sharp - the walk to value - cox college · avoid preventable readmissions focus on patient wellness...

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Confidential – Do Not Distribute 11

The Walk To Value

April 6, 2018Jamie S. Sharp, MD, CPE

Value Journey

Agenda

• Impetus for transformation

• ACO Strategies in Post Acute Care

• Home Health Care Oversight

• High Value Specialist Network

• Provider and Patient Engagement

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Aging in the United States

Personal Assistance with ADLs

0% 10% 20% 30% 40% 50% 60%

15-64

65-69

70-74

75-79

80-84

> 85

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American Health Care at its Tipping PointAmerican Health Care at its Tipping PointAmerican Health Care at its Tipping PointAmerican Health Care at its Tipping Point

Shifts in Payer Mix

Medicare FFS Managed Care

Managed Care

FFS

Health Systems

Hospitals

Other PAC providers

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Better EXPERIENCE

Better OUTCOMES

Lower COST

Population Health:

The Centerpiece of Value Based Care

Commitment to Value

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Confidential – Do Not Distribute13prepared for

ACO Strategies in

Post Acute Care

Confidential – Do Not Distribute 14* Note: only includes the 1/3 of Home Health episodes

that begin w/in 15 days of dischargeSource: Evolent analysis of MedPAC data.

Post-Acute Care (PAC) Spending OverviewPost-Acute Care spending averages ~$110 PMPM for Medicare FFS patients; however, this can range from $50-300 PMPM between low-spend and high-spend regions.

61.4%15.0%

12.8%

10.8%

Skilled NursingFacilities (SNFs)

Inpatient RehabFacilities (IRFs)

Home HealthAgencies (HHAs)*

Long-Term AcuteCare (LTAC/LTCH)

Medicare Spending on PAC, by Setting

Notes Avg Paid per Episode

• For patients who need dailyskilled care from RN, PT/OT, etc

• Paid per day (avg ~$500 for Days 1-20, $340 for Days 21+)

~$12,000

• For patients who need more intensive rehab and monitoring

• Paid per stay using a case rate~$18,000

• For patients who are homebound but require ongoing therapy

• Paid per 60-day episode, based on # of visits delivered (~$250/visit)

~$3,000

• For patients who need acute inpatient-level care, but for extended periods

• Paid per stay using a case rate

~$40,000


The Importance of Post-Acute Care to Medicare ACOs

“Post-Acute Care is the largest driver of overall variation in Medicare” – NEJM, 2014

“The lowest-spending regions tend to spend about $100-150 PMPM less than average, and the highest-spending regions tend to spend about $100-150 more than average”

“Changes in Postacute Care in the Medicare Shared Savings Program” – JAMA, Feb 2017

“Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were consistent with clinicians working within hospitals and SNFs to influence care for ACO patients”

“Hospitals select preferred SNFs to improve post-ac ute outcomes” – Modern Healthcare, May 2015

“Atrius Health, which selected 35 SNFs out of 100, found that average length of stay in preferred facilities is no more than 15.8 days, compared with 22.3 days outside the network… And hospital readmissions are 25% lower for patients using the preferred network.”

“Of the more than 90 applications Banner received for inclusion in the select group [of Preferred SNFs], the system chose only 34 SNFs”

“Of 140 skilled-nursing homes that applied to be included in Partners HealthCare's Massachusetts' network, Partners selected 47”

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Initiative Est. Savings for ACO w/ 20K Lives*(Before Operational Costs)

Level of Effort

Medium-HighCan focus on high-volume

facilities and providers

HighWould need to engage &

impact broad SNF network

HighWould need to impact broad

SNF network

HighRequires significant education, implementation, and monitoring

* Note: Includes “offsetting” costs. For example, reduction in SNF admits is partially offset by increased HH use.

PAC Savings Opportunities

$0.4M

10% Reduction in SNF Readmissions

$0.6M

10% Reduction in SNF LOS

SNF 3-Day Waiver

$1.3M

10% Reduction in SNF & IRF Admits

$1.6M

ILLUSTRATIVE


Components of SNF PartnershipsDescription TME Goal

• Take advantage of Medicare coverage for SNF stays w/o preceding inpatient stay

SNF 3-Day Waiver

Reduce inpatient admissions

5

• Improve quality of clinical care during SNF staysCare Delivery in

SNFsReduce SNF LOS and readmissions

4

• Adapt Evolent Care Management programs to engage SNF patients

Care Management for

SNF Patients

Reduce SNF LOS and readmissions

3

• Reduce variation in PAC referrals and encourage use of lower-cost PAC settings when appropriate

Site-of-Care Optimization

Reduce PAC total spend

1

• Build close relationships with SNFs and encourage use of high-performing SNFs

SNF Collaboration

Network

Reduce SNF LOS and readmissions

2

Confidential – Do Not Distribute18

Site of Care Optimization

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Proportion of Medicare Patients Placed in an Avoidably Proportion of Medicare Patients Placed in an Avoidably Proportion of Medicare Patients Placed in an Avoidably Proportion of Medicare Patients Placed in an Avoidably

HighHighHighHigh----Cost Setting StudyCost Setting StudyCost Setting StudyCost Setting Study

Findings by Post-Acute Settings

HHA SNF IRF LTACH

OP Therapy HHA SNF IRF

14%

15%

5%

20%

3%

9%

18%

30%

31%

11%

42%


Site-of-Care Optimization

Setting Average Medicare Payment

Inpatient Rehab Facility (IRF) ~$19,000 per stay

Skilled Nursing Facility (SNF)

~$12,000 per stay (~27 days at ~$450/day)

Home Health (HH) ~$2,800 per episode(avg 1.9 episodes per user)

Up to $6-8Ksavings per

case switched

Up to $6-9Ksavings per

case switched

Reducing Length of Stay by 5 days would save $2-2.5K

per patient

~$3K savings from reducing unnecessary episode renewal


• “For hip and femur procedures, joint replacement, and stroke, whether patients received IRF was the key driver of variation in PAC spending”

• “For pneumonia and heart failure, whether patients received SNF care was the key driver of variation in post-acute spending”

% of Patients Discharged to IRF

Does Lower Site of Care Adversely Impact Quality?

Literature review

Health Affairs, Jan 2017. “Spending On Care After Surgery Driven By Choice Of Care Settings Instead Of Intensity Of Services”

• Analyzed average PAC spending by hospital for 3 major surgeries (total hip, CABG, colectomy) and grouped hospitals into quintiles

• After controlling for Length of Stay and coding patterns, the difference between top and bottom quintiles drops a bit, from $6,600 to $5,900

• After controlling for site of care, the difference drops all the way to $1,200

25%

11%

17%

4%

-30%

StrokeLower Extremity Joint Replacement

-66%Medicare Advantage

Medicare FFSHealth Affairs, Jan 2017. “Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service”

Health Services Research, Oct 2016. “The Relative Importance of Post-Acute Care and Readmissions for Post-Discharge Spending”

PAC: Post-Acute Care. IRF: Inpatient Rehab Facility. FFS: Fee-For-Service.

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Clinical Review

SNF and HHC Networks

Specialists and Inpatient Provider Engagement

Pre-Surgical Optimization


prepared for

SNF Collaboration Network

Choose Your TEAM

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Partner Selection

Partner Development

Performance Evaluation

Sample Collaboration ScorecardSample Collaboration ScorecardSample Collaboration ScorecardSample Collaboration Scorecard

Sample ACO Metrics ScorecardSample ACO Metrics ScorecardSample ACO Metrics ScorecardSample ACO Metrics Scorecard

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prepared for

SNF Care Transformation

Care Redesign is Imperative

Safe, effective transitions

Manage LOS

Reduce variability

Avoid preventable readmissions

Focus on patient wellness

Develop and utilize predictive modeling


Predictive Models Built on Impactable Risk

Any Acute Event

Total Cost of Care

Impactable event

Increasing predictive model performance

Advanced machine learning techniques used to predict adverse outcomes

Data sources integrated in clinically-relevant constructs

Outputs continuous risk score weighted by most significant predictors

ADMINISTRATIVE DATA(Medical claims, Rx claims,

eligibility, provider data)

CLINICAL DATA(Lab values, EMR ADT,

Biometric screening)

ADDITIONAL DATA(HRA, Identifi assessment

data, SES data, Census data)

Models with more focused outcomes performed twice as well as those that

attempted to predict general outcomes

Models with more focused outcomes performed twice as well as those that

attempted to predict general outcomes

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Care Advisor Oversight


Care Advisor Support

Hospital SNF Discharge

• Advise patients, families and providers of SNF Collaborative Network to make informed choice

• Follow high risk patients from acute to SNF

• Enroll in Care management programs

• Deliver care advising support to high risk patients

• Conduct care conferences with SNF staff

• Collaborate with SNF provider to overcome barriers and update progress

• Assist in discharge planning process with SNF staff, SNF provider and PCP

• Connect SNF patients with essential community resources and HHC

• Transition Care program oversight

SNF Provider Oversight

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Impacting SNFist Care

TacticTacticTacticTactic AdvantagesAdvantagesAdvantagesAdvantages DrawbacksDrawbacksDrawbacksDrawbacks

Employ clinicians to care for ACO patients in specific SNFs

• Gives the ACO maximal control over the clinical care

• More capital-intensive

Arrange for ACO Providersto care for ACO patients in specific SNFs

• Engages the ACO’s participating providers

• Does not require a dedicated resource

• More difficult to do performance management

• May be more difficult to achieve best-practice protocols (e.g., clinical visit w/in 24 hours)

Work with SNFs to get current providers to enhance their level of care

• Does not require the ACO to arrange for specific providers to see ACO patients

• Less effective, since the ACO lacks a direct relationship with the providers

“Ideal” SNFist Clinical Care

At Admission During Stay At Discharge

H&P within 1 business day of admission

• Goals of Stay• Target Discharge Date

• Utilize High risk assessment tool

• Assess palliative care needs

• Collaborate with Care Advisors

• Develop acute event escalation protocol for ED avoidance

• Collaborate SNF staff to ensure patient isprogressing towards goals

• Citizenship

• Family communication

• Warm transfer to patient’s PCP

• Share Metrics with ACO


Home Health Care Oversight

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Care Management Home Health Review

�Case Management review of CMS home health forms for compliance with home health guidelines

�Case Manager will contact home health agency and patient/family to discuss care plan and needs

�Fewer home health forms to sign overall

MSSP Home Health

Recertification Metrics

(July 30th – Nov 14th)

ADL Services

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High Value Specialist Network

Ideal Specialist Partners

Evidence-based clinical protocols

Coordinate with PCPs

High value cost and quality outcomes

Prioritize care team support and partnership

Overall Network Improvement

Improved Quality and

Value

Timely Access to Care

Effective Communication

Coordinated Transitions

Closed Loop Referrals

Cost-effective Facilities and

Ancillaries

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Patient & Provider Engagement


Clinical Care Integration

Network/Community Resources

IntegratedCare Team

PhysicianPatient, family and care giverCare

Advisor

Pharmacist

Health Coach

Dietitian

Program Coordinator

Social Worker

Corporate Clinics

Sub acute

facilities

Community-Based

Resources

Home health

agencies

Behavioral Health Specialist

Housing Agencies

Transportation Agencies

Provider Engagement

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46

Patient Engagement

Think Differently

Be PROACTIVE

Be INFORMED

Be INNOVATIVE

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A Wise Man Proportions His

Believes to the Evidence

- David Hume

A Wise Man Proportions His Beliefs to the Evidence-David Hume

sharp - the walk to value - cox college · avoid preventable readmissions focus on patient wellness...

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