NE Home Health Leadership Summitnehomehealthsummit.com/wp-content/uploads/2016/01/...HHS Advancing Alternative Payment Models • Triple Aim: –Better Care –Smarter Spending –Healthier

NE Home Health Leadership Summit

The Hospital – Post Acute Landscape

January 19, 2016

1

OVERVIEW • PAC Landscape

• Policymakers

• Challenges

• Bridging the Continuum

• Discussion

AHA Constituency

American Hospital Association Membership

– 5,000 hospitals, health systems and health care

organizations;

• 350 LTCHs

• 1,200 IRFs

• 1,000 hospital-based SNFs

• 1,100 hospital-based HH agencies

– 43,000 individual members

CHANGING

LANDSCAPE

Post-Acute Landscape

TWO TRACKS FOR PAC POLICY-MAKERS

1. Refinements to traditional Post-Acute Care silos

– LTCH criteria

– IRF-specific market basket

– HH rebasing and case-mix cuts

– SNF refinements expected for FY 2017

2. Steady movement toward Alternative Payment Models that cross silos

– Bundled Payment

• BPCI: voluntary

• CJR: mandatory in 67 markets for joint replacement cases

– ACOs

© American Hospital Association

HHS Advancing Alternative Payment Models

• Triple Aim:

– Better Care

– Smarter Spending

– Healthier People

• Moving from

volume to value – Pay-for-performance

initiatives

– Alternative

payment models

Target percentage of payments in ‘FFS

linked to quality’ and ‘alternative payment

models’ by 2016 and 2018


Where Does PAC Fit In?

PAC Reforms In Process:

• BPCI

– Demonstration run through 2018

– Model 2 (STACH-Doc-PAC Bundle)

– Model 3 (PAC-Only Bundle)

• CJR

– Takes effect Apr 1, 2016

– Indirect impact on PAC volume

• Site-Neutral Payment

– 2014: MedPAC Proposal on IRF Site-Neutral Payment

– 2015: MedPAC working on PAC Site-Neutral prototype

• MedPAC reports to Congress in June 2016

• Many steps in this process

• Final recommendation to Congress in 2022.


Correlating PAC Risk & Reg Relief

Traditional

FFS

• LTCH PPS

• IRF PPS

• SNF PPS

• HH PPS

Current

Alternative

Models

• BPCI Models 2 & 3

• CJR

Population

Health

• Medicare

Advantage

• Full capitation

Greater Risk = Greater Regulatory Relief

All PAC

Regulations

in Effect

PARTIAL

STACH/PAC

WAIVERS

• 3-day stay

• Expanded HH

benefit

• Telehealth

FULL PAC

WAIVERS

• No STACH

discharge

requirements

• Bene choice?

• IRF regs

• LTCH regs

• 3-day stay

Other

Models??

• CJR 2.0 • New conditions

• New parameters

• Unified PAC

PPS

• Other?

Additional

Regulatory

Relief

•

•

•


9

BCPI AND CJR TIMELINES AND OVERLAP

* BPCI continues for 3 full years from start date for each bundle and will end at intervals in 2018

* BPCI takes precedence over CJR for hospitals in Model 1 as of July 2015; Model 2 or 4 as of Oct 2015

* BPCI Model 2 and Model 3 initiated by post acute or PGP takes precedence over CJR

BPCI*

Jan, April, July, Oct

2015

CJR

April 2016

CJR

Jan 2016

CJR

Jan 2017

CJR

Jan 2018

CJR

Jan 2019

Year 4

Full downside

risk begins

BPCI ends

in 2018

Year 5

Full downside

risk continues

CJR ends Dec 31

Year 3

Partial Downside

risk continues

Go Live

Year 1 Upside

risk only

Year 2

Partial Downside

risk begins

BPCI

Risk bearing for

Episodes

began in Jan,

April or Oct

10

BCPI: MODEL 2 PARTICIPANTS BY

PROVIDER TYPE AS OF OCT 2015

Hospital

PGP

Fast Facts

About 60% providers use external awardee conveners

About 5 % of SNFs participate in BPCI

Top 3 bundles:

• Major joint replacement of lower extremity

• Simple pneumonia

• CHF

245

395

11

BCPI: MODEL 3 PARTICIPANTS BY

PROVIDER TYPE AS OF OCT 2015

Fast Facts

About 40% use external awardee conveners

About 12 % of PPS hospitals participate in BPCI

Top 3 bundles:

• Major joint replacement of lower extremity

• CHF

• Simple pneumonia

SNFs

HHA

IRF

PGP

LTCH

723

103

60

9 1

IMPACT Act

12

IMPACT Act Overview

• Signed into law Oct. 6, 2014

• New reporting infrastructure for PAC that is

“standardized and interoperable”:

– Patient assessment data

– Quality measures

• New discharge planning criteria for hospitals

and PAC.

• New, combined payment system for PAC

• Significant regulatory activity in 2015

13 © American Hospital Association

IMPACT Act: Patient Assessment Data

• Functional status (e.g., mobility, self care)

• Cognitive function and mental status (e.g., depression,

ability to understand)

• Special services, treatments, and interventions (e.g.,

ventilator use, dialysis, chemotherapy, central line

placement, TPN)

• Medical condition (e.g., diabetes, CHF, comorbidities

such as severe pressure ulcers)

• Impairments (e.g., incontinence, impaired and an impaired

ability to hear, see, or swallow.

• Other categories deemed necessary and appropriate by

the Secretary of HHS


No rulemaking yet on these measures:

IMPACT Act: Quality Measures

Measures must address following topics:

– Functional Status

– Skin Integrity

– Major Falls

– Medication reconciliation

– Patients preferences

– Resource use, including at a minimum:

• Medicare spending per beneficiary

• Discharges to community

• Potentially preventable admissions and

readmissions


Addressed in FY 2016 SNF,

IRF, LTCH Final Rules

Addressed in CY

2016 HH Final

Rule

No

Rulemaking

Yet

MedPAC

MedPAC Recs for FY 2017

FY 2017 Medicare Payment Recommendations • HH

– Zero update;

– rebase HH payment system over a two-year period starting in 2018; and

– eliminate therapy as a factor in setting HH payments.

• SNF

– Zero update;

– Reform the SNF PPP and report in 2019 on the impact and need for further changes.

• IRF

– Zero update;

– Focused audits of IRFs that have “unusual patterns of case mix and coding;” and

– Expand outlier pool “to redistribute payments more equitably across cases and providers.”

• LTCH

• Zero update


MedPAC & IMPACT Act

Development of a Single Post-Acute Payment System

• Last week:

• Update on development of a unified, PAC system prototype.

• Mandated by IMPACT Act; will be presented to Congress in June.

• Policymaking duties shared by MedPAC and HHS, with final payment system

recommendation to Congress in 2022.

• Services would be paid for based on patients’ clinical characteristics, rather than care

setting.


Long-Term

Care Hospitals

Key Challenges: New Dual-Rate Structure

Standard LTCH PPS

Cases (54% of 2014 Cases)

• No rehab or psych principal

diagnosis; and

• Immediately discharged from

inpatient PPS hospital; and

• Either 3 ICU/CCU days during

prior inpatient PPS stay; OR

>=96 hours of ventilator services

during LTCH stay

Site-Neutral

Cases (46% of 2014 Cases)

Paid the lesser of:

Inpatient PPS-Comparable Per

Diem, with any outlier payment

OR

100% of Estimated Cost

CMS’s Estimate of Fiscal Impact:

• Standard LTCH PPS Cases: +1.5%

• Site-Neutral Cases: -14.8%

• NET CHANGE: -4.6% (-$250 million)


Inpatient Rehabilitation Facilities

21

Key Challenges

Bundled Payment

• Fall 2015: CMS finalized mandatory bundling for joint replacement cases

• Effective April 1, 2016 – Dec. 31, 2020

• Hospital-led bundled; 67 markets

• 90-day episode triggered by MS-DRG 469 + 470

• No risk adjustment

• Limited PAC regulatory waivers

MedPAC

• MedPAC focused on high Medicare margins for IRFs, and margin disparities.

– FP vs NFP

– Units vs Freestanding

• Ongoing margin research has identified concerns about possible upcoding.

• Possible long-term policy response: Rebase the IRF PPS

Demonstrating value, given high cost of setting


Skilled Nursing Facilities

23

Key Challenges

• Major rulemaking expected for FY 2017 that may

propose to replace the RUGs payment system;

• Many health systems and conveners focusing on

post-acute care networks that strive to reduce

SNF length of stay.


Home Health

25

Key Challenges

• Payment:

– CY 2016: Medicare paired a sizeable rebasing cut (-2.4%)

with substantial case-mix cut (-0.97%) in each of CYs 2016,

2017, 2018

– Persistently high Medicare FFS margins will result in ongoing

policy spotlight.

– Policymakers do not support therapy as a payment driver.

• VBP:

– Mandatory VBP in 9 states (AZ, FL, IA, MD, MA, NE, NC, TN,

WA) will be challenge for smaller agencies.

– AHA did not support the scope of the VBP pool: upward,

neutral or downward adjustments of up to 8 percent based on

performance on 24 measures


CMS Proposed Rule on

Discharge Planning

© 2015 American Hospital Association

Snapshot

Proposed rule issued on Nov. 3, 2015.

Proposes new discharge planning requirements for:

hospitals, including: o general acute-care hospitals,

o long-term care hospitals,

o inpatient rehabilitation facilities,

o psychiatric hospitals.

critical access hospitals (CAHs), and

home health agencies (HHAs).

It also implements discharge-related provisions of the

IMPACT Act of 2014.


Discharge Plans

Caregiver/support person and community-based care availability

The patient’s or caregiver’s capability to perform required care

Relevant co-morbidities and past medical and surgical history

Admitting diagnosis or reason for registration

The patient’s goals and treatment preferences

The patient’s access to non-health care services

Communication needs

Relevant psychosocial history

Anticipated ongoing care needs and readmission risk

Criteria for the evaluation of discharge needs. CMS outlines numerous factors

that hospitals/CAHs must consider in evaluating discharge needs, such as:


Follow-up Process for

Patients Discharged to Home

Post-discharge follow-up. Hospitals and CAHs would

be required to establish a post-discharge follow-up

process for patients discharged to home.

However:

CMS does not specify the mechanism or timing of

follow-up programs.

The rule also is unclear as to whether the process

would apply to all patients discharged to home.


IMPACT Act & Discharge Planning

The proposed rule would require hospitals and CAHs to:

assist patients/support persons in selecting a post-acute

provider by sharing relevant data that includes the quality

and resource use measures for HHAs, SNFs, IRFs and LTCHs

be available to discuss and answer questions about a

patient’s post-discharge options and needs, and

consider the IMPACT Act quality measure data in light of

the patient’s goals and treatment preferences.


Discharge to Home

Discharge instructions to patients/caregiver AND, if known, any

PAC providers.

Components include:

• A copy of the discharge instructions and the discharge summary

within 48 hours of the patient’s discharge

• Pending test results within 24 hours of their availability

• written information on warning signs and symptoms that may

indicate the need to seek immediate medical attention

• prescriptions

• reconciliation of all discharge medications with the patient’s

pre-hospital/CAH admission medications, and

• written instructions regarding the patient’s follow-up care.


The IMPACT Act:

• expanded quality data reporting

requirements for HHAs, and

• requires HHAs “to take into account”

certain quality, resource use and other

data in discharge planning.

IMPACT Act & Discharge Planning

As with hospitals and CAHs, HHAs must assist

patients and their caregivers in selecting a post-acute

provider by sharing HHA quality and resource use

measure data.


HHAs:

Development of the Plan

People involved.

• the physician responsible for the home health plan of care

should be involved in the ongoing process of establishing

the discharge plan, and

• the patient and caregiver(s) should be involved in the

development of the discharge plan and informed of the

final plan.


HHAs:

Discharge/Transfer Summary The proposed rule lists specific medical information that HHAs would

need to send to a receiving facility or health care practitioner:

1. Demographic information

2. Physician contact information

3. Advance directive, if applicable

4. Course of illness/treatment

5. Procedures

6. Diagnoses

7. Laboratory tests and results of pertinent laboratory and diagnostic

testing

8. Consultation results

9. Functional status assessment

10. Psychosocial assessment

11. Social supports

12. Behavioral health issues

13. Reconciliation of all discharge medications

(Cont’d)


HHAs:

Discharge/Transfer Summary

14. Known allergies, including medication allergies

15. Immunizations

16. Smoking status

17. Vital signs

18. Unique device identifier(s) for implantable device(s), if any

19. Recommendations for ongoing care

20. Patient’s goals of care & treatment preferences

21. The patient’s current plan of care, and

22. Any other information necessary to ensure a safe and effective

transition of care that supports the post-discharge goals for the

patient.

*For any elements that do not apply to a patient,

HHAs would need to use “N/A” or another

appropriate notation.


AHA Concerns

AHA agrees with overall intent, but has concerns. • Provide flexibility to address the lack of community resources in some areas; and

• CMS should revisit its cost estimates to reflect the true impact of increasing the discharge

planning. (staff, training, process refinements, EHR, etc.)

• The range of patients requiring a full discharge evaluation and plan is too extensive. Practitioners

should be able to flag patients who need only a robust set of discharge instructions.

• For transferring patients, the information required should align as much as possible across

current meaningful use requirements, discharge planning standards, and quality measures.

• The discharge planning process should be completed in a timely manner but CMS should strike

the wording related to a universal 24-hour requirement.

• CMS should clarify the exact data to use to assist patients (and caregivers) in selecting a post-

acute provider;

• CMS should clarify how providers may assist patients in choosing a post-acute care provider

without raising concerns about improperly steering patients to particular providers.

• CMS should establish an effective date that is two years from the date of the final rule.


Building

Partnerships between

Hospitals & PAC

38

AHA Trendwatch on PAC

39

• December 2015

• Role of PAC

• Education Piece for

Policymakers and

Providers

• Factors Driving PAC

Changes in Marketplace

• 6 Case Studies

• Next Steps for PAC


40

FOCUS OF TRENDWATCH:

INSIGHT INTO RESPONSES OF PAC LEADERS

New Payment Models and Regulatory Changes PAC Innovations and

Strategies

• Factors Driving Change

• Case Studies of Innovations

PAC-Led

Partner-Led

• Next Steps for PAC

• Addendum: Background on PAC

41

SCOPE OF TRENDWATCH

42

IN-DEPTH INTERVIEWS

Post-Acute Provider Hospitals/ACOs/Payers

• Catholic Health Initiatives

• Allegheny Health Network

• Advocate Health Care

• Christiana Health Care

System

• Ascension Health-Mission

Point Health Partners

• RML Hospital

• Brooks Rehabilitation

• Health South

• Kindred Health Care

• Medical Facilities of

America (non member)

• Bayada Home Health

Care (non member)

43

INTERVIEWEES’ ASSESSMENT OF

FACTORS DRIVING CHANGE

• ACOs, bundled payment and population health models

elevate PAC performance a critical success factor

• Site neutral payment is inevitable

• Despite expected increase in demand for home health

and continued decline in need for institutional care (SNF,

IRF, LTCH), many PAC providers believe that winners are

possible

• However, there are differing views on whether

winners will be SNF or IRF

• Evidence based discharge tools and processes are lacking

• Effective care transitions and longitudinal care

management models are critical success factors

44

HOSPITAL/ACO/PAYER

STRATEGIC RESPONSES

• Acquire or partner with HH, hospice, HME

• Create SNF networks based upon performance

metrics with a focus on readmission rates and ALOS

• Pursue soft steering to reduce “leaking” and

improve PAC performance

• Develop discharge tools in attempt to determine

optimal discharge setting

• Enter bundling now as a learning opportunity

45

• Improve PAC performance to become preferred

partner

• Clinically integrate with hospitals and ACOs and use

their physicians in SNF and LTCH; improve clinical

competencies in SNF

• Pursue partnerships and JVs with hospitals and

payers

• Create post-acute continuum; Acquire or partner

with HHA, hospice and HME

• Enter bundling as a learning opportunity

PAC STRATEGIC RESPONSES

46

• Focus on the highest

acuity patients

• Seek preferred network

selection

• Track outcomes to

demonstrate value for

long stay patients (greater than 180 days)

• Tel-Health partnership

with SNFs

• Received $10 million

CMMI grant to develop IT

enabled care

management model with

predictive analytics for

cardiac patients

CASE STUDIES

47

CASE STUDIES (continued)

• Enter bundled payment

as a catalyst for clinical

and organizational

transformation

• Became Model 3 Risk

Bearing Awardee and

Model 2 risk bearing

partner

• Pursue market specific

integrated market

strategy with hospital and

payer partnerships

• Pursue payer and

bundling opportunities in

selected markets (ACO

and bundled payment)

48

CASE STUDIES (continued)

• Operates an ACO in 10

market and entered

bundled payment in 6

markets

• Develop SNF network in

each market with an ACO

• Create SNF network in

advance of ACO

formation

• Maximize referral to own

HHA and Hospice

49

AHA NEXT STEPS FOR STRENGTHENING PAC

Strengthen Evidence Base for Next Stage

of Delivery System Reform

1

Increase Patient-centered Focus of

Delivery System Reform

2

Streamline Data Collection Requirements

for PAC Providers

3

Improve Hospital-to-PAC Discharges 4

50

NEXT STEPS FOR

STRENGTHENING PAC (continued)

Develop Alternative Approaches for Low-

volume Providers, including PAC Providers

5

Develop More Effective Risk Adjustment

Methodologies

6

Enhance Regulatory Relief 7

AHA Webinar Series: www.aha.org/bundling

• 4 Webinars: Nov 2015

through Feb 2016

• Highlight innovations

in the field

• Multiple perspectives

• Case examples

• Materials posted for

convenient access


Next AHA Webinar

• Improving the Hospital Discharge Process

• Thursday, February 18

• 2-3:30 pm ET

• Presenters: – Jennifer Skeels, JD, Hall Render

– Tamara Cull, Catholic Health Initiatives, Nat. Director, Population Health Mgmt.

– Lisa McLean, Chief Strategy Officer, Post Acute Medical

– Janet Tomcavage, Chief Population Health Officer, Geisinger Health System

• REGISTER HERE:

www.aha.org/bundling


Questions

&

Discussion

53

Rochelle Archuleta

Policy Director

202-638-1100

[email protected]

Documents

NE Home Health Leadership Summitnehomehealthsummit.com/wp-content/uploads/2016/01/...HHS Advancing Alternative Payment Models • Triple Aim: –Better Care –Smarter Spending –Healthier