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Navigating the Current
Landscape of LTC Lisa Thomson
Chief Marketing and Strategy Officer
Pathway Health
THE JOURNEY BEGINS…
2
New Era of Healthcare Quality and
Efficiency
VBP is Around the Corner
5
6
INDUSTRY LANDSCAPE
7
Industry Landscape
• Trends and Health Care Reform
– Post Acute Care Impact
• Reality Check
– Operational Challenges
– Impact on Consumers
– Examples of Redesign in New Environment
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Healthcare Challenges
• Government Unrest
• Reform of Health Care as we know it
• Reimbursement Changes
• Increased Costs
• Regulatory Changes
• External Oversight
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Medicare Growth Impact
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Medicare Growth
11
Financial Impact
Part A ($203.1 billion gross
feeforservice spending in
2015
Part B ($167.8 billion gross
fee for service spending in
2015)
Part C ($149.8 billion in
2015): Medicare Part C, the
Medicare Advantage (MA)
Part D ($85.2 billion projected
gross spending in 2015)
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Challenges Post Acute Care
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Government Response
Need to Reform Health Care!
• Quality Consistency
• Decrease Costs
• Decrease Reimbursement
• Increase Access
• Consumer Engagement
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Health Care Reform
Patient Protection and Affordable Care Act (PPACA)
– Signed into effect March 23, 2010
– Reduce long term costs of health care
– Link reimbursement to quality outcomes
– Move from Fee for Service to Bundled Payment
methods
– Person Centered Care
– Consumer engagement
– Access to data
– Strengthen the quality, accessibility, and
sustainability of care 17
Themes
Quality and
Value
Compliance
Patient
Engagement
and
Satisfaction
Performance
Measures and
Expectations –
Efficiencies
Chronic
Disease
Management
Care Integration
and Transitions
REFORM DRIVERS OF
CHANGE
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Reform Initiatives
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ACA Partners to Improve
Outcomes
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Initiate Redesign
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Innovation Center A new engine for revitalizing and sustaining the Medicare, Medicaid and CHIP programs and ultimately to help to improve the healthcare system for all Americans.
•Flexibility and resources
•Test innovative care models
•Test innovative payments models
http://innovations.cms.gov
Accountable Care Organizations
Other Models
• Bundle Payments for Care Improvement (9)
– Defined by episodes for care
– Set target price and quality measures
• Medicare Share Savings Program (15 +)
• Medicare Acute Care Episode (4)
• Integrated Health Networks (many)
• Dual Eligible Programs (15 and More)
• PACE (5)
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IMPROVE QUALITY OF CARE
Reform Drivers of Change
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• US Department of HHS
– CMS
– AHRQ
• MedPAC
• GAO
• OIG
• State Medicaid programs
• NQF - NQS initiatives
• Affordable Care Act – driving quality outcomes,
increasing performance
Stake Holders in Performance
Measurement
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National Quality Strategy
The Affordable Care Act (ACA) requires the
Secretary of the Department of Health and Human
Services (HHS) to establish a national strategy
that will improve:
– The delivery of health care services
– Patient health outcomes
– Population health
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Healthy People/Healthy Communities
Better Care
Affordable Care
The strategy is to concurrently
pursue three aims:
Better Care
Affordable
Care
Healthy People
Healthy
Communities
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National Quality Strategy
• From the National Strategy for Quality Improvement in Health Care
• http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm
• Guiding force in quality improvement efforts across the nation and health care entities
• Develop a national QAPI model
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National Quality Strategy
• Adopts unified measures
• Across federal government,
private sector, States, health
systems and providers
• Gauge performance
outcomes
• Create continuity
• Consistency between
providers
• Creates a “buying Value”
initiative (VBP)
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National Quality Strategy
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Quality Measures
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Measure Inventory for QMs
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NEW !
CMS AND OIG FY 2015
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CMS FY 2015
• Medicare
– Budget includes projected savings of $407.2
billion in 10 years (VBP – efficiency and quality)
• Medicaid
– Budget includes projected savings of $7.3 billion
(Dual eligible initiative)
• Program Integrity
– Fraud Prevention System (FPS) increased
oversight (yield $1 billion over 10 years)
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CMS FY 2015
• Implement Bundled Payment for PCA providers by 2019 (initiate data gathering and phase in) SNF, LTAC, IRF, HHA
• Savings of $8.7 billion in 10 years
• Adjust Skilled Nursing Facilities Payments to Reduce Hospital Readmissions – 19 percent of Medicare patients that are discharged from a hospital to a
SNF are readmitted to the hospital for conditions that could have been avoided.
– To promote high quality care in SNFs, this proposal reduces SNF payments by up to three percent beginning in 2018 for facilities with high rates of care-sensitive preventable readmissions. [$1.9 billion in savings over 10 years]
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CMS FY 2015
• Equalize Payments for Certain Conditions Treated in Inpatient
Rehabilitation Facilities and Skilled Nursing Facilities
– Equalize payments of 3 conditions involving hips, knees
and pulmonary
– Commonly treated in both settings
– Beginning October 1, 2015, IRFs must record the total number of
therapy minutes received and the type of therapy provided (i.e.
individual, group, concurrent or co-treatment) during the first two
weeks of an IRF stay.
– CMS also is revising the IRF Quality Reporting Program to
update measures, add a reconsideration policy, and adopt a
data accuracy validation policy
– Decrease costs and increase efficiencies.
– Savings of $1.6 billion - 10 years 36
CMS FY 2015
• Implement Value-Based Purchasing
– SNF
– HHA
– Ambulatory Surgical Centers
– Hospital Out Patient Departments
– Beginning in FY 2016.
– At least 2 percent of payments must be tied to
the quality and efficiency of care.
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Initiatives
ICD 10–CM
Coming Soon!
Prepare Plan Implement
Acute, Skilled Nursing,
Home Care, Hospice,
physicians and more 39
Initiatives
NEW! IMPACT legislation (Improving Medicare Post-Acute Care Transformation Act)
standardized platform/assessment tool
Quality Measures
SNF Performance Measures
Public reporting of Data
Re design NH Compare
New Payment Model
Acute, Skilled Nursing,
Home Care, Hospice
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• Bi-partisan bill introduced in March, U.S. House & Senate; passed on September 18, 2014 and signed into law by President Obama October 6, 2014
• Requires Standardized Patient Assessment Data for: – Assessment and Quality Measures
– Quality care and improved outcomes
– Discharge Planning
– Interoperability
– Care coordination
Improving Medicare Post-Acute Care
Transformation (IMPACT) Act of 2014
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Requirements for Standardized
Assessment Data
• IMPACT Act added new section 1899(B) to Title XVIII of the Social Security Act (SSA)
• Post-Acute Care (PAC) providers must report:
– Standardized assessment data
– Data on quality measures
– Data on resource use and other measures
• The data must be standardized and interoperable to allow for the:
– Exchange of data using common standards and definitions
– Facilitation of care coordination
– Improvement of Medicare beneficiary outcomes
• PAC assessment instruments must be modified to:
– Enable the submission of standardized data
– Compare data across all applicable providers
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Standardized Patient
Assessment Data
• Requirements for reporting assessment data:
– Providers must submit standardized assessment data through
PAC assessment instruments under applicable reporting
provisions
– The data must be submitted with respect to admission and
discharge for each patient, or more frequently as required
• Data categories:
– Functional status
– Cognitive function and mental status
– Special services, treatments, and interventions
– Medical conditions and co-morbidities
– Impairments
– Other categories required by the Secretary 43
Use of Standardized
Assessment Data:
HHAs: no later than
January 1, 2019
SNFs, IRFs, and
LTCHs: no later than
October 1, 2018
One Response: Many Uses
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Care Planning/
Decision Support
Payment
Quality
Reporting
QI Care
Transition
s
Data Element and Response Code
Data Elements:
Standardization
IRF-PAI
LTCH CARE
Data Set
OASIS-C
MDS 3.0
Data Elements
HCBS CARE
Uniformity
CMS Framework for Measurement
• Measures should
be patient-
centered and
outcome-oriented
whenever possible
• Measure concepts
in each of the six
domains that are
common across
providers and
settings can form
a core set of
measures
• Patient experience
• Caregiver experience
• Preference- and goal-
oriented care
Efficiency and
Cost Reduction
• Cost
• Efficiency
• Appropriateness
Care Coordination
• Patient and family
activation
• Infrastructure and
processes for care
coordination
• Impact of care
coordination
Clinical Quality
of Care
• Care type
(preventive, acute,
post-acute, chronic)
• Conditions
• Subpopulations
Population/
Community Health
• Health Behaviors
• Access
• Physical and Social
environment
• Health Status
• All-cause harm
• HACs
• HAIs
• Unnecessary care
• Medication safety
Safety
Person- and
Caregiver- Centered
Experience and
Outcomes
Function
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Initiatives
Safe Care Transitions – Patient Safety
New Measurement • Care Transitions
• Patient Education
• Medication Reconciliation
• Transfer protected
information
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Acute, Skilled Nursing, Home
Care, Hospice, Assisted Living,
HME, Physicians, others coming
soon!
Initiatives
By 2050, up to 16 million will have the disease.
Currently, one in every 8 Americans age 65
and older has Alzheimer’s, and nearly half of
people age 85 and older have the disease.
Alzheimer’s disease is the sixth
leading cause of death in the
United States and the only
cause of death among the top
ten that cannot be prevented or
cured.
Dementia Growth 2050
“Epidemic
Proportions”
National Initiatives
“BRAIN” Initiative —
a bold new research effort to
revolutionize our understanding of
the human mind and uncover new
ways to treat, prevent, and cure
brain disorders like Alzheimer’s,
schizophrenia, autism, epilepsy,
and traumatic brain injury.
Initiatives
Bundle Payment methodology by 2017!
Medicare Value Based Purchasing
Performance based pay
Quality metrics
New-Performance Measures
Acute, Skilled Nursing, Home
Care, Hospice, Assisted Living,
HME, Physicians, others
coming soon! 52
H.R. 4302 – Protecting Access
to Medicare 2014
• Sustainable Growth Rate – SRG
• “Doc” fix – repeals the 24% cut for Physicians
• Extension of Therapy Caps
• Extension of the two –midnight rule for acute care
• Skilled Nursing Facility Readmission Measure (10/1/15 – All Cause All condition hospital readmission factor) must be specified by the Secretary phase in 2016 and beyond
• Public Reporting of SNF – Readmission and other performance measures
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SNF Readmission Measure
NEW - Readmission Measure
– 10/1/15 – All-cause all-condition hospital readmission measure
– 10/1/16 – Resource Use Measure • Measure to reflect an all-condition risk adjusted
potentially preventable hospital readmission rate for SNF
• Quarterly feedback to SNF on performance from CMS
• Public Reporting of readmission rate!
54
HR 4302 Components For
SNF VBP
• SNF Performance Scores
• SNF Ranking Based on Performance
Scores
• Readmission Rate – first measure
• Quality Measures – alignment with health
care providers
• Value Based Incentive Payment
• Public Reporting
55
The Road to VBP
Data gathering and review!!!
HHS - Establish SNF all-condition hospital readmission measure PRIOR to 10/1/15
HHS - Establish SNF all-condition risk-adjusted preventable hospital readmission measure
HHS - Begin providing “confidential feedback” to SNFs quarterly
PUBLIC REPORTING - Readmission Measure on Nursing Home Compare Site
Medicare reimbursement rates for SNF will be based partially on their performance scores beginning on October 1, 2018.
10/1/15
10/1/16
10/1/18
10/1/14
10/1/17
Initiatives
Hospital Readmission Reduction Program
Acute
Skilled Nursing
Home Care
Hospice
Soon…Assisted Living 57
READMISSIONS – WHY THIS
FOCUS?
HRRP October 2012
Started October 2012
• Not paying for readmissions within 24
hours of discharge
• Medicare will “recover” payments for
unnecessary readmissions within 30
days of discharge if the patient has one
of the above 3 conditions
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Potentially preventable hospitalizations from
Medicare and Medicaid Research Review from
2014
OIG
OIG
OIG
OIG
Destination: Quality + Value = Lower Cost
Start 2010
Arrival 2015 and beyond
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ASSESS READINESS
Assess Organizational
Readiness
Assess Organization Systems
– Corporate Programs and Outcomes
– Facility specific protocols
Assess need to change
Benchmark internal systems for review
– Current status
– Industry standards
– Best practice approach
Identify opportunities
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Assess Organizational
Readiness
Assess Clinical Readiness
– Your Role
– Industry initiatives
– Market initiatives and expectations
– Quality Outcomes
• Payer and External Expectations
• Consequences
– Internal competency process
– Right People and Right Roles
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Resources
DATA AND QUALITY
MEASURE
Data Driven Decisions
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• Data Driven Decisions
–Understand what the real business
question is. (Who, What, Why, When,
How)
–Create an analysis plan with
hypotheses.
–Collect or review the “right” data
–Gather insights
–Make recommendations
–Take action
Leadership Strategies
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PUBLICALLY REPORTED
DATA
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Five Star Ratings
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Benchmark Data
• Your organization’s performance is being compared,
right now, to other facilities across town and across the
country.
– Hospital performance data is readily available
– Gathering meaningful data is vital in the era of “pay for
performance,” and payers and agencies are calling for
more transparency in quality improvement data.
– Need for benchmarking is growing
76
Quality Mapping
Develop quality strategy • Goals
• Prioritize
• Impact
• Systems and tools needed to change processes
• Resources applied or needed
• Time frames
• Approval/Agreement
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Most Important - QAPI
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QAPI
Together, Quality Assessment and Process
Improvement provide the model for:
– effective problem identification
– root cause analysis
– system and culture changes
Establish care delivery improvements to
realize healthcare consumer defined goals.
79
PREPAREDNESS AND
PROTECTION
Preparedness and Prevention
Audit Entities 2015
82
Preparedness and Prevention
High Risk Areas
• Sudden changes in billing
• Spikes in billing
• Compromised identities
(provider/beneficiary)
• High error rates
• RUG changes or discrepancies
• Overpayments/underpayments
– MDS
– RUGs distribution
– Therapy Utilization
– Quality Measures
– Claims submissions
– Patterns of errors
– Spike in reimbursement
– Readmission/Discharge data
– Survey Results!
Organization Data used by
Auditors
Data Driven Decisions
85
INNOVATION
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Strategic Innovation
• Creation of growth strategy
• Creation of new products or services
• Creation of business models that
change the game
–Generating significant value for
new consumers, customers and the
organization
“Today’s successful business leaders will be
those who are most flexible of mind. They will have
the ability to embrace new ideas and routinely
challenge old ones. They will be alert to learning
from others and quickly adapt from the best.”
– Tom Peters
“I skate to where the puck is going to be, not
where it has been."
– Wayne Gretzky
Implementation
• Facility Overall Goals
– Increase communication
– Efficiency and effectiveness
– Collaboration with partners
– Reduce redundancy
– Determine roles and anticipated processes
– Improve patient outcomes
– Care Transitions
Implementation and Innovation
For Sustainability
Preparation
Operational Readiness Assessment
Services
Internal Systems
Team composition
Increase clinical competencies
Validation and benchmark data
Excellent outcomes – quality and financial
Evaluate, reposition, partner and implement
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Vision for Change
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Redesign – Innovation
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“Great leaders are almost great simplifiers, who can
cut through issues or doubt to offer a solution
everybody can understand.”
Colin Powell, Statesman,
General Retired
95
Thank You!
96
Lisa Thomson
Chief Marketing and Strategy Officer
Pathway Health
