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Fred BenjaminAHCA/NCAL Regional Multifacility Council Chair
President LTC Division, Lexington Health Network
The Two Big Unfixables – Aging and Dying. A Discussion about Being Mortal
Is More Better? Prolonging Life At The
Expense Of Quality Of Life
David Gifford, MD MPH
Senior Vice President for Quality & Regulatory Affairs
1. Mor et al., 20102. CMS NHC site3. Commonwealth 20114. Jencks NEJM 20095. Analysis of SNF Claims
Churning at End of Life
Home
Assisted Living
Nursing Home
DeathER
Hospital SNF
23%1
50%2
20%1
19%4
20%3
5%5
45%2
2.2M Medicare admissions
A third use LTC but account for 87% of Costs
Costs of Long-Term Care Services 2007
Elderly want to stay in their home1
▪ Surveys of community elderly show a strong aversion to nursing home; • in a study of a large sample of seriously ill persons >70 years
old, 29% indicated that they would rather die than enter a nursing home.7
▪ In contrast, “Families often opt for nursing homes because they fear leaving their relatives at home where some untoward event may occur.”1
1 Kane RL & Kane RA. What Older People Want From Long-Term Care, And How They Can Get It. Health Affairs, 20, no.6 (2001):114-127
WRAPPING OUR CHILDREN IN BUBBLE MAY PROTECT THEM FROM INJURY BUT AT WHAT EXPENSE?
Rehospitalization Marker of Increased Mortality
Hospitalized beneficiaries who have an early hospital readmission nearly 3 times more likely to die within 1 year (one-year mortality = 38.7 % vs patients who were not readmitted = 12.1 %; p<0.001). Lum et al. J Gen Intern Med 2012; 27(11): 1467-74.
Mobility levels following hospitalization
hospitalized for major surgical procedurehospitalzed for non-surgical reasons
Ann Intern Med. 2009 Mar 17; 150(6): 372–378.
6 month Survival after ICU care
Guidet B. et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France A Randomized Clinical Trial JAMA. 2017;318(15):1450-1459.
ICU admission Rate Controls vs Intervention
34% vs 61%
intervention
Control
Five Questions to Explore
1. What is your understanding of where you are and of your illness?
2. What are your fears and worries for the future?
3. What are your goals and priorities?
4. What outcomes are unacceptable to you? What are you willing to sacrifice and not?
5. What would a good day look like?
From Atul Gwande’s book: “Being Mortal”
Play the film - http://www.pbs.org/wgbh/frontline/film/being-mortal/
10-Minute Break
Gail SheridanChief Clinical Operations Officer
Tealwood Senior Living
BEING MORTAL
PHIL FOGG
AGING
DYING
UNFIXABLES
AGING
DYING
PATIENT vs PERSON
L IFE JOURNEY
CHAMPION OF EACH JOURNEY
CHAMPION OF EACH JOURNEY
L I V E T H E B E S T
R E S T O F T H E I R
L I V E S
W H E R E H A V E T H E Y C O M E F R O M ?
L I V E T H E B E S T
R E S T O F T H E I R
L I V E S
H O W D I D T H E Y G E T H E R E ?
W H E R E A R E T H E Y N O W ?
H O W D O T H E Y W A N T T O L I V E T H E
B E S T R E S T O F T H E I R L I F E ?
P O S I T I V E E M O T I O N
E N G A G E M E N T
P O S I T I V E R E L A T I O N S H I P S
M E A N I N G + P U R P O S E
A C C O M P L I S H M E N T
HAPPINESS vs
WELL-BEING
P R O G R A M S TO S U P P O R T W E L L - B E I N G
I - S N P
M A N A G E D C A R E F O R
L O N G - T E R M L I V I N G P O P U L A T I O N
I N L O N G T E R M C A R E
H E A LT H P L A N
PA T I E N T | R E S I D E N T H I S T O R Y
E N D O F L I F E P L A N N I N G
F O C U S O N H E L P I N G I N D I V I D U A L
L I V E B E S T R E S T O F T H E I R L I V E S
N E W C H A P T E R S
A S P I R A T I O N A L R E H A B
R E C O V E R Y
R E - E X P E R I E N C E
B U C K E T L I S T
V I TA L L I F E
F O U N D AT I O N
B A C K PA C K T O S C H O O L
J O U R N E Y O F H E R O E S
M E M O R I E S I N T H E
M A K I N G
M U S I C + M E M O R I E S
V I TA L V O L U N T E E R S
INTENTIONAL FOCUS
E A S I E R W H E N YO U
R E A L LY K N O W S O M E O N E
Phi l Fogg, Sr
“ THE BEST REST OF YOUR L I F E ”
HAS UN IQUE MEAN ING
TO EACH PERSON
CHAMPION
OF EACH
JOURNEY
L I V E T H E B E S T
R E S T O F T H E I R
L I V E S
Risk Bearing OpportunitiesCleo Kitt, Director of Special Projects-Operations and
Executive Director of LifeWorks Advantage Jason Lee, CEO, Arkansas Superior Select/Tribute Health Plans
David Norsworthy, CEO, Central Arkansas Nursing Centers,
Risk Bearing Opportunities: I-SNP Operations
Risk Bearing Opportunities: I-SNP Operations
From the LifeWorks Advantage Perspective
Cleopatra Kitt, MPHDirector of Special Projects-OperationsExecutive Director of Lifeworks AdvantageMedical Facilities of America, Inc.
38
AGENDA
LifeWorks Advantage
Risk and Rewards
Operations
39
LifeWorks Advantage
LifeWorks Advantage is a Medicare Advantage Instutionalized Special Needs Plan (I-SNP)
LifeWorks Advantage is limited to Medicare beneficiaries who are long-term residents in one of our nursing centers throughout the Commonwealth of Virginia
40
Lifeworks Advantage
Service Area
41
Goals of the Plan 42
Position MFA to access premium dollar directly
Own and control data
Leverage MFA Model of Care to drive better outcomes for
patients
Superior growth opportunity and financial model
Transformation platform: proprietary technology + change
management protocols
✔
✔
✔
✔
✔
Risks and Rewards
Market Summary
Provider Networks
Medicare Advantage Regulations
Star Ratings
Integrations with Current Systems
43
Skilled Nursing Facilities 44
Industry
Pressures
Gov’t Reimbursement
Spend Margin
Medicare $29.8B 12.6%
Medicaid $46B 1.60%
Variation in Medicare Margins
• 75th percentile: 21%
• 25th percentile: 2.4%
Skilled Services Under Pressure
• Primary focus of bundles is
SNF spend
• CMS dropping therapy as element
of Medicare reimbursement
• Significant utilization decrease
due to cumulative impact of MA
growth, bundles, ACOs, MSSP etc.
Managed Care Environment
• Government programs will
continue to expand
• Medicaid Managed Care Expansion
• Medicare Advantage Growth
Industry Response
✔✔ Experience diminishing
returns of current market forces
- Continue to invest in skilled
services and referral streams
- Manage cost basis for long
stay patients
✔✔ Utilize political influence with
new administration and state
decision makers
✔✔ Pursue SNP Model
Industry Pressures
SNF Market Snapshot
Long Term Care Industry is Poised for a Significant Shift to Value-Based Care
Government Goals- 90%of Medicare payments link to quality/value by 2018
- Significant focus on reducing post acute spend
Payer Goals - Medicare Advantage poised for growth; “safe haven”
- Focus on Medicaid managed care expansion
Population Growth
Provider Goals
Projected Market for Long Term Care Value-Based Care Services
$9.4B+Total Addressable Market
✔ 2.7 million long term care residents
✔ $98B in healthcare spend
✔ Available market at 9-10% of spend
- Increase in 85+ population accelerates in 2020
- Alzheimers/Dementia comprises 1/3 of 85+ population
- Invest to control own destiny
- Capture value from care coordination
45
Operations
Infrastructure
Policies
INTERGRATION of Systems
Resource Requirements
Financial Plan
Metrics to Measure
Performance
46
Financial Plan
Outline a high-level financial plan that defines your financial model and assumptions.
Enrollment Projections
Bureau of Insurance
License
Medical Loss Ratio (MLR)
Catastrophic loss
47
18 Month Application:
Transformation Cycle
Thru Feb
2016
June
2016
June-
December
January
2017
48
July
2015
Policies and Integration of
Systems
Current System Policies
Clinical
Model of Care
Pharmacy
Information Technology
Billing
49
Resource Requirements
Resource Requirements:
Personnel
Technology
Finances
Marketing
Professional Fees
Services
50
Metrics to Measure
51
- - - - - - - - - - - - - - - - - - - - -
Lifeworks Advantage Executive DashboardExecutive Summary
Period: 1/1/2017 thru 6/30/17 Data as of 11/1/17
Superior Demonstrated Outcomes 52
VALIDATION
53
MFA’s Goal is to Capture and Create Value54
Benefits of an Effective
Compliance Program
Promotes patient safety and ensures the delivery of high
quality patient care
Helps ensure proper submission and payment of claims
Reduces billing mistakes
Improves outcomes from Medicare claims reviews
Reduces potential for Fraud, Waste and Abuse
55
Key Issues
Near term
Identify if you need a partner to help develop a D-SNP or
I-SNP based on your organizations assessment
Understand CMS Guidelines for Medicare Managed Care
Special Needs Plans
Identify the project lead times
Prepare financial assumptions
56
LifeWorks Advantage Partner:
AllyAlign Health
57
✔ Unique offering across clinical and financial continuum for LTC residents
✔ Full continuum of data and proven outcomes
✔ Physician/NP/SNF-owner driven MOC for high risk institutional population
✔ Performance-driven network alignment
✔ Purpose-built shared services model
Key Issues
Long-term
Understand the impact on the care of your patients
across the long-term care continuum
Understand the risk and rewards on your company’s
financial health.
58
The Road Ahead 59
Requisite for Growth
Buy into Model at Facility Level
Care Team Formulation
Demonstrated outcomes; Gain share distributions
Follow on wave of membership
✔
✔
✔
✔
60
Resources
www.lifeworksadvantge.com
www.allyalign.com
www.cms.gov
61
Questions & Discussion
Cleo Kitt, MPH
Executive Director of LifeWorks Advantage
62
