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Challenges and Opportunities for Nutrition Programs in Healthcare Integration
Timothy P. McNeill, RN, MPH
Changes to the Healthcare Landscape • The Patient Protection and Affordable Care Act
– Health Reform. Commonly called the Affordable Care Act or ACA
– Signed into law by President Obama on March 23, 2010
– On June 28, 2012, the Supreme Court rendered a final decision to uphold the law
• MACRA: Medicare Access and CHIP Reconciliation Act
Where is change happening • One of the two biggest areas of change that are impacting
nutrition programs – Medicaid Managed Care – Bundled Payment
• Are you aware of these opportunities? • If so, what are you doing to prepare?
For-Profit Reaction to Change • For-Profit entities are developing programs to target the
market opportunity • Tailoring services and marketing to the opportunity • Securing contracts and expanding market penetration • *CBOs must adopt the same posture
– This is not driven by Older Americans Act Funding – There are pure capital driven incentives in play
Greatest Change is impacting… • Medicare Eligibles
– Age 65+ – Persons with Disabilities under age 65 – Retirees with employer based coverage 65+ – Those age 65+ still in the workforce
• Duals • The Market is Reacting Accordingly
– Are you prepared or are you preparing
50 Year Anniversary of the Older Americans Act (OAA)
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DoD CMS OAA 2004 Budget $379.90 $523.40 $1.80 2014 Budget $527.50 $747.70 $1.88
Bill
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Federal Funding Trends: 2004 – 2014 (Billions)
Sources: U.S. Department of Defense, Under Secretary of Defense Comptroller. CMS Research Sta;s;cs Data Reports. AARP Public Policy Ins;tute.
Shift Toward Value-Based Purchasing • The current system is changing from Fee-For-Service to
payment for outcomes. • A Value-Based Purchasing system provides financial
incentives for outcomes (Value) • MACRA legislation provides direct incentives to
Physicians and Hospitals to move towards a system that pays for outcomes
• In the past, there were real financial incentives to providers, when complications occur
Where are there costs in the system • A system that pays for value will focus on where the
highest cost drivers are. – Reduction in Institutional Care – Readmissions – Nursing Home Placement – Preventable Primary Admissions
What is the Role of Medicaid for Duals • Medicare is the primary payer for Healthcare services for
Duals • Medicaid becomes the secondary payer
– Operates in a manner as the Medigap policy • When a Dual has both
– Medicare pays for health services – Medicaid pays supplemental costs – *Medicare is most often the primary
Medicaid Funding for HCBS • 1915(c) Home & Community-Based Waivers
– Goal is to support consumers in the community that are at-risk for institutional placement
• Incentives are aligned with Value-Based payment models for Medicare
• This creates more opportunity for this target population
MLTSS Risk Pool • Managed 1915 Waiver • Target Population for 1915 Waiver
– Beneficiaries at-risk for institutional care – Support them in the home to prevent premature
institutionalization • Target services to this target group • This group may also have Medicare and will be subject to
Medicare reform initiatives
Medicare Coverage • Medicare Part A covers the following services:
– Inpatient hospital care – Skilled Nursing Care – Home Health Care – Hospice Care
• Medicare Part B covers the following services: – Preventive Health Services – Doctor visits – Ambulance Services – Supplies/DME (wheelchairs, walkers, etc.)
Medicare Part B and the Dual • Medicaid pays for the supplemental costs for all Part B
services • Providers can support a reduction in Medicare costs by
maximizing prevention covered by Medicaid • Medicaid is responsible for all supplemental costs • When Medicaid Managed Care is implemented, the MCO
is responsible for the supplemental costs
Alignment of Payment Incentives • Medicare • Medicaid (Medicare Supplemental Coverage) • Managed Long-Term Services and Supports
– Medicaid Waiver
Medicaid Funding for HCBS • 1915(c) Home & Community-Based Waivers
– Goal is to support consumers in the community that are at-risk for institutional placement
• Incentives are aligned with Value-Based payment models for Medicare
• This creates more opportunity for this target population
Bundled Payments for Care Improvement Initiative
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• Initiative first awards were announced January 31, 2013 • Under this initiative, organizations enter into payment
arrangements that include financial and performance accountability for episodes of care
• Episode of Care – Key component of the initiative – All services rendered are bundled into one payment for an
episode of care – Provides a financial incentive for the org. to keep costs
down
Is there a BPCI Near You?
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Role for Nutrition Programs • Malnutrition and Unintentional weight loss are direct
contributors to functional decline and increase risk of mortality
• Direct correlation with these cost drivers – Increased length of stay in hospitals – Increased likelihood of institutional care placement
Comprehensive Nutrition Program Svcs
• Nutritional Assessment • Plan developed to address nutrition needs • Implementation of the plan • *Quarterly reassessment to determine if plan is meeting
the needs of the consumer – **Performed monthly in institutional settings
• Tracking outcomes at the consumer and population level
Medicare Basics
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• Medicare (2015) consists of 4 parts – Part A
• Inpatient hospital, SNF care, home health, hospice – Part B
• Doctor services, office visits, screenings, therapies, preventive services, outpatient services, emergency care, ambulance care, medical supplies, & durable medical equipment
– Part C • Medicare Advantage
– Must cover all Part A and Part B benefits – Part D
• Pharmacy benefits
BPCI Financial Incentives
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• Rewards providers for improvements in quality and efficiency of care
• Aligns incentives for coordinated care with the following provider types: – Hospitals, Post-Acute Care Providers, Physicians, and other
Practitioners – Post-Acute Care Providers – Home Health Agencies – CBOs
BPCI Models
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• Four Models – Each model links payments for multiple services serving beneficiaries
• Model 1 – Retrospective Acute Care Hospital Stay Only • Model 2 – Retrospective Acute Care Hospital Stay Plus Post-
Acute Care • Model 3 – Retrospective Post-Acute Care Only • Model 4 – Prospective Acute Care Hospital Stay Only
Eligible Beneficiaries
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• Must be enrolled in Medicare Part A and Part B • Must not have End Stage Renal Disease • Must not be enrolled in any managed care plan for Medicare
benefit coverage • Beneficiary participates by selecting a participating provider for
care
Retrospective vs. Prospective
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• Retrospective – All relevant ACTUAL expenditures are reconciled against a
target price for an episode of care • Prospective
– A Lump sum payment is made to a provider for the entire episode of care
Pre-BPCI Example
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• 67 y/o female, Requires Knee Replacement Surgery – History of diabetes and CHF – Enrolled in Original Medicare – Part A & Part B
• Post surgery admission to SNF – Part A covers hospital care & SNF stay – Part B covers professional services – No financial incentive to coordinate between providers to keep
costs down – What would make the most sense financially?
• Pre-BPCI vs Post-BPCI
Model 2 - Retrospective
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• Retrospective Acute Care Hospital Stay Plus Post-Acute Care
• Episode of Care: Inpatient stay plus related Post-Acute Care – 30 days – 60 days – 90 days
• Includes: All non-hospice Part A and Part B services • Participants must select from 48 different clinical
conditions
Example
• 68 y/o female admitted to a SNF after knee replacement surgery
• National Range for Knee Replacement surgery – $16,500 to $33,000 (90 days Acute + Post Acute Care)
• National Median SNF rate (Private room): – $240/day = $7440/mo. – $7,440/mo. @ 90 days ($7,440 X 3 = $22,320) – PT, OT, MD care in addition to the SNF rate – Post Acute Expense is already +$25K
CBO Partner Example
• 68 y/o female admitted to a SNF after knee replacement surgery
• SNF Stay is limited to 30 days = $7440 (Median SNF Expenditure)
• Day 31, beneficiary is transferred to home • CBO provides home delivered meals, personal care aide
and transportation at a fraction of the cost of the SNF stay
• Bundled Payment facility pays the CBO for services and achieves significant cost savings
CBO Partner Example is a Win – Win for All
• SNF reduces their costs and EARNS savings from the bundled rate – If the SNF bundled rate is $25,000, for 90 days – Through improved support in the community, the total
costs equate to only $18,000, then the SNF retains the additional $7,000 as a BONUS
• SNF is able to free the bed and fill it with another paying customer – while collecting the savings from the bundle ($7,000)
Model 2
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• To SNF or Not to SNF? • Financially, we do not want to SNF • Target Price for 30 – 90 days • Limiting high cost, post acute care reduces the potential profits in
a bundled payment scenario • If no SNF?
– Coordinate support services in the home – Ensure coordinated post acute care and follow-up – Regular monitoring to advert complications
Model 3 - Retrospective
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• Retrospective Post-Acute Care Only – Inpatient care in not included in the Model 3 bundled payment
• Episode of Care: Post-Acute Care Services with a participating skilled nursing facility
• Range of time: 30, 60, or 90 days – The longer the episode, the higher the payment
• Includes: All non-hospice Part A and Part B services • Example: Rehab facility, long-term care hospitals, home health,
and community support services
BPCI 48 Conditions List
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Acute Myocardial Infarction Amputation Atherosclerosis Automatic implantable defibrillator Back and neck except spinal fusion Cardiac arrhythmia Cardiac defibrillator Cardiac Valve Cellulitis Cervical Spinal Fusion Chest pain COPD, bronchitis/asthma Anterior/posterior spinal fusion Non-Cervical spinal fusion Congestive Heart Failure Coronary artery bypass surgery Diabetes Esophagitis other digestive disorders Joint replacement Factures of femur and hip/pelvis GI Bleed GI Obstruction Hip and Femur procedures Lower extremity procedure Major bowel Major cardiovascular procedure
BPCI Conditions Cont.
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Major joint replacement of lower ex. Major joint replacement of upper ex. Medical non-infectious orthopedic Medical peripheral vascular disorders Nutritional and metabolic disorders Other knee procedures Other respiratory Other vascular surgery Pacemaker Pacemaker Device replacement Percutaneous coronary intervention Red blood cell disorders Removal of orthopedic devices Renal failure Revision of the hip or knee Sepsis Simple pneumonia and resp. infections Spinal fusion (non-Cervical) Stroke Syncope and collapse Transient Ischemia Urinary tract infection
BPCI Roles
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• BPPP – Bundled Payment Physicians/Practitioners • BPPO – Bundled Payment Provider Organization • Risk Bearing
– Awardee – Awardee Convener
• Non Risk-Bearing – Facilitator Convener
• Can serve in an administrative or technical capacity • Supports awardees that are assuming financial
responsibility
Who can be a convener
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• Conveners can a a provider or a non-provider organization • Convener can participate in Gain-sharing • The Convener does not have to accept risk
– Facilitator Convener – Non-Risk bearing – Awardee Convener – Risk bearing
Episode Initiators
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• Model 2 – Acute Care Hospital Admission for a selected DRG
• Model 3 – SNF, Home Health or LTCH service initiation within 30 days
of an Acute Care Hospital Admission
BPCI Phase 1
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• Phase 1 – No Risk Period – Applicants submitted by April 2014 – Must submit plan to redesign care delivery – Applicant receives monthly beneficiary-level claims – Participates in learning activities – Begins developing target price – Only upside risk during Phase 1
BPCI Phase 2
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• Phase 2 – Risk Period – Awardee enters into a contract with CMS for the target price – Awardee assumes risk – Agreement allows awardee to have waivers from fraud and
abuse authorities – Waivers of certain Medicare payment policies – Awardees begin transitioning to Phase 2 beginning January
2015 • As of July 2015, there were 360 Awardees that
transitioned over to Phase 2
Retrospective Approach
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• Medicare continues to pay all Part A and Part B claims for services to providers
• At the completion of the defined episode of care, there is a reconciliation of the aggregate of paid claims in comparison to the contracted Bundled rate (target price)
• If there is a gain, the provider receives the difference • If there is a deficit, the provider owes CMS the difference
Model 2 and Model 3 Payment
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• Aggregate of total Medicare spending for the beneficiary over the episode of care
• When the total Medicare spending is less than the target price, the Awardee receives the difference – Awardee can provide Gain Sharing with other organizations
• If the total spending is greater than the target price, the Awardee is responsible for paying CMS the difference
Fraud and Abuse Waivers
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• Phase 2 provides waivers for gainsharing, incentive payment and patient engagement arrangements – Awardee can share gains with other organizations and enter
into direct financial arrangements with other providers – Awardee can provide incentives to patient to engage in
prevention – Incentive payments can be made to other providers to support
the goal of managing costs
Gainsharing
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• When the total cost is lower than the contracted bundled rate, there is a “Gain”
• The Gain is paid to the Awardee • The Awardee can have one or more gainsharing arrangements,
where they Share the “Gains” with other organizations in the care team
• Provides incentives to improve efficiency and lower costs • Most Gains can be found in the PAC space
Payment Policy Waivers
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• 3-Day Hospital Stay Req. for SNF Payment – Waived for any 3-Star facility or greater
• Tele-health – Geographic area requirement is waived to support tele-health
provision anywhere • Post-Discharge Home Visit
– CMS waives the Direct Supervision requirement for “Incident To” services
– Licensed person under General supervision can provide 1 visit every 30 days – billed as a provider encounter
Comprehensive Care for Joint Replacement Model (CCJR)
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• Proposed rule published in the Federal Register on 7/14/2015 • Acute care hospitals in each of the 75 geographic areas will
receive retrospective bundled payments for episodes of care • All related care within 90 days of hospital discharge • Episode initiator – Admission to the Acute Care Hospital • DRG – Knee and Hip replacement surgery
States Impacted
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• AR, AL, CA, CO, CT, FL, GA, IL, IN • KS, KY, LA, MI, MO, NC, ND, NE, • NJ, NV, NY, OH, OK, OR, PA, SC • TN, TX, UT, VA, WA, WI
CCJR Risks
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• Year 1 – No downside risk • Year 2 – Participant hospitals will begin bearing financial risk • Eligible beneficiaries who receive care at these hospitals will
automatically be included in the model • CMS proposed to test the model for five (5) years • Retrospective reconciliation
– If negative, CMS will require payment from the participant hospital for the difference
Reconciliation Payments
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• Reconciliation does not occur unless the participant hospital achieves the following: – Meets cost control goals below the target price – Hospital must assume financial risk
• Cannot distribute risk to a convener – Performs well on Quality measures
• All-Cause 30-Day Hospital Readmissions • HCAPHS Survey Measure
CCJR Proposed Waivers
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• Gainsharing • Tele-health waiver • 3-Day Hospitalization requirement for SNF coverage • General supervision for home visits
– CMS proposes to establish a set of new billing codes specific to the home visits
– Home visit billing does not prevent the provider from billing for Tele-health during the same episode of care
CMS Stated Expectations
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• “We expect that participant hospitals will identify key providers and suppliers for CCJR beneficiaries in their communities and then establish close partnerships with them to assist in managing care…we believe [participant hospitals] may want to enter into financial arrangements with other providers and suppliers to share risks and rewards – CCJR Final Rule, Page 225
CBO Participation
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• Know who is participating in Bundled Payment in your market • Make yourself aware of the level of risk that they are incurring • Propose an intervention that aligns with the financial and quality
goals in support of the bundled payment • Define your ROI and track your ability to deliver this ROI to the
customer
Role for Nutrition Programs • Malnutrition and Unintentional weight loss are direct
contributors to functional decline and increase risk of mortality
• Direct correlation with these cost drivers – Increased length of stay in hospitals – Increased likelihood of institutional care placement
Comprehensive Nutrition Program Svcs
• Nutritional Assessment • Plan developed to address nutrition needs • Implementation of the plan • *Quarterly reassessment to determine if plan is meeting
the needs of the consumer – **Performed monthly in institutional settings
• Tracking outcomes at the consumer and population level
