plans
3. Medical care tailored to frail elders (including at
home)
4. Incorporating health, social, and supportive
services
5. Monitoring and improvement guided by a
Community Board
6. Core funding derived from shared savings from
current medical overuse (e.g., a modified ACO)
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Identification of Frail Elders in Need of Medicaring
Age >65
AND one of the following:
>1 ADL deficit or
Requires constant supervision OR
Expected to meet criteria in 1-2Y
Unless Opt Out
Frail Elderly
Age >85
Want a sensible care system
With Opt In
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Steps in optimal care planning
1.
2.
Targeting
Care Planning
A. Current patient/family situation
B. Likely future situation(s) with various strategies
C. Patient/family priorities – hopes, fears, values – goals
D. Negotiated, patient-driven care plan
E. Available to those who need it, promptly
3. Evaluation and Feedback – system learning
4. Care plan use in system management – supply and quality issues for
community
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The Chronic Care Management Code
List of Elements “typically included” in a Care Plan
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Problem list; expected outcome and prognosis; measureable
treatment goals
Symptom management and planned interventions (including
preventive care)
Community/social services
Plan for care coordination with other providers
Medication management
Responsible individual for each intervention
Requirements for periodic review/revision
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Sad Tale #2 – NY Times Sept 28, 2014
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Mr. Andrey’s Story
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Elderly man, living alone, one daughter who must work – mobility
problems, multiple hospitalizations, Medicaid aides around the clock
Hospitalization – no home care would take him -- Medicaid managed care
Multiple NHs, pressure ulcers, hospitalizations, medication errors
Finally home with aides, but living long meant discontinuation – and
hospice also meant losing aides
Inpatient hospice at the end – no physician, no last rites
Nothing worked – everyone followed the dollars
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The “bottom line” for Mr. Andrey
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Last year included about 4 nursing homes, many more ERs
and hospitalizations
Cost >$1million to Medicare and Medicaid
And he did not get his only wish…
To be at home.
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Geriatricize Medical Care
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Continuity
Reliability, 24/7 to the end of life
Enabling self-management around disabilities
Respecting and including family and other
caregivers
Attend to the burden of medical care
Move services to the home
Prevent falls, wrong actions
Enhancing relationships, activities, meaningfulness
Enduring with persons living with dementia
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Health Care Spending ≠ Health Status
2013 Per Capita Health Services Spending ($US)
-- Top 12 OECD Countries -10,000
8,713
Average = 29th (of 34!)
8,000
6,325
6,000
4,000
2,000
5,862
5,131 4,904
4,819 4,553 4,553
4,351 4,256 4,124
3,939
38% > Swiss spending
81% > avg of other 10
US Rank:
5 OECD Health Stats, 34 Nations
#27 Life Expectancy at Birth
#31 Infant Mortality
#27 Men/Years of Potential Lost Life
#31 Women/Years of Potential Lost Life
#5 Share of Adult Daily Smokers
-
Want your
money back?
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But, We Can’t Afford Social Supports, Right?
2013 Per Capita Spending ($US)
-- Top 12 OECD Countries -18,000
Recall US’s #29
3 ranking?
avg.
Sweden’s
avg. = 5th
2.5
Switzerland is 10th
15,000
12,000
9,000
6,000
3,000
2
6,535
1.5
8,713 11,385 11,139
6,325 5,862
8,209 10,299 8,674 10,928 9,562
6,092 9,363 7,423 5,514
5,131 4,904 4,819 4,553 4,553
4,351 4,256 4,124 3,939
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1
0.5
0
It’s the ratio!
Health Services
Social Services
Social-$ per Health-$
US ratio = 0.75
Avg. of 11 = 1.86
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“The Ratio” in Our Work—Elder Care
The Older Americans Act at 50 –
Community-Based Care in a
Value-Driven Era (NEJM 2015)
Ravi B. Parikh, M.D., M.P.P., Anne Montgomery,
M.S., and Joanne Lynn, M.D.
The Older Americans Act clearly
affirms our Nation’s sense of
responsibility toward the wellbeing of all of our older
citizens….Every State and every
community can now move
toward a coordinated program
of services and opportunities for
our older citizens. We revere
them; we extend them our
affection; we respect them.
Lyndon B. Johnson, 1965
Cumulative % Change
(since 2004)
190
150
186%
110
54%
7%
70
30
-10
2004
2006
2008
Population 65+
2010
2012
Medicare $
2014
2016
2018
2020
Older Americans Act $
The ratio is getting
much worse!
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Disaster for the Frail Elderly: A Root Cause
Social Services
• Funded as safety net
• Under-measured
• Many programs, many
gaps
Medical Services
• Open-ended funding
• Inappropriate
“standard” goals
• Dysfx quality measures
Inappropriate
No
Integrator
Unreliable
Unmanaged
Wasteful “care”
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Äldres läkemedelsanvändning i Jönköpings län
Jonkoping hospitals
and municipalities
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How could local management arise?
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Care Transitions
Age-friendly cities and other urban planning
Local coalition building for healthy communities – CDCengendered coalitions
Public health
Local aging authorities – commissions, offices
Area Agencies on Aging (and Administration for Community
Living)
ACOs
Managed care
And more….
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Frail Elderly People Need Some New Spending…
$ Housing
$ Nutrition
$ Personal Care
$ Caregiver training, respite, income
$$$
$ New drugs and other treatments
$$$
$$$
Where will it come from?
$$$
$$$
$$$
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Estimating Potential Savings in Medical Care
Estimate frail as 10% of >64 population in a
geographic area
 Estimate PMPM total costs (except for unpaid
caregiving)
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 Use CMS HRR and county data for aggregate costs,
population, utilization
 Use sources in literature for LTC costs and small ancillary
costs
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Estimate realistic goals of reducing medical care,
delaying Medicaid, reducing use of nursing homes generally, about half of the maximal effect (e.g., 25%
reduction in hospital, 5% in LTC)
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Estimating Potential Savings in Medical Care
Assume it will take 2 years to get to full impact
 Adjust for expected deaths, assume no mortality
effect
 Adjust for inflation
 Ignore moving in and out of area (assume
balance, and modest)
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MediCaring Communities Financial Simulation:
Utilization Estimates (Akron, OH)
Service
Category
Without
MediCaring
With
MediCaring
Percent Change Absolute
Change
Inpatient
Hospital
$966
$725
-25%
-$242
Outpatient
Hospital
$331
$364
10%
$33
Professional
Primary Care
$270
$351
30%
$81
Skilled Nursing
Facility
$315
$252
-20%
-$63
Medicaidcovered LongTerm Care
$2,307
$2,191
-5%
-$115
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MediCaring Communities Financial Simulation
Per Beneficiary Per Month Savings ($) by Site, Over Time
$600
$537
$500
$467
PBPM Savings ($)
$400
$328
$291
$285
$300
$253
$269
$250
$234
Year 1
$200
$153
$136
$125
Year 2
Year 3
$100
$Akron
Milwaukie
Queens
Williamsburg
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MediCaring Communities Financial Simulation
Return on Investment, Years 1- 3
350%
300%
289%
279%
Return on Investment (%)
250%
200%
150%
148%
Akron
100%
97%
Milwaukie
Queens
Williamsburg
50%
0%
-50%
Year 1
Year 2
Year 3
-100%
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A Winning Possibility: MediCaring ACOs…
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Four geographic communities - 15,000 frail elders
as steady caseload
Conservative estimates of potential savings from
published literature on better care models for frail
elders
Yields $23 million ROI in first 3 years
Net Savings for CMS
Beneficiaries
Before Deducting InKind Costs
After Deducting InKind Costs
Yr 1
Yr 2
Yr 3
3-Yr
-$2,449,889
$10,245,353 $19,567,328 $27,362,791
-$3,478,025
$8,463,101
$17,629,209 $22,614,284
For more on financial estimates, see http://medicaring.org/2013/08/20/medicaring4life/
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NorthStar – What to Aim For
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Fully integrated system, with monitoring and management
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Honest care plans
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Client/family perspective guides system and care
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Adequate supply of critical supportive services
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Medical services routinely attentive to function, comfort, meaningfulness
– available at home, 24/7
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Sustainable – to family, community, and country
Is it value-based?
Is it an APM?
Does it achieve the aims, within budget?
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Engage your representatives!
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Encourage allowing innovation – including some local management
and control
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Require population-based metrics
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Demand appropriate measures of quality
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Develop language that can enable us to deal honestly and sensitively
with frailty and death – join our Party Platform Project (email to
[email protected] )
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Talk with every political leader and wannabe about services and
finances for elders
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The MediCaring Reforms
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The MediCaring Community Model: Core Elements
1. Frail elders enrolled in a geographic community
2. Longitudinal, person-driven care plans
3. Medical care tailored to frail elders (including at
home)
4. Incorporating health, social, and supportive
services
5. Monitoring and improvement guided by a
Community Board
6. Core funding derived from shared savings from
current medical overuse (e.g., a modified ACO)
38
We can have what we want and need
When we are old and frail
But only if we
deliberately build that future!
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