Transcript 4 - LeadingAge

Navigating Integrated Health
Networks
Strategies to Ensure Mutually
Beneficial Relationships with
Payer
and Provider Networks
3
The Advisory Board is Uniquely Positioned to Help
Research and Relationships at the Intersection of a Dynamic Industry
The Advisory Board Difference
Hospitals
Post-Acute and
Long-Term Care
Providers
Physician
Groups
We are …
 Willing to challenge conventional wisdom
 Devoted to exceeding member
expectations at every turn
And we offer …
Insurers
Nursing Leaders
©2013 The Advisory Board Company • 27604A
Suppliers
3,000+
Hospitals and
Health Systems
200+
1,500+
Independent Physician Post-Acute Care
Facilities and
Practices
Agencies
 Unique visibility into provider CXOs’ world
– challenges, priorities, vendor
perceptions
 Direct access to over 500 in-house health
care experts
200+
5,000+
Health Care Product
and Service
Companies
CXO Relationships
Across the Care
Continuum
4
Addressing the Key Questions of Post-Acute Providers
Becoming the Post-Acute
Partner of Choice
©2013 The Advisory Board Company • 27604A
Navigating the Future of
Post-Acute Care
Industrywide Relationships Offers Unparalleled Perspective on the
Value-Based Post-Acute Environment
Building the Seamless Post-Acute Network
Forging a Sector-Specific Value Proposition
•
• What role should each post-acute sector
assume in a value-based delivery system to
meet evolving delivery system demands?
How can post-acute providers create a
seamless post-discharge solution that appeals
to referrers and payers?
• What partnerships, mergers or affiliations
should be considered to align the right set of
offerings?
• How do post-acute providers build a care
management infrastructure to manage patients
across settings?
• What are the patient populations that should be
prioritized for specialty program development?
• What services and clinical factors differentiate
an organization from competitors?
Generating a Consistent Referral Stream
Developing Meaningful Clinical Capabilities
• What are the latest trends with regards to
post-acute network development?
• What are the clinical competencies that best
meet emerging market demands?
• How are hospitals and physician groups
approaching the creation of post-acute
scorecards?
• What quality tracking and information
technology investments are required to build a
best-in-class care infrastructure?
• Where are patients going following discharge
from the hospital setting?
• How can we upskill our nursing staff and
engage them in key clinical priorities?
5
Road Map
1
A Network-Driven Marketplace
2
The Focus on Cost-Efficient Behavior
3
©2014 The Advisory Board Company • advisory.com
Meeting a Dual Set of Mandates
6
ACA Brings1 Changes in Coverage, Reimbursement
Three Major Components of ACA
Changes in Coverage
Health Insurance
Exchanges
Create online marketplace
where individuals and small
businesses can buy
insurance
Medicaid
Change in Reimbursement
Expansion
Expand Medicaid eligibility
to include individuals and
families with incomes up to
133% of the FPL2
Risk-Based
Payments
Introduce payment and
care delivery models that
ties reimbursement to cost
and quality outcomes
1) Affordable Care Act
2) Federal poverty level
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Advisory Board interviews and analysis.
7
Hospitals Face Outcomes Pressure Even Under “FFS1”
Evolving Hospital Mandates, by Degree of Provider Risk
Total Cost
Risk
• Tightly manage total costs through
value-based referrals and care pathways
• Reduce avoidable hospitalizations
Episodic
Risk
• Tightly manage episodic costs, with new focus on
post-acute care spending
• Secure bundled contracts with cost-sensitive
employers, payers
De Facto Risk • Tightly manage inpatient costs within DRG
(“FFS”) • Maintain revenue integrity in CMS’s mandatory pay-for-performance programs
• Secure inclusion in narrow networks by demonstrating quality, efficiency
Degree of Provider Risk
Hospitals have significant opportunity
to partner with specialists to advance
outcomes in FFS market (e.g., cost per
case, readmissions, length of stay)
Outcomes most critical under
FFS still important under riskbased payment models
1) Fee-for-service.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Physician Executive Council interviews and analysis.
8
Networks A Popular Solution for Today’s Problems
Formation Motivated by a Range of Issues
Variety of Questions Facing Providers, Payers
How do I improve
patient access?
How do I ensure
cross-provider
collaboration?
What steps can I
take to reduce costs?
What can I do to
enhance downstream
quality?
One Common Answer:
Network Formation
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
9
Network Emergence a Widespread Trend
Accountable Care
Alliance
Networks Forming Across the Nation
Provider-led ACO,
including Methodist
Health System and
the Nebraska
Medical Center
Massachusetts
GIC1
Employersponsored
insurance network
for state employees
Anthem Blue
Cross Vivity
AARP
MedicareComplete
Focus
HMO composed of
Anthem Blue
Cross with 7
California health
systems
Medicare Advantage plan
organized by United with
St. Elizabeth and Trihealth
as preferred providers
The Ideal Network
“The best narrow plans would avoid high-cost, low-quality providers, while
still offering customers the services they need...”
New York Times
1) Group Insurance Commission.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: “Anthem, Seven California Health Systems Team Up to Form HMO,” CaliforniaHealthline, www.california
healthline.org/articles/2014/9/17/anthem-teams-up-with-seven-calif-health-systems-to-form-hmo; “UnitedHealthcare
Introduces New Medicare Advantage Plan for Beneficiaries in Cincinnati and Northern Kentucky,” UnitedHealth
Group, www.unitedhealthgroup.com/Newsroom/Articles/Feed/UnitedHealthcare/2014/1017UHCNewMAPlan.aspx;
Gruber J, McKnight R, “Controlling Health Care Costs Through Limited Network Insurance Plans,” NBER Working
Paper Series, no. 20462 (2014), www.nber.org/papers/w20462.pdf; Sanger-Katz M, “Narrow Health Networks:
Maybe They’re Not So Bad,” The Upshot, September 9, 2014, www.nytimes.com/2014/09/10/upshot/narrow-health
-networks-maybe-theyre-not-so-bad.html?abt=0002&abg=0; Post-Acute Care Collaborative interviews and analysis.
10
Early Results of Network Development Positive
Massachusetts Trial Reduces Avoidable Costs, Shifts Utilization
Employee Network Options
Broad Network
Narrow Network
• Free choice
of provider
• Restricted choice
of provider
• More expensive to
employee
and employer
• Less expensive
to employee
and employer
Broad network offers 100%
more physician options,
50% more hospital options
1) Primary Care Physician.
©2014 The Advisory Board Company • advisory.com • 29490A
Narrow Network Lowers Spending
36%
4.2%
Decrease in per
employee medical
spending
Decrease in overall
program spending
Change in Provider Spending Per
Employee Under Narrow Network
28%
Specialist
Outpatient
(45%)
(43%)
Lab
PCP1
(71%)
Source: Gruber J, McKnight R, “Controlling Health Care Costs Through Limited Network
Insurance Plans,” NBER Working Paper Series, no. 20462 (2014), www.nber.org/
papers/w20462.pdf; Post-Acute Care Collaborative interviews and analysis.
11
Bundled Payments for Care Improvement
Physicians and PACs Opting in to BPCI1
Bundled Payments Framework
Providers Participating in BPCI, by Model Type
Primarily
physician groups
or PAC providers
Payer
1329
9
2050
701
Lump sum payment drives
coordination
through shared accountability
11
Model 1
Physicians
Hospitals
©2014 The Advisory Board Company • advisory.com • 29490A
Post-Acute
Model 2
Model 3
Model 4
Total
12
Accountable Care Organizations
©2014 The Advisory Board Company • advisory.com • 29490A
13
ACO Model Continues to Grow Despite Challenges
First Year Performance Results a Mixed Bag
ACO Performance in Medicare Shared
Savings Program
ACOs of All Types Seeing
Strong Participation
First Performance Year
20.5M
Americans enrolled in or
attributed to Medicare,
Medicaid, or commercial ACOs
Did not hold
spending
below
benchmark
24%
52%
52M
Patients treated by ACOs
as of April, 2014
Held spending
below benchmark,
earned shared
savings payment
24%
Held spending
below benchmark,
but did not earn
shared savings
1 in 10
Medicare FFS beneficiaries attributed
to an ACO
©2014 The Advisory Board Company • advisory.com • 29490A
Source: CMS, “More Partnerships Between Doctors and Hospitals Strengthen Coordinated Care for Medicare
Beneficiaries,” December 23, 2013; CMS, “New Affordable Care Act tools and payment models deliver $372
million in savings, improve care,’ September 16, 2014; Post-Acute Care Collaborative interviews and analysis.
14
Medicare Advantage Growth Unlikely to Abate
Precipitating an Individualization of the Medicare Market
Projected Number of Medicare Advantage Enrollees
Millions of Enrollees
29.5% of
Medicare
beneficiaries
19.0M
(1.9%)
Initial proposed 2015
MA1 payment rate cut
10.4M
8.2M
0.4%
Final announced 2015
MA payment rate increase
2009
2020
2013 Projections
1) Medicare Advantage.
©2014 The Advisory Board Company • advisory.com • 29490A
2010 Projections
Source: Hollander C, “CMS to Increase Medicare Advantage Pay Rate By 0.4%,”
ModernHealthcare, April 7, 2014, www.modernhealthcare.com/article/20140407/
NEWS/304079938; Jacobson G, et al., “Projecting Medicare Advantage Enrollment:
Expect the Unexpected?” Kaiser Family Foundation, June 12, 2013, www.kff .org/
medicare/perspective/projecting-medicare-advantage-enrollment-expect-theunexpected/; Post-Acute Care Collaborative interviews and analysis.
15
The Emerging Medicaid Managed Care Environment
Policy Evolution of Medicaid Long-Term Care
III
Dual Eligibles Integration
II
Medicaid Managed LTSS
I
Home and CommunityBased Service Expansion
• New federal funds increase
spending for HCBS1
• States shift balance of
LTSS services toward
non-institutional care
• States adopt managed
long-term services and
supports programs
• MCOs assume state’s role
in managing LTSS
• States partner with CMS to
integrate Medicare/Medicaid
for dual eligible beneficiaries
• MCOs manage Medicare and
Medicaid benefits
Combined Impact:
“Medicalization” of LTC,
primary care provider as
LTSS coordinator
Combined Impact:
Intensified HCBS
demand, LTC rate
and utilization risk
Time
1) Home and Community-Based Services.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
16
Trend #1: Emphasis on the Home Setting
MCOs1 Prioritizing the Home Setting
Ohio Medicaid Actively Transitioning Patients Home
AAAs2 Empowered to Educate Beneficiaries
on Options, Oversee Transitions
Positive Results After
15 Months of Transitions
1,555
1
Identify
potential
candidates for
transition
2
Prioritize
residents with
a high probability
of transition
3
Solicit program
referrals from
SNFs, educate
SNF caregivers
Residents transitioned
into the community
74%
Living residents transitioned into
and still living community
Targeting Those Most Appropriate for Lower-Cost Setting
Focus on Facilities with:
A high proportion of low
case mix residents, as
indicated by the MDS
1) Managed Care Organizations.
2) Area Agency on Aging
©2014 The Advisory Board Company • advisory.com • 29490A
A high volume of residents
who indicate interest in
returning to the community
A high proportion of
residents with stays longer
than three months
Source: Bardo A, et al., “Everyone’s Talking About It, But Does It Work? Nursing Home Diversion and Transition,” J Appl Gerontol
(2013), jag.sagepub.com/content/early/2013/09/30/0733464813505702.abstract; Post-Acute Care Collaborative interviews and analysis.
17
Trend #2: Active, Interventionist Care Managers
MCOs Driving Volumes to Preferred Providers
”
Case Managers Dictating
a De Facto Network
PCPs Preferable for Formal
Network Development
Minnesota’s Integrated Care System Partnerships
MCO Care Manager Perceptions
Drive Patient Utilization
“It’s our care managers and our data
that drives who we contract with….
We may be contracting broadly, but as
our [case managers] work with
different organizations, we will tend to
drive volume to the ones we work
well with.”
Dual Eligibles Health Plan Executive
©2014 The Advisory Board Company • advisory.com • 29490A
Managed Care
Organization
Risk Contract,
(Medical and LTC)
Physician
Practice
Physician
Practice’s
Preferred
Providers
Source: Minnesota Department of Human Services, “Managed Care Update,” October 3, 2013, www.dhs.state
.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowI
nterrupt=1&noSaveAs=1&dDocName=dhs16_180117; Post-Acute Care Collaborative interviews and analysis.
18
Trend #3: In-Network Utilization
Network Efficacy Dependent on In-Network Utilization
Patient Attribution Process
Pioneer ACO Program
Care Sought Outside of Network,
By Contract
Daisy Physician Group
40%
Members assigned to ACO
Medicare Advantage, Commercial HMO
5%
Members select plan,
assigned
to provider via plan choice
Medicare Advantage, Pioneer ACO
Commercial HMO Plans Program
Case in Brief: Daisy Physician Group1
• Small IPA2 in the East
• Participates in Pioneer ACO program, has additional risk contracts with commercial HMO plans,
Medicare Advantage (MA) plans
• Leakage rates under Pioneer ACO much higher than MA plans; leakage attributed to choice patients
make to enroll in HMO, MA plans
1) Pseudonym.
2) Independent Physician
Association.
.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
19
Trend #4: Management of Post-Acute Care
Sensing Commoditization of Post-Acute Care
Referrers, Payers Unable to Differentiate Individual Provider Value
Common Payer Strategies for Constricting Post-Acute Spend
Avoiding Higher
Daily-Cost Settings
Demanding Lower
Utilization
Forcing Price
Competition
Steering typical
LTACH, IRF patients to
SNFs, home health
Denying additional
SNF days,
scrutinizing RUGs
Negotiating substantial
rate concessions
Race to the Bottom
Providers accept unsustainable
rates, attempt to outlast competitors
as market consolidates
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Blom A, et al., “Development of a CMS Bundled Payment Program,” presented at Healthcare Financial
Management Association Fall Summit 2013, firstillinoishfma.org/wp-content/uploads/2_PBC_Development-of-aCMS-Bundled-Payment-Program.pdf; Post-Acute Care Collaborative interviews and analysis.
20
Trend #5: Use of External Managers
External Forces Recognizing PAC Inefficiencies
Multiple Models for Managing Post-Acute Quality, Utilization
ACOs
Narrow networks to providers
willing to promote quality
improvement, control utilization
Bundled Payment Conveners
Developing, provide analytics and
care management to independent
provider networks
Case Management Solutions
Provide hospital discharge
planners with tools to select
first PAC site of care
©2014 The Advisory Board Company • advisory.com • 29490A
Episodic Managers
Establish 90-day PAC episodes in
the hospital and manage progress
against benchmarks
Source: Atrius Health, www.atriushealth.org/; RightCare, www.rightcaresolutions.com/;
naviHealth, http://navihealth.us/; Remedy Partners, www.remedypartners.com/;
PostAcute Care Collaborative interviews and analysis.
21
Road Map
1
A Network-Driven Marketplace
2
The Focus on Cost-Efficient Behavior
3
©2014 The Advisory Board Company • advisory.com
Meeting a Dual Set of Mandates
22
Market Demands Dictate Utilization Changes
Four Key Post-Acute Actions Necessary for Success
Factors Driving Additional Demands on Post-Acute Providers
Legislative Forces
Commercial Forces
Demographic Forces
• Additional regulatory
requirements
• Opportunity for higher
reimbursement rates
• Rising complexity, acuity of
patient profile
• Expanded public payer
coverage of select services
• Emergence of
utilization managers
• Rapid growth in elderly
population
Suite of Emerging Expectations for PAC Providers
1
Optimal Patient
Placement
2
3
4
Complex Patient
Management
Elevated Provision of
Cost-Saving Services
Enhanced Downstream
Coordination
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
23
Expectation #1: Optimal Patient Placement
Policymaker Action Foreshadows Payment Overhaul
IMPACT Act of 2014 in Brief
Standardizing Data Reporting…
Required Domains and Sample Metrics
…To Guide Patient Placement
Three Stated Purposes
1
Compare quality across PAC settings
• Cognitive function
2
Inform hospital discharge planning
Quality Measures
3
Create foundation for future PAC
payment reform (likely via site-neutral
or bundled payments)
Patient Assessment
• Special services required
• Changes in skin integrity
• Medication reconciliation
Resource Use Measures
• Medicare spending
per beneficiary
• Rate of discharge to community
1) Acute care and critical access.
©2014 The Advisory Board Company • advisory.com • 29490A
New Discharge Planning Requirements
To meet CMS conditions of participation,
hospitals1 and PAC providers must
incorporate PAC quality and resource
use data into discharge planning
procedures by January 1, 2016
Source: Senate Committee on Finance, “Improving Medicare Post-Acute Care Transformation Act of 2014,”
2014,
www.govtrack.us/congress/bills/113/hr4994; House Ways and Means Committee, “Bipartisan, Bicameral
Effort Underway to Advance Medicare
Post-Acute Reform,” 2014, www.finance.senate.gov/newsroom/ ranking
/release/? id=c0c98f25-db43-45d8-9055-3959a1c6d997; Post-Acute Care
Collaborative interviews and analysis.
24
Support Platform Availability Surging
Vendors Targeting Payers, Providers With PAC Utilization Solutions
Robust Market for Care Support Tools
Vendor Categories
Patient Placement
Solutions
Care Management
Workflow Integration
Multi-faceted
Solutions
1) Acquired by Advisory Board Company in 2013.
©2014 The Advisory Board Company • advisory.com • 29490A
Representative Services
Select Vendors
Equip hospital discharge planners with
tools that match patient risk,
care needs to appropriate
postacute location
• PointRight
• Aidin
• Rightcare
Enable providers to communicate patient
management plans and follow patient
management throughout the continuum
of care
• Care Team Connect1
• ReAdmission
Solutions
• Civic Health
• Pinpoint Care
Provide patient placement and
management solutions, including
in-person management or telehealth
follow up, collects and analyzes data
•
•
•
•
Navihealth
Remedy Partners
Paradigm Outcomes
Medsolutions
Source: Aidin, myaidin.com; PointRight, www.pointright.com; naviHealth, navihealth.us; Care Team Connect, www.advisory.com/
technology/crimson-care-management; ReAdmission Solutions, LLC, http://readmissionsolutions.net; Civic Health, http://civichealth.com;
Pinpoint Care, www.pinpointmd.com; naviHealth, navihealth.us; Remedy Partners, www.remedypartners.com; Paradigm Outcomes,
www.paradigmoutcomes.com; Medsolutions, www.medsolutions.com/; Post-Acute Care Collaborative interviews and analysis.
25
External Managers Willing to Step Back
Health Plans Trading Control for Collaboration When Strategic
WellPoint Signaling Shift from Vertical Integration
Vertically
Integrated Model
Provider-Contracted,
Customized Model
• WellPoint employs
physicians to operate
CareMore model
• Partners with capable
providers, to operate
“CareMore-like” model
• Difficult to implement
nationally
• Increases scale,
coordination, impact
naviHealth Waiting for PAC to
Become the Quarterback
“Post-acute care managers are put in
place because current payment
models do not incentivize the
quarterbacking of a post-acute
episode—guiding a patient from
hospital back to the community.
So we’re putting decision support
technology and care coordination in
place out of necessity.”
Skeptical of Vertical Integration’s Potential
“I don’t believe any insurer, health system, or provider group
can acquire or consolidate their way to sustainable success.”
SVP Business Development,
naviHealth
CEO, Wellpoint
©2014 The Advisory Board Company • advisory.com • 29490A
Source: “The CareMore Model,” CareMore, http://www.caremore.com/About/How-We-DoIt/The-CareMore-Model.aspx; NaviHealth; Swedish J, “WellPoint’s Joseph Swedish argues
for collaboration, not integration,” Modern Healthcare, June 28, 2014,
www.modernhealthcare.com/article/20140628/MAGAZINE/306289978/; Post-Acute Care
Collaborative interviews and analysis.
26
Expectation #2: Complex Patient Management
Service Demands Driven by Demographics
Patients, Residents Older and Sicker
Chronic Disease Prevalence
Residential Care Facilities, 2010
30%
Seniors as a Portion of the US
Population
Projected
Actual
20%
50%
1 condition
2-3
conditions
18%
6%
10%
26%
0 conditions
4-10
conditions
0%
1990
2010
65-84
2030
75-84
2050
85+
Key Reasons for Higher Patient Acuity and Complexity
in Post-Acute Care Settings
Aging Population
Population growing older,
with more
chronic
conditions
©2014 The Advisory Board Company • advisory.com • 29490A
New Payment Models
Reimbursement changes
incent shorter LOS,
favor
lower-cost settings
Source: Administration on Aging, “Projected Future Growth of the Older Population,” www.aoa.gov/Aging_
Statistics/future_growth/future_growth.aspx#age; Gerace A, “Assisted Living Adapts to Changing Resident Acuity”,
August 12, 2013, www.seniorhousingnews.com; Post-Acute Care Collaborative interviews and analysis.
27
Solving ACO Care Managers’ Challenges
Hartford HealthCare at Home’s ACO Partnership
Model Sustainability,
Home Health Conversions
Revenue from nurse investment
surpassing costs
Hospital sends at-risk
patient home, without PAC
100%
ACO care manager
identifies patient with needs
not addressable by phone
HHA transition nurse conducts
non-billable home visit, reports
status to ACO care manager
HHA provides appropriate services
to fill gaps
Telehealth Private DutyMedicare Home
Health
(non-billable) (self-pay)
(billable)
©2014 The Advisory Board Company • advisory.com • 29490A
50%-60%
Preliminary
Results
25%
Breakeven
Point
Conversion Rate to Medicare
Home Health
Source: Hartford HealthCare at Home; Post-Acute Care Collaborative interviews and analysis.
29
Leveraging Disease Management Experience
Humana Building Seniors’ Primary Care Infrastructure from Scratch
Iora Health-Humana’s
Senior Care Practices
Iora’s Health’s Primary Care Practice Locations
Wellness Integration Expertise Fuels Western Expansion
• Iora Health traditionally builds
primary care practices for
exclusive employer populations,
operates under individual risk
contracts
• Opened 4 practices in Phoenix
and Seattle to exclusively serve
Humana Medicare Advantage
members
• Clinics offer integrated behavior
health, wellness programming,
yoga, knitting, diabetes
management classes
Senior Population-Focused Clinics
Employee Population-Focused Clinics
©2014 The Advisory Board Company • advisory.com • 29490A
Source: BusinessWire, “Humana and Iora Health Partner to Launch Accountable Care Agreement in Arizona and Washington,” 2014,
available at: www.businesswire.com/news/home/20140916006232/en/Humana-Iora-Health-Partner-Launch-AccountableCare#.VFpzD_nF_Tk; Post-Acute Care Collaborative interviews and analysis.
30
Trading Long-Term Care Beds for a Medical Home
Health Services Transformation Plan at Mathis1 Senior Care
PRESENT
FUTURE
1 Right-size long-term care
Long-Term Care
Organization
• Financial success
dictated by
occupancy,
length of stay
• Traditional primary
care practice
• Services relatively
limited to residents,
post-acute patients
Remove 86 of 159 long-term care beds,
increase short-term sub acute beds
from 83 to 96, expand and create
space for outpatient services
2 Evolve primary care model
Shift focus from on-campus primary care
to community medical home for seniors
model, integrate with specialists
3
Build senior wellness services
Senior Health Center
• Financial success
also dictated by
seniors’ health,
number of seniors
served
• Geriatric medical
home model
• Services open to
surrounding
community
Expand on-campus and home wellness
offering, including “virtual senior center”
home technology
1) Pseudonym.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
32
Expectation #3: Elevated Provision of Cost-Saving Services
Remote Solutions Address Access Challenges
Telephonic End-of-Life Care Counseling
An Extender for Plan Case Managers
Nationwide Access to Palliative Care Experts…
For the first time during the
course of my illness, someone took
a genuine interest in explaining the
delicate topic of possible scenarios
that may happen and the choices
that are available.
Vital Decisions Patient
Plan case manager
refers patient to
counselor
Counselor (e.g. LCSW)
reaches out, facilitates
ongoing conversations
as appropriate
…When Patients Need an External Confidant
I can’t talk that way with my
son in the room.
Vital Decisions Patient
©2014 The Advisory Board Company • advisory.com • 29490A
If requested, counselor
helps communicate
decisions with providers,
family
Source: The Atlantic, “A Hotline for End-of-Life Care,” August 2014,
www.theatlantic.com/health/archive/2014/08/a-hotline-for-end-of-lifecare/379212; Post-Acute Care Collaborative interviews and analysis.
34
An Access Point for High-Risk Seniors
Adult Day Oversight a Physician ACO Solution
Populations Excluded from Senior Housing Market Driving Physician Challenges
Low-income seniors
“Frequent Flyers”
More likely to be high-utilizers and
non-compliant with medications
Seniors with dementia
choosing to age in the
community
Office Behavioral Challenges
Disrupt physician office dynamics,
physician workflow
Adult Day Care Solutions
Low-Cost Care
• Inexpensive relative to
senior living or long-term
care
• Does not count toward
ACO Medicare distribution
©2014 The Advisory Board Company • advisory.com • 29490A
High-Touch Oversight
Contact up to 60 hours a week
Nutrition and hydration
Aligned
with core senior
living capabilities
Skilled oversight and health
status monitoring
Source: Post-Acute Care Collaborative interviews and analysis.
36
Building a Co-Located Adult Day Care Center
Opportunity to Synergize and Expand Senior Living Assets
Key Features of Austero Senior Living’s1 Adult Day Care Centers
Building Modifications
•
• Renovated wing of
existing facility to utilize
secure unit features for
Alzheimer’s clients
Built spaces into new buildings
designed for multipurpose use
such as night meetings
Transportation
Built transportation
company to ensure
consistent attendance,
accessibility
Onsite Physician Visits
Recruited PCP and neurologist
for onsite visits to residents and
adult day clients
Staffing Synergies
Shares staff training
and dining services with
housing businesses
Dual Funding Sources
Operate centers through both private
pay and Medicaid streams
“What [our ACO partner] is really excited about is that it takes away the Medicare funding aspect….
and we have an opportunity to manage [high-risk] people 7:30am-5:30pm, 5 days a week.”
Vice President, Austero Senior Living
1) Pseudonymn.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
37
Expectation #4: Enhanced Downstream Coordination
Enhancing Traditional Home Health Episodes
Home Health, Hospice Spending Associated with Lower Total Costs
Financial Impact of Medstar’s Medicare Home-Based Primary Care Demonstration
Mean 2-year spending per patient
Service Category
Intervention
Control
Change
Hospice
$3,144
$1,505
109%
Home Health
$6,579
$4,170
58%
Physician
$4,143
$5,718
(28%)
Skilled nursing
$4,821
$6,098
(20%)
Other1
$7,962
$11,392
(30%)
Hospitalization
$17,805
$22,096
(19%)
Total Medicare
$44,455
1) Diagnostic testing, transportation, Medicare Part B drugs, nonphysician
practitioners, durable medical equipment, outpatient facility.
©2014 The Advisory Board Company • advisory.com • 29490A
$50,978
(13%)
HBPC Model
• Primary care team of
geriatricians, NPs,
social workers, LPNs,
office coordinators
• Physicians visit every
3-4 months and provide
24/7 call, NPs visit
regularly as needed
• Team conducts weekly
care conferences with
home health, mental
health, pharmacy
Source: De Jonge, Erik K, et al., “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,”
Journal of the American Geriatrics Society, 2014, http://onlinelibrary.wiley.com/doi/10.1111/jgs.12974/pdf; PostAcute Care Collaborative interviews and analysis.
39
Shrink Volumes to Maximize Per-Patient Impact
Stratification by Patient Frailty Intensifies Program Results
Medicare Spending for Home-Based Primary Care by Patient Frailty
Frailty
Category
(JEN Index)
Proportion
of Sample
Intervention
Control
Change
Statistically
Significant?
Low (0-3)
20%
$22,611
$19,146
18%
No
Medium (4-6)
43%
$42,223
$43,383
-3%
No
High (7+)
37%
$58,689
$76,827
-24%
Yes
(p < 0.001)
With Proper Risk Stratification, Less Can Be More
63%
©2014 The Advisory Board Company • advisory.com • 29490A
Patients included in the intervention cohort who could
have been served with routine care to achieve similar
spend reduction results at a lower program cost
Source: De Jonge, Erik K, et al., “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,” Journal of the American
Geriatrics Society, 2014, http://onlinelibrary.wiley.com/doi/10.1111/jgs.12974/pdf; Post-Acute Care Collaborative interviews and analysis.
40
Road Map
1
A Network-Driven Marketplace
2
The Focus on Cost-Efficient Behavior
3
©2014 The Advisory Board Company • advisory.com
Meeting a Dual Set of Mandates
41
Market Changes Prompt New Approach
New Realities Require Evolution in Provider Alignment, Service Offerings
Network-Driven
Marketplace
1
Curate the Right Set of Assets
Focus on
Efficiency
New
Mandates for
Post-Acute
Success
Bring together necessary services,
sectors to address network concerns
and extend organizational reach
Cost-
2 Offer a Differentiated Product
Develop services that rise above the
status quo to appeal to network
conveners, secure future role
Key Underlying Organizational Commitments
Demonstrate
CostConscious Behavior
©2014 The Advisory Board Company • advisory.com • 29490A
Provide Coordinated,
Patient-Centered
Care
Source: Post-Acute Care Collaborative interviews and analysis.
42
Curate the Right Set of Assets
Developing a Range of Services to Support Core
Genesis’ Ancillary Services Enable High-Quality SNF Care
Genesis Physician
Services
Enhances compliance,
improves timeliness
of care
Genesis
Care Transitions
Offers care
management for
patients returning home
via in-person visits,
weekly telephone calls
$2M
©2014 The Advisory Board Company • advisory.com • 29490A
Core Offering:
Skilled Nursing
Facilities
Genesis Rehab
Range of therapy
services offered within
SNFs; developing
product to follow
patients home
Genesis SelectCare
Private duty home
care ensures quality
care following
discharge from
Genesis SNF
Estimated savings for Aetna in managed care
contract due to Genesis care improvement model
Source: Genesis HealthCare; “Aetna, Genesis HealthCare take aim at reducing hospital readmissions,”
Aetna, August 10, 2011, aetna.com; Post-Acute Care Collaborative interviews and analysis.
44
“Goldilocks and the Three Market Shares”
Potential Risk
Determining Optimal Market Size
Too Big
Risks antitrust
violations; unable to
control for quality
“It’s a balancing act between
making sure we have enough
capacity to get noticed and we
are not so big that we lose
control over our quality.”
Just Right
25%-35%
Director, Health Care Strategic
Initiatives, Cincinnati PACN
Member Organization
Too Small
Unable to command
payer attention
Market Share
©2014 The Advisory Board Company • advisory.com • 29490A
Source: U.S. Department of Justice and Federal Trade Commission,
“Statements of Antitrust Enforcement Policy in Health Care,” August
1996; Post-Acute Care Collaborative interviews and analysis.
45
Delivering on Network Quality Assurance
Interventions Target Underperforming Members
Covenant Health Network’s
“SWAT Teams”
•
•
SWAT Team Intervention Process
1
Perform facility review
2
Create report and remedial plan
Team composed of 3 RNs
and 2 administrators
3
Ensure member
implementation of plan
Dispatched to members
underperforming relative to
state and national benchmarks
4
Remove member from network
if no improvement seen
Network Quality Brings Shared Savings, Premiums on Rates
4.2
15-30%
$1M
Average Medicare
five-star quality rating
Average premium on
Medicaid contract rates
Annual marginal revenue
from shared savings
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Covenant Health Network; Post-Acute Care Collaborative interviews and analysis.
47
Offer a Differentiated Product
Defining True Specialization
What Is Specialization?
Specialization is a business philosophy wherein the organization makes conscious,
principled decisions to focus on specific patient groups and creates dedicated,
distinct clinical programs to serve those patients.
Key Components of a Specialty
Organizational
Commitment
Dedicated
Resources
Differentiated
Offerings
Clinical
Excellence
• Executives,
leadership, and
clinicians visibly
support specialty
• Distinct staff,
leadership, and/or
equipment dedicated
to the specialty
• Specialty stands out,
is sufficiently different
from competitors’
offerings
• Staff and leaders
committed to
delivering excellent
clinical outcomes
• Specialty program is
a key organizational
strategic priority
• Additional investments
in staffing, training and
technology made as
necessary
• Specialty performance
is demonstrably
superior to competitors,
or is unique in the
market
• Ongoing staff
education and
protocol development
supports quality
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
48
Building a Mutually Beneficial Program
Palmetto Health and Lutheran Homes Partner for High-Acuity Patients
Palmetto Health System
Lutheran Homes of South Carolina
• Struggled to place high-acuity
Medicaid patients, creating a
bottleneck in the inpatient setting
• Saw chance to work closely with
primary referrer, access clinical
training and support for staff
• Few SNFs willing or able to care for
these complicated patients
• Higher complex-care rate available
for high-acuity Medicaid patients1
• Sought SNF partner to collaborate
on complex care unit
• Expanded abilities attractive to other
referral sources
Provided Training, Referrals
“Most of the SNFs in our market
don’t want to get pushed out of
their comfort zone… the hunger
just isn’t there.”
Judy Baskins, VP Clinical Integration
Palmetto Health System
High-Acuity
SNF Unit
Provided Staff, Space
“We have a reputation now of
being able to handle a more
complex patient… to step up to the
plate and try something new.”
Tom Brown, President
Lutheran Homes of South Carolina
1) Reimbursement is approximately 2.5 times greater than
for regular Medicaid patients.
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Lutheran Homes of South Carolina, Irmo, SC; Palmetto Health,
Columbia, SC; Post-Acute Care Collaborative interviews and analysis.
50
An Ongoing Evolution
Specialties, Service Offerings Must Change to Meet Market Needs
Craig Hospital’s Specialty History
1907
1957
Craig Hospital founded as “Tent
Colony of Brotherly Love” for
indigent men with tuberculosis
Polio cases fall due to
widespread vaccination; Craig
switches specialty to spinal cord
injury
©2014 The Advisory Board Company • advisory.com • 29490A
1955
1976
Tuberculosis incidence
declines due to increased
antibiotic use; Craig
switches specialty to
polio
Invention of CT scanners lead
to improved survival for brain
injury patients; Craig adds
traumatic brain injury specialty
Source: Craig Hospital, Denver, CO; Post-Acute Care Collaborative interviews and analysis.
51
Upcoming Meeting Series Convenes Hospital, PAC Executives
The Post-Acute Care Collaborative’s 2015-2016 National Meeting Series
The High Performing Post-Acute Enterprise
Disruptive Trends Impact Senior Care
• Keeping Pace with Health Care Dynamics
• Understanding Overlooked Consumer Trends and
Patient Demographic Realities
• Evaluating Emerging Technologies, Clinical Advances
The Productive Preferred Provider Network
• Achieving Results with a Post-Acute Network
• Establishing Cohesive Cross-Continuum Governance
• Balancing Competing Financial Incentives
Caring for Higher-Acuity Patients
• Innovating on the Care Delivery Model
• Sourcing, Recruiting, Retaining, and Upskilling Clinical Staff
• Improving Efficiency of Complex Patient Management
Mark Your Calendars
Dates and Locations for the 2015-2016 Post-Acute Care Collaborative National Meeting Series
November 2, 2015
January 6, 2016
February 22, 2016
April 26, 2016
Washington, DC
Dallas, TX
Washington, DC
Chicago, IL
©2014 The Advisory Board Company • advisory.com • 29490A
Source: Post-Acute Care Collaborative interviews and analysis.
5252
Interested in our latest research?
Post-Acute Resources for Hospital Discharge Planners
When discharge planners have the right tools at their finger tips,
they can make a huge impact on LOS and readmissions rates.
This resource guide provides templated and sample resources to
help discharge planners smooth post-acute referrals across five
key areas:
1.
2.
3.
4.
5.
Identifying Challenges
Frontloading Discharge Planning
Making the Post-Acute Referral
Facilitating Safe Handoffs
Addressing Readmissions
Want a copy? Drop off your business card with either Jared Landis or Chloe
Bellomy and we will make sure you get one.
©2014 The Advisory Board Company • advisory.com • 29490A
To Learn More About the Advisory
Board’s Post-Acute Care Collaborative
• Please contact:
• Please contact:
Jared Landis
Chloe Bellomy
Practice Manager
Director
[email protected]
[email protected]
202-266-6925
202-568-7794