5/22/2012

1

Working With ACOs and Shared SavingsPayment Plans. What Operational and Policy Changes Will Be Required?

Tim Rowan, Publisher/EditorHome Care Technology Report

RowanResources.com

Nearly 12,000 certified providers

6,500 of them gross $2M or less

5/22/2012

2

5,500 of them gross $1M or less

CMS prefers to deal with 12,000 providers

Will not long tolerate uncontrolled growth in the number of Medicare certified agencies

PPACA gives CMS several pruning tools:1. Fraud abatement2. Overpayment control3. Moratorium on awarding new certificates4. The Replacement for PPS…

5/22/2012

3

Free‐Market Pruning:AmedisysLHC GroupLHC GroupGentiva

Government Pruning:RHHI denialsZPIC extrapolationsMAC auditsMAC auditsRAC overpayments“After PPS”

October 14, 2010: $35 M Armenian Medicare Crime Ring Broken UpLos Angeles, New York, New Mexico, Ohio, Georgia

September 7, 2011: 91 Medicare Providers ArrestedBaton Rouge, La.; Brooklyn, N.Y.; Chicago, Dallas, Detroit, Houston; Los Angeles and MiamiAngeles and Miami.

September 12, 2011: Maxim Settles DOJ Medicaid Fraud Accusation for $150 Million; criminal charges pending

October 3, 2011: LHCGroupSettles Therapy Abuse Accusations for $65 Million; Amedisys and Gentiva under investigation

February 28, 2012: The Curious Case of Dr. Jacques Roy

April 21, 2012: Four Arrested in Baton Rouge for $37 Million Scheme

5/22/2012

4

May 2012107 arrested7 cities

  illi$450 million

Obstacles to Opening New Agencies

36‐month rule3‐Tier Surveyor System3‐Tier Surveyor System3 risk levels for new agencies determine limited, moderate or high categorical screening levels

Accountable Care Organizations

Payment Bundling

Shared Savings Plans

Pay for Performance

76 million Baby Boomers

5/22/2012

5

If you liked IPS…

1995: 7 500 Medicare certified home health 7,500 Medicare certified home health agencies

1999: 5,000 Medicare certified home health agencies

2012: 12,000 Medicare certified home health agenciesagencies

2017: ???

Penalties if 30‐day readmission rate remains above threshold:

FY13 (10/1/2012)  1% of FY13 (10/1/2012): 1% of annual Medicare paymentsFY14 (10/1/2013): 2% of annual Medicare paymentsFY15 (10/1/2014): 3% of annual Medicare payments

Where will these people turn for help?

5/22/2012

6

Home Care Providers with SkillsLow HH Compare readmission scoresproactive readmission prevention measures in place?place?with helpful  technologies implemented▪ home telehealth▪ medication management▪ PERS▪ fall prevention▪ patient educationstrong data analysis demonstrating the effect of those technologies

Home Care Providers with Visible Skills

Preventing rehospitalization of home care patients is not the same as the hospital knowing an agency can reduce their admissions

New sales orientation programFrom asking for referrals to promising resultsFrom discharge planner to CFOFrom “My agency can care for your patients” 

to “My network can manage your patients’ care”

Let’s start at the very beginning

5/22/2012

7

Home Health, SkilledHome Care, non‐SkilledHospice and Palliative Care ProvidersRehab HospitalsLong Term Care Skilled Nursing FacilitiesAssisted Living CentersHome Medical EquipmentGroup Homes

Home Health

HospiceHome Medical 

Equipment

Physician

Case Manager LTC/SNF

Group Home

Rehab Hospital

Assisted Living

5/22/2012

8

Community Health Innovation Network

Accepts patients most at‐risk for readmission

Coordination and patient education begin in the hospital, before discharge

Nurse Care Coordinator manages plans of care and assigns each patient to a care location. When possible, patients go to the location of their choice.

Home Health

HospiceHome Medical 

Equipment

Physician

Case Manager LTC/SNF

Group Home

Rehab Hospital

Assisted Living

Employed by various members of the network, not by the network itself

L l  hi hLoyalty hierarchy:1. patient (considering comfort, care needs and 

outcomes)

2.payer

3. each healthcare provider within the network

5/22/2012

9

Patients are tracked by the Network a full 90 days after hospital discharge

appointment remindersppreminders to follow care plan and dietreminders to take medications as prescribed teach about all relevant community services they would previously have had to seek out on their own

1. One of twelve local hospitals agreed to a 90‐day pilot, no permanent commitment, CHF and COPD patients only.

Aft    d   d    d i i  th  h it l 2. After 90 days and zero readmissions, the hospital insisted the Network expand to its five other locations.

3. Today, all thirteen area hospitals participate; all chronic conditions are accepted.

4. 167 participating physicians

First eight months: Network served ±100 patients

Total hospital readmissions = 1 (For a procedure unrelated to the patient's chronic condition) 

A handful of patients have expired, but all of those deaths were expected and occurred in comfort, under the care of hospice nurses.

After 18 months: 90‐day hospital readmission rate = 8%

5/22/2012

10

HomeSNF

Assisted Living

Long Term Care

Group Home

Major changes are comingNew payment systems try to save MedicareHospital incentivesFraud control measuresFraud control measures

Survival depends on your ability to adapt to these changes; change your thinking from:

‘Referrals’ to ‘partnerships’‘Competing’ to ‘cooperating’ with other post‐acute providers‘Manual’ to ‘technology assisted’

“Delta Study of Hospital Readmissions and Home Care” deltahealthtech.com/research/projects/hospitalizations/

Home Care Technology ReportHome Care Technology ReportHomecaretechreport.com/article.asp?id=1356

Homecaretechreport.com/category.asp?id=7

CMS.govHealth Information Exchanges

Coordinated Care Demonstration

5/22/2012

11

Point‐of‐care automation

Electronic Medical Record

Health Information Exchanges (HIE)

Home TelehealthVital signMed managementPERS

Point‐of‐care automation

Electronic Medical Record

Health Information Exchanges (HIE)

Home TelehealthVital signMed managementPERS

1. When and Where?

2 Diagnosis: Chronic Inaccuracy 2. Diagnosis: Chronic Inaccuracy 

5/22/2012

12

1. The finite human memory

2. Inaccuracy results in lower revenue

OASIS accuracy degrades by the minute from patient’s home to nurse’s home.

(Eidetic (photographic) memory is either a myth or is found in .001% of the population depending on which scientific theory you believe If the population, depending on which scientific theory you believe. If you are that rare individual, you may disregard #1.)

5/22/2012

13

SIS Consistency Between Clinicians in a Training Settingmparison of 400 Class Attendees over Three Years

rage Decrease in Accuracy Among the Groupsument Imm2 Hours Post A4 Hours Post Assessment

93.0% 78.8% 62.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%93.0%

78.8%

62.0%

Document Immediately 2 Hours Post Assessment 4 Hours Post Assessment.0%

10.0%

20.0%

30.0%

40.0%

Findings reported by one outsource coding service organization: 80% average clinical documentation error rate nationwide

Within that 80%:20% of cases are found to be familiar, comfortable, result in upcoding

80% of cases are less familiar, harder to code correctly, result in downcoding

Net revenue across the board is $300 loss per Medicare episode

Point‐of‐care automation

Electronic Medical Record

Health Information Exchanges (HIE)

Home TelehealthVital signMed managementPERS

5/22/2012

14

Count on hospitals selecting post‐acute partners that can most easily exchange p y gpatient data with their existing EMR software.

Have you asked your vendor to outline their plans to help you upload and download 

ti t i f ti  t    l l HIE?patient information to your local HIE?

Point‐of‐care automation

Electronic Medical Record

Health Information Exchanges (HIE)

Home TelehealthVital signMed managementPERS

5/22/2012

15

At Least 9 TypesVital sign monitoringGeneral condition Q&AVideo visitsVideo visitsPERSVoice recognitionPOTsPatient portals & Social networkingMotion detectionMedication management

Platforms:

Vital sign monitoringGeneral condition Q&AVideo visits

Familiar Vendors:

American Medical Alert Corp.American Telecare Inc.Bosch (Health Hero)

PERSVoice recognitionPOTsPatient portals & Social networkingMotion detectionMedication management

Purchase or Lease-to-own

( )Bosch (ViTel Net)CardiocomCare Innovations (Intel/GE)Continuity HealthHoneywell HomMedIdeal LifeInfopia USAMEDITECHPhilipsViterion (Bayer)

5/22/2012

16

Platforms:

Vital sign monitoringGeneral condition Q&AVideo visitsPERS

New Vendors:

Acadian Telehealth Monitoring Advantage Home TelehealthAvery Telehealth

PERSVoice recognitionPOTsPatient portals & Social networkingMotion detectionMedication management

Per patient per month rentalCall center services

yConnections365Guardian Medical Monitoring HealthCOMPharos InnovationsSmartLinkTelehealth 360VRIWebPlus

Be Creative:

Some hospital‐affiliated agencies are tracking cost savings to the hospital and receiving bonuses.Managed care contracts  some agencies have received Managed care contracts: some agencies have received payments or renegotiated contracts based on demonstrated cost savings. Private Duty: patients are increasingly willing to pay to keep monitors upon home care discharge.

HHS will step up its focus on patient‐centered care

HHS will decrease its concern for the survival of individual providers, increase its efforts on survival f th  h lth   t  it lfof the healthcare system itself

Hospital readmission penalties kick in on October 1, 2012

Home health care agencies are going to adapt or die.

5/22/2012

17

Working With ACOs and Shared SavingsPayment Plans. What Operational and Policy Changes Will Be Required?

Tim Rowaneditor@HomeCareTechReport.com

www.RowanResources.com