Getting Involved with ACOsAdam Sholar

Heidi White, MD

Objectives• Describe concepts of value-based care, pay for performance

and the pressures that are driving these approaches.

• Describe the impact of these priorities and ACOs on SNFs in regard to their business model.

• Delineate the roles and responsibilities of the medical director and SNF medical staff in collaborating with their SNFs and leading the way toward better care at lower costs.

• Describe examples of SNF/ACO collaborations regarding primary care capabilities, transitional care, targeted clinical programs and care integration.

Context: What is driving the trend to Value-Based Payments?

Source: MedPAC, June 2018 A Data Book: Health Care Spending and the Medicare Program; Chart 1-13. June 2018. Available at: http://www.medpac.gov/docs/default-source/data-book/jun18_databookentirereport_sec.pdf?sfvrsn=0

Context: What is driving the trend to Value-Based Payments?

Source: MedPAC, June 2018 A Data Book: Health Care Spending and the Medicare Program; Chart 2-4. June 2018. Available at: http://www.medpac.gov/docs/default-source/data-book/jun18_databookentirereport_sec.pdf?sfvrsn=0

Context: What is driving the trend to Value-Based Payments?

Source: MedPAC, June 2018 A Data Book: Health Care Spending and the Medicare Program; Chart 1-14. June 2018. Available at: http://www.medpac.gov/docs/default-source/data-book/jun18_databookentirereport_sec.pdf?sfvrsn=0

Context: What is driving the trend to Value-Based Payments?

Source: Anne Tumlinson Innovations (ATI), January 2018, Presentation to NCHCFA Annual Convention.

CMS Utilizes a Variety of Programs to Shift to VBP

Source: Anne Tumlinson Innovations (ATI), January 2018, Presentation to NCHCFA Annual Convention.

One Population - Medicare Advantage

• MA is experiencing

steady growth

nationally

Source: Kaiser Family Foundation. Medicare Advantage, October 2017. Available at: https://www.kff.org/medicare/fact-sheet/medicare-advantage/

One Population – Medicare Advantage• MA market penetration

varies by county

• North Carolina is 32%– 11.4% in Dare County

– 58.6% in Stokes County

• South Carolina is 24%– 18.6% in Beaufort

County

– 40.5% in Allendale County

Source: Kaiser Family Foundation. Medicare Advantage, October 2017. Available at: https://www.kff.org/medicare/fact-sheet/medicare-advantage

Source: CMS. Medicare Advantage, State/County Penetration, October 2018. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/MA-State-County-Penetration-Items/MA-State-County-Penetration-2018-10.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending

CMS Utilizes a Variety of Programs to Shift to VBP

Source: Anne Tumlinson Innovations (ATI), January 2018, Presentation to NCHCFA Annual Convention.

Remaining Population – Medicare

Source: Anne Tumlinson Innovations (ATI), January 2018, Presentation to NCHCFA Annual Convention.

Physicians also impacted through MACRA (MIPS, APM)

CMS Utilizes a Variety of Programs to Shift to VBP

Source: Anne Tumlinson Innovations (ATI), January 2018, Presentation to NCHCFA Annual Convention.

Accountable Care Organizations (ACOs)What is an ACO?

• ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.

• The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

• When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.

Source: CMS. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/

Growth of ACOs Nationally• “At the end of the first quarter of 2018,

we were tracking a total of 1,011 ACOs

representing 1,477 distinct active

accountable care payment contracts

with public and private payers.

Combined, these contracts cover

about 32.7 million patients in all

regions of the country.”

• “As a result, about 10 percent of the

US population is now covered by an

ACO, representing an increase of

about two million people (about 6

percent) compared to the previous

year’s revised estimates.” Source: Health Affairs (Aug. 14, 2018), by Muhlestein, Saunders, Richards, McClellan. Recent Progress In The Journey: Growth Of ACOs and Value-Based Payment Models in 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/

Growth of ACOs Nationally• “In the first quarter of 2018,

commercial ACO contracts accounted

for a little more than half of all ACO

covered lives, while Medicare

contracts accounted for 37 percent,

and Medicaid contracts accounted for

the remaining 10 percent (not shown).”

• “Despite being almost equal in

numbers, commercial contracts tend to

cover more lives than Medicare

contracts (24,300 versus 17,500 lives

on average). Medicaid contracts have

by far the highest number of lives per

contract, at 43,500 on average.”

Source: Health Affairs (Aug. 14, 2018), by Muhlestein, Saunders, Richards, McClellan. Recent Progress In The Journey: Growth Of ACOs and Value-Based Payment Models in 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/

ACO Prevalence Varies By Market

Source: Health Affairs, by Muhlestein, Saunders, Richards, McClellan. Recent Progress In The Journey: Growth Of ACOs and Value-Based Payment Models in 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/

Source: Health Affairs (Aug. 14, 2018), by Muhlestein, Saunders, Richards, McClellan. Recent Progress In The Journey: Growth Of ACOs and Value-Based Payment Models in 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/

ACOs in North and South Carolina• More than 30 ACOs operate

in North Carolina– 27 ACOs participate in the

MSSP

– 3 ACOs participate in the Next Gen Program

– ~6 ACOs have contracts with commercial payers

• ~5 ACOs have commercial contracts and participate in the MSSP

• More than 20 ACOs operate in South Carolina*– 21 ACOs participate in

the MSSP

– 0 ACOs participate in the Next Gen Program

– Some ACOs have commercial contracts

*7 MSSP ACOs operate in NC and SC; several of those have commercial contracts

Source: Toward Accountable Care Consortium (TAC). Available at: http://www.tac-consortium.org/nc-acos/

Source: CMS. Available at: https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Performance-Year-2018-Medicare-Shared-Savings-Prog/28n4-k8qs/data ; https://data.cms.gov/Special-Programs-Initiatives-Speed-Adoption-of-Bes/Next-Generation-ACO-Models/tn2j-iqcf

How this shift impacts care delivery

Source: MedPAC. Report to the Congress: Medicare Payment Policy, March 2018. Available at: http://www.medpac.gov/-documents-/reports

Impact on Skilled Nursing Facilities Nationally

Source: MedPAC, June 2018 A Data Book: Health Care Spending and the Medicare Program; Chart 1-3. June 2018. Available at: http://www.medpac.gov/docs/default-source/data-book/jun18_databookentirereport_sec.pdf?sfvrsn=0

Impact on Skilled Nursing Facilities Nationally

Source: MedPAC. Report to the Congress: Medicare Payment Policy, March 2018. Available at: http://www.medpac.gov/-documents-/reports

Impact on Skilled Nursing Facilities Nationally

Source: MedPAC. Report to the Congress: Medicare Payment Policy, March 2018. Available at: http://www.medpac.gov/-documents-/reports

Impact on Skilled Nursing Facilities Nationally

Source: MedPAC. Report to the Congress: Medicare Payment Policy, March 2018. Available at: http://www.medpac.gov/-documents-/reports

Impact on Skilled Nursing Facilities Nationally

Source: MedPAC. Report to the Congress: Medicare Payment Policy, March 2018. Available at: http://www.medpac.gov/-documents-/reports

Skilled Nursing Facilities at a Glance• North Carolina

429 nursing facilities – Ownership

• 76.2% multi-facility (2 or more under same ownership)

• 23.8% independent

• 3.7% hospital based

– Status• 80.2% for-profit

• 17.0% non-profit

• 2.8% governmental

– Certification• 4.7% Medicare

• 0.5% Medicaid

• 94.9% Medicare & Medicaid

• South Carolina191 nursing facilities

– Ownership• 77.0% multi-facility (2 or more under

same ownership)

• 23.0% independent

• 5.8% hospital based

– Status• 78.0% for-profit

• 15.2% non-profit

• 6.8% governmental

– Certification• 19.9% Medicare

• 0.0% Medicaid

• 80.1% Medicare & Medicaid

Source: CASPER data, June 30, 2018

Impact on Skilled Nursing Facilities in NC and SC

Source: Consonus Healthcare analysis of Medicare Cost Reports.

Impact on Skilled Nursing Facilities in NC and SC

North CarolinaAverage Occupancy (median)

– June 201880.6% (84.7%)

– June 201781.7% (85.0%)

– July 2016 82.4% (86.1%)

– July 2015 82.8% (86.7%)

– June 201483.4% (86.7%)

– June 201085.6% (89.5%)

– June 200588.7% (91.9%)

South CarolinaAverage Occupancy (median)

– June 201885.5% (89.8%)

– June 201786.0% (90.5%)

– July 2016 86.5% (89.2%)

– July 2015 87.2% (89.7%)

– June 201486.6% (89.3%)

– June 201091.3% (93.3%)

– June 200592.5% (94.3%)

Source: CASPER data

If the average is lower than the median, it means that most values in the data set are higher than average.

Impact on Skilled Nursing Facilities in NC and SC

North Carolina• 83.4 average residents

• Resident Days– 14.6% Medicare

– 64.4% Medicaid

– 21.0% Other

• Activities of Daily Living Score– US – 4.26

– NC – 4.46 (8th highest in US)

South Carolina• 89.0 average residents

• Resident Days– 15.3% Medicare

– 60.5% Medicaid

– 24.3% Other

• Activities of Daily Living Score– US – 4.26

– SC – 4.46 (7th highest in US)

Source: CASPER data, June 30, 2018

ACO Impact - Example

• One ACO in North Carolina: SNFs in-

network with the ACO/SNF Collaborative

average 125% more admissions per 6-

month period than similarly located SNFs

which are out-of-network

Why should I concern myself with

an ACO? • Necessity

• Relevance

• Opportunity

What is a SNF Collaborative?• A SNF Collaborative is a group of facilities that meet certain quality

standards and engage in preferred partnerships with an ACO.

• By establishing a SNF Collaborative, Duke Health and DCC seek to advance its engagement with local SNFs as partners.

Informal

Engagement

Formal

CollaborationContracted or Employed

• Interaction between

ACO providers and

SNF (e.g., HOPE

program, PHMO

coordinators, CJR)

• Advise development

of protocols to ease

transitions of care

• Designate SNF

partners to accelerate

collaboration

• Mutually designed

standards and

protocols (e.g.,

MedLink expectations,

PCP communications)

• Share utilization and

performance

information

• Standard agreements

identifying shared

expectations

• Broader patient and

provider-level data

sharing (e.g., MSSP

data)

• May include financial

risk/gain potential

• Providers may be

employed or owned by

ACO Participant

Table adapted from Tu, Tianna, Ike Bennion, and Michelle Templin. (2014, Sept). The Right Care for the Right Cost: Post-Acute Care and the Triple Aim. Retrieved from: https://www.mhainc.com/uploadedFiles/Content/Resources/MHA_Leavitt%20Partners%20White%20Paper%20091814.pdf

ACO – PAC Engagement Spectrum

Why Focus on PAC? • Post-acute care (PAC) comprises a large portion of annual Medicare costs and is a major driver of growth

• Medicare payments to PAC providers have more than doubled between 2001 and 20121

• PAC accounts for 73% of the variation in Medicare spending2

• In 2012, PAC services represented the largest per episode expense per beneficiary3

• Majority of these PAC expenses are for SNF care (~50% in 2015)4

• New payment models align mutual areas of interest for ACOs and PAC providers5

• IMPACT Act, MACRA, HRRP, CCJR, BPCI

• Many MSSP quality measures are impacted by post-acute care providers

• ACO-12 Med reconciliation post discharge

• ACO-8 Risk-Standardized, All Condition Readmission

• ACO-13 Falls screening

• ACO-14,15 Immunizations and vaccinations

1Medicare Payment Advisory Commission. (2001, June) A data book: healthcare spending and the Medicare program. Washington (DC): MedPAC.2IOM (Institute of Medicine). (2013). Variation in Health Care Spending: Target Decision Making, Not Geography. Washington, DC: The National Academies Press.3Tu, Tianna, Ike Bennion, and Michelle Templin. (2014, Sept). The Right Care for the Right Cost: Post-Acute Care and the Triple Aim. Retrieved from: https://www.mhainc.com/uploadedFiles/Content/Resources/MHA_Leavitt%20Partners%20White%20Paper%20091814.pdf4 MedPac. (2017, June) A Data Book: Healthcare Spending and the Medicare Program. Retrieved from: http://www.medpac.gov/docs/default-source/data-book/jun17_databookentirereport_sec.pdf5IMPACT Act and CMS indicating shift towards value-based payment, similar to other Medicare payment reform efforts. Reform includes Health Agencies, SNFs, IRFs, and LTACs, and requires PAC providers to report quality, cost, and utilization data to CMS as early as 2018. Hospice payment reform similar but on later timeline. In 2017, MedPac would recommend how these measures could be used as basis for value-based payment reform. For more information see: https://www.gpo.gov/fdsys/pkg/PLAW-113publ185/pdf/PLAW-113publ185.pdf

What are the opportunities?• Value

• Care Integration

• Primary Care Enhancement

• Transitional Care Capabilities

• Targeted Clinical Programming

Care Integration

• Data Exchange

• Transitional Care Models

• Collaborative Clinical Models

SNFs & ACO: Shared Expectations & Values

• Data sharing & transparency• Willingness to exchange information on quality and utilization and

coordinate care to improve performance and achieve results

• Engagement• In-person meetings to discuss transition issues and opportunities for

improvement

• Bidirectional communication and timely transfer of records to improve care transitions

• Commitment to achieving program goals • Improvement in transitional care processes

• Utilize QI methodology to make small changes and evaluate impact

• Flexibility • Willingness to think innovatively about the role of the SNF in the

continuum of care34

Transitional Care QI Projects

• Post-discharge phone follow-up

• Discharge Instructions

• Engage in DC planning and understand Home Health

Partnerships with

our QIO Alliant,

Health

Department,

Area Agency on

Aging,

Community

Resources and

NCHCFA

What role can I play?• Make sure you know what relationships your SNF is

engaged in or considering

• Participate, your expertise is needed

• Help your facility make the most of their collaborations– Ask for resources, bring problems to be solved, learn

• Avoid pitfalls• Trying to do too much with too little

• Limited engagement

• Not fully appreciating what your SNF brings to the table

Questions to

help evaluate

ACO

opportunities

Are you ready to partner?•Organizational culture

•Staff stability

•Timing: Shift to value-based care and public reporting

Is this the right partner?

What type of partnership do you want?

•Informal, Formal, Contractual

What are the expectations of the partnership?

•Resources needed to be engaged

What is the benefit to being a partner?

•Resources provided? What is the value-add?

How can you help each other?

•Identify mutually beneficial goals

Do you understand your partner’s role?

•Acute care providers understanding of post-acute and vice versa