GROWING PACE WHILE NAVIGATING COMPETITION · Growing PACE While Navigating Competition National PACE Association Annual Meeting October 24, 2016 Jade Gong and Associates @ JadeGongRN

Growing PACE While Navigating Competition

National PACE Association Annual Meeting

October 24, 2016

Jade Gong and Associates

@ JadeGongRN 1

GROWING PACE WHILE NAVIGATING

COMPETITION

NATIONAL PACE ASSOCIATION ANNUAL MEETING

OCTOBER 24, 2016

PANEL PRESENTATION AND DISCUSSION

2

PACE in the World of Value-

Based Care

Jade Gong, RN, MBA Principal, Jade Gong & Associates

Edo Banach, JDPartner, Gallagher, Evelius & Jones

PACE Innovation With and

Without Innovation

PACE Expansion at Trinity

Health PACE

Anne LewisVP, Trinity Health PACE



October 24, 2016


@ JadeGongRN 2

3

TARGET MARKETSERVING THE 8.2 MILLION DUAL ELIGIBLES WHO

ARE NOT NOW IN ORGANIZED SYSTEMS OF CARE

Source: Bipartisan Policy Center, Delivery System Reform: Improving Care for Individuals Dually

Eligible for Medicare and Medicaid, September 2016, page 18

8.2M

2.1M

Dual Eligibles

Not in System of Care In System of Care

* Includes enrollment in MMP, FIDE and PACE in 2015

4

• Center of gravity for patients,

families: where patients want to be

• Most illness, suffering, coping,

caregiving take place in the home

• Failure of home care environment

leads to hospitalization as care of

last resort

• Less than 3% of total health care

spending, but…

• 50% of total health care effort

- Very little research or medical

education in this setting

- Little-to-no professional medical

attention

PAYOR FOCUS ON CARE @ HOME



October 24, 2016


@ JadeGongRN 3

5

EMERGING RISK-BASED PAYORS NEED

ASSISTANCE WITH LONGITUDINAL CARE

MANAGEMENT @ HOME AND ACROSS SETTINGS

Home PCP SNF HHAOther PAC

Home

Hospital

Current Focus

Lily Tomlin

6

The tipping point is that

magic moment when an idea,

trend, or social behavior

crosses a threshold, tips,

and spreads like wildfire.

Malcolm Gladwell

Author, The Tipping Point



October 24, 2016


@ JadeGongRN 4

SCALING “CLASSIC” PACE AND NEW PACE

Traditional

PACE

Accelerants

• Flexibility with primary care, community-

based physicians and core assessment

team (proposed)

• Telehealth and home-based technologies

• For Profit PACE / Venture Capital

• New populations allowed by Innovation

Act (PD/IDD, under age 55, not yet NH

eligible)

Scaled

PACEFor Traditional and

Expansion Populations

7

• Grow “classic” PACE and consider “new” PACE

• Partner with other plans taking risk for high

cost/high need populations

• Consider other innovative models such as

MediCaring Communities

• You growth plan should assess:

- Where are the emerging opportunities in your

local market?

- Where can PACE infrastructure and expertise

add value and improve care?

8

DEVELOPING YOUR GROWTH PLAN



October 24, 2016


@ JadeGongRN 5

INNOVATION: PACE AS A MEDICARING

COMMUNITY

Source: Gretchen J Lynn, MediCaring Communities: Getting what We Want and Need in

Frail Old Age at an Affordable Cost. Altarum Institute, 2016. Available on Amazon.com

9

VALUE-BASED PAYMENT ACCELERATES

CMS Target 50% of FFS

payment through APMs

by 2018

Health Care Transformation Task Force Target of 75% through

Value-Based Payment by 2020

MACRA Physician Payment Report APM Incentives

begin in 2019

10



October 24, 2016


@ JadeGongRN 6

MEDICARE ALTERNATIVE PAYMENT

MODELS IN 2018 AND BEYOND

Medicare 2016

69 % FFS

34 % Alternative Payment

ACOs Bundled Payment

34% FFS

31 % Medicare

Advantage

CMS has

already

reached its

2016 target of

30%

alternative

payment

11

NEW PHYSICIAN PAYMENT 2019

12

Beginning in 2019, physicians will receive a 5 % bonus if a

significant proportion of revenue from APMs



October 24, 2016


@ JadeGongRN 7

Fully Integrated Dual Eligible Special Needs

Plan (FIDE SNP)

13

COMPETITORS – DUAL ELIGIBLE PLANS

PACE

Medicare and Medicaid Plan (MPP)

Financial Alignment Demonstration

Medicare ACOs

14

COMPETITORS AND COLLABORATORS

Medicare Advantage

Plan

D SNP MLTSS



October 24, 2016


@ JadeGongRN 8

• An ACO should have a financial incentive to reduce the total costs of care for a Medicare beneficiary and manage care across settings

• However, most ACOs have not accepted downside risk(about 5 %)

• Complex care management is not a priority for ACOs that do not have downside risk

• There are more Physician Group Practice sponsored ACOs that hospital sponsored ACOs; more PGP sponsored ACOs achieved shared savings

• Substantial ACO growth in models with downside risk expected due to MACRA incentives on physicians

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/sharedsavingsprogram/Downloads/MSSP-ACO-data.pdf

STATUS OF ACOS TODAY

16

ACOS PAID VIA SHARED SAVINGS:

MEDICARE EXAMPLE• Current average per-capita spending for Medicare patients in

market area determined from claims for past three years

• Spending target is determined by CMS

• If actual spending lower than target, savings are shared IF quality targets are also achieved

16

ActualShared Savings

ACO Launched

TargetProjected

Adapted from Brookings Institute

Today, only 5% of

Medicare ACOs

have downside

risk. Change by

2019.



October 24, 2016


@ JadeGongRN 9

Pioneerupside & downside

risk

MSSP

Track 1

upside risk only

MSSPTracks 2 & 3

upside & downside risk

Next Generation

upside & downside risk

17

THREE MEDICARE ACO MODELS WITH

DIFFERENT LEVELS OF RISK BEARING

Only ACOs with downside risk have

strong incentives to manage care

CONTINUED MEDICARE ACO GROWTH *

18

146

243

353

404

460

0

50

100

150

200

250

300

350

400

450

500

2012 2013 2014 2015 2016

Medicare ACOs

66%

45%

14%

14%

* Includes MSSP, Pioneer and Next Generation ACOs



October 24, 2016


@ JadeGongRN 10

19

ACO PENETRATION VARIES BY STATE

Source: http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-

private-and-public-sector-growth-and-dispersion/

• There has been a steady growth in MA

enrollment from 19 percent in 2007 to 31

percent in 2016

• 23 states have a MA penetration of at least

30 percent

• D-SNP and MLTSS integration show promise

in integrating care

20

STATUS OF MEDICARE ADVANTAGE PLANS

TODAY

http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-private-and-public-sector-growth-and-dispersion/



October 24, 2016


@ JadeGongRN 11

21

MEDICARE ADVANTAGE GROWTH CONTINUESDEFACTO PAYMENT REFORM – NATIONAL ENROLLMENT 31%

Source: Gretchen Jacobson, et al., as published on Kaiser Family Foundation May 11, 2016,

http://kff.org/medicare/issue-brief/medicare-advantage-2016-spotlight-enrollment-market-update/

22

OVERALL MEDICARE ADVANTAGE PENETRATION

AT 31% BUT GREAT VARIATION ACROSS STATES

Source: Gretchen Jacobson, et al., as published on Kaiser Family Foundation May 11, 2016,






October 24, 2016


@ JadeGongRN 12

23

D SNP ENROLLMENT VARIES BY STATE

Source: Kaiser Family Foundation State Health Facts. Medicare Advantage:

Special Needs Plan (SNP) Enrollment, by SNP Type http://kff.org/medicare/state-

indicator/snp-enrollment-by-snp-type. Retrieved 10/201/16

• Goals of MLTSS:

• Hold a single entity accountable for outcomes (quality, cost)

• Have a predictable budget

• Shift balance from institutional care to HCBS

• Improve coordination of care across settings and providers

• 23 states have implemented one or more types of MLTSS

programs

• Enrollment increased from 800 K in 2012 to 1.2 million in 2015

• States leveraging housing and social services to keep people in

the community (Arizona, Texas)

• States expanding to ID/DD Populations (Tennessee, Texas,

Kansas)

24

STATUS UPDATE OF MLTSS PLANS

http://kff.org/medicare/state-indicator/snp-enrollment-by-snp-type



October 24, 2016


@ JadeGongRN 13

MLTSS PLANS ARE INTEGRATING WITH MEDICARE

AND EXPANDING POPULATIONS SERVED

Types of MLTSS

Medicare MCO: includes

Medicaid acute & LTSS

Medicaid LTSS only

Medicaid MCO

incorporated into FAD

Demonstration

Medicaid MCO + Medicare

D SNP

Medicaid MCO + FIDE SNP

Populations Served:

Seniors

Persons with ID/DD

Non-elderly adults with

physical disabilities

Full-benefit dually

eligible beneficiaries

26

DISRUPTORS WITH NEW BUSINESS MODELS

TRY TO BEND THE COST CURVE FOR HIGH

RISK/HIGH COST POPULATIONS



October 24, 2016


@ JadeGongRN 14

CHRONIC CARE MANAGER:

STARTING WITH HOME BASED

PRIMARY CARE AND IDT TEAM

• Provides home-based medical care to individuals

with multiple chronic conditions. 24/7 care is

provided by a team of physicians, physician

assistants, and nurse practitioners who deliver

house calls as part of an IDT team.

• Contracts with health plans and receives a

percent of premium and a share of savings.

• Currently contracting with 7 health plans serving

30,000 lives including 2 plans in NY State.

27

Source: CRAIN’s Health Pulse NY, September 7, 2016; Company Offering House Calls for

Medicare Patients expands to Metro New York

CHRONIC CARE MANAGER:

STARTING FROM PACE

• For profit venture-backed PACE program with

current enrollment of about 2,500 in Colorado

seeks SCALE

• Now expanding InnovAge Care Management to

help consumers, managed care and associated

senior service organizations provide life-long care

management services to members

• Care navigation team assesses every participant to

determine how older adults can best be served

28

Source: http://myinnovage.org/ProgramsandServices/InnovAgeCareManagement.aspx

Accessed on October 18, 2016

http://myinnovage.org/ProgramsandServices/InnovAgeCareManagement.aspx



October 24, 2016


@ JadeGongRN 15

29

DUAL ELIGIBLES IN ORGANIZED SYSTEMS OF

CARE

Source: BiPartisan Policy Center report on Delivery System Report, September 2016, page 18

http://cdn.bipartisanpolicy.org/wp-content/uploads/2016/09/BPC-Health-Dual-Eligible-Recommendations.pdf

Total Dual Eligibles 10.3 million

Total D SNP enrollment 1.7 million

Total MMP Enrollment 355 thousand

Total PACE Enrollment 33 thousand

Combined 20 % of

Dual Eligible Population

New Opportunities for PACEGrowth and Expansion

National PACE Association Annual Conference

October 24, 2016

http://cdn.bipartisanpolicy.org/wp-content/uploads/2016/09/BPC-Health-Dual-Eligible-Recommendations.pdf



October 24, 2016


@ JadeGongRN 16

©2016 Trinity Health - Livonia, Mich. 31

*Owned, managed or in JOAs or JVs.

**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.

***Includes multiple locations for Trinity Home Health Services, Trinity Senior Living Communities and PACE facilities.

Our 22-State Diversified Network

Home Care & Hospice Locations Serving 116 Counties47 Continuing Care

Facilities59PACE CenterLocations14

Hospitals* in 20 Regional Health Ministries**92 Mission Health

Ministries4Employed Physicians 5,300

Affiliated Physicians23,900National Health

Ministries***3

Trinity Health

• Dr. Richard Gilfillan, CEO of Trinity Health (TH) and past director of CMS Center for Innovation

• As the Innovation Center's first leader, Dr. Gilfillan was instrumental in ushering in new payment and delivery models such as Medicare ACOs and bundled payments and is using his vision to change how TH operates

“Continue to be the sponsor of the largest number of PACE organizations in the country”

32©2015 Trinity Health PACE - Livonia, Mich.

Trinity Health’s Visionary Leadership



October 24, 2016


@ JadeGongRN 17

Trinity Health PACE National Footprint

33

1

CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID

WY

OK

KSCO

UT

TX

NMSC

FL

GAAL 1MS

LA

AR

MO

IA

VA

TN

IN 1

KY

IL

M 1I

WV

WA

OH

PA 3

NY 2

VT

ME

CT

NJ 2

D.C.

WINH

MA

RI

DE 1MD

NC 1

AK

HI

PACE State

Non-PACE State

TH PACE State

Program State City Date Opened October 2016 Census

Catholic Health LIFE New York Buffalo 1-Nov-09 227

Eddy SeniorCare New York Schenectady 1-Oct-96 190

LIFE at Lourdes New Jersey Camden 1-May-09 235

LifeCircles Michigan Muskegon 1-Feb-09 292

LIFE St. Francis New Jersey Trenton 1-Apr-09 325

LIFE St. Joseph of the Pines North Carolina Fayetteville 1-Apr-11 280

LIFE St. Mary Pennsylvania Langhorne 1-Mar-10 244

Mercy LIFE (AL) Alabama Mobile 1-Jan-12 169

Mercy LIFE (MA) Massachusetts Springfield 1-Mar-14 177

Mercy LIFE (PA) Pennsylvania Philadelphia 1-Oct-98 718

Saint Francis LIFE Delaware Wilmington 1-Feb-13 195

Mercy LIFE –West Philadelphia Pennsylvania Philadelphia 1-Oct-98 454

Saint Joseph PACE Indiana South Bend 1-Aug-16 4

Total 3,510

Trinity Health PACE Organizations

TH PACE has experienced over 125% census growth since 2012



October 24, 2016


@ JadeGongRN 18

Trinity Health PACE Operating Model

35

• Trinity Health PACE (TH PACE) was formed in early 2015 to manage and support Trinity Health System's PACE assets including Trinity Health owned PACE organizations (PO) and POs operating under TH PACE ownership and management.

• TH PACE aligns with TH’s Continuing Care strategic initiative to expand services in the care of the dual eligible and service to the poor and underserved by:• Developing an infrastructure to support the delivery of services to the

PACE population• Leveraging the expertise of PACE Interdisciplinary Teams to manage

the dual eligible population in Non-PACE expansion programs• Developing new PACE through the operating company• Utilizing the combined strength of the PACE operating company to

shape industry and regulatory direction

As a National Health Ministry, TH PACE has multiple functions:

• Operator with direct ownership of PACE plans

• Manager of non-owned plans

• System level support to Trinity Health System PACE plans

36

TH PACE Functions

TH PACE

Operator ManagerSystem Support

Mercy LIFE of AlabamaMercy LIFE – West Philadelphia

Saint Joseph PACE

Future OpportunityTrinity System PACE

Organizations



October 24, 2016


@ JadeGongRN 19

•Expansion into Albany CountyEddy SeniorCare – New

York

•Expansion into Burlington CountyLIFE at Lourdes – New

Jersey

•Expansion into mid Bucks CountyLIFE St Marys –Pennsylvania

•Replacement Center in Bordentown

•Expansion into Middlesex County

LIFE St Francis – New Jersey

•Expansion into Montgomery CountyMercy LIFE SEPA –

Pennsylvania

•New center in existing service area St Francis LIFE – Delaware

•Existing center expansion

•Expansion into additional countiesLIFECircles – Michigan


FY 2016-2017 Growth Initiatives

• New Jersey – Lourdes Health System and St Francis Medical Center• Existing initiatives through DSRIP and Medicare Shared

Savings Program are effective; however, additional focus needed

• Developing through partnership with the Safety Net and Community Health

• Initiative resembles Patient Centered Medical Home

• Enter into a full risk arrangement with third-party payor to manage the health of dual eligible participants

• Establish clinic under the comprehensive care model to support high-risk dual eligible population served under full-risk arrangement


New Growth Opportunities: PACE - Light



October 24, 2016


@ JadeGongRN 20

Select Health Network, ACO Mishawaka, IN

• Select Health Network is a collaboration between Saint Joseph Health System and over 750 physicians and healthcare providers

• St Joseph PACE contracted with ACO as its provider network

• Select has identified at-risk prospects for referral to PACE

• Opportunity in New Jersey for

partnership with health

system ACO


New Growth Opportunities: Partnership with ACOs

Initiatives in process:

• New York sisters provide capital to fund PACE center

• Pennsylvania state requesting PACE to serve religious

• Indiana PACE reduce financial burden on brothers through assuming care


New Growth Opportunities: Partnership with Religious Organizations New York, Pennsylvania and Indiana



October 24, 2016


@ JadeGongRN 21

• LIFECircles, a partnership between Porter Hills, Mercy Health (Trinity Health), and Senior Resources

• Based on success of LIFECircles, an innovative model TANDEM 365 was developed and included collaboration between four CCRCs and an ambulance company help older adults with complex health needs navigate the complicated health care system

• Provided services not typically reimbursed by insurance companies and working directly with individual primary care providers, team members develop a comprehensive care plan for individuals age 55 and over who don’t necessarily qualify for nursing home care

• The PACE Innovation Act provides an opportunity for using the PACE Model of Care and lessons learned from TANDEM365 as a foundation to create a MediCaring Community which is aimed at meeting the needs of at-risk, Medicare-only beneficiaries


Michigan

PACE Innovation with or without the

Innovation Act

Edo Banach

October, 2016



October 24, 2016


@ JadeGongRN 22

PACE Opportunities and Threats

• Excitement surrounding PACE Innovation Act, but it is not yet a reality

• PACE Regulation is out, but it is incremental and only proposed

• PACE for-profit expansion, but with growth comes more scrutiny

• More focus on dual eligibles, but many other entities in the mix

• So…what’s a PACE entity to do?

43

PACE: Innovation without the Innovations Act

• Opportunities for Collaboration

• Focus on social supports, housing and employment

• Composition of the IDT

• Alternative Care Settings

44



October 24, 2016


@ JadeGongRN 23

Focus on Social Supports

• Housing

• Employment

• Healthy living

• Mobility

• Social connections

45

Alternative Care Settings

• Explore further CMS flexibility on Alternative Care Settings

• Push the use of technology to supplement in-person care

46



October 24, 2016


@ JadeGongRN 24

Opportunities for Collaboration

• Partnering with MCOs (Medicaid MLTC and Medicare MA)

• Partnering with ACOs

• Joint ventures

• Partnering with MMPs in states pursuing financial alignment demonstrations

• Partnering with religious, social, and housing organizations

47

PACE Innovation Act

• Provides CMS (CMMI) with the authority to waive the PACE Statute. This includes previously non-waivable PACE requirements:

• Under-55

• Non-nursing home eligible

• Also creates opportunities:

• to think about what additional innovations– in IDT composition, PACE Center, or ACS might be possible

• to creatively partner with housing, transportation, or other partners

48



October 24, 2016


@ JadeGongRN 25

DISCUSSION AND QUESTIONS

49

THANK YOU!

50

Jade Gong

703-243-7391

[email protected]

Anne Lewis

406-647-2980

[email protected]

Edo Banach

410-951-1421

[email protected]

mailto:[email protected]



Documents

GROWING PACE WHILE NAVIGATING COMPETITION · Growing PACE While Navigating Competition National PACE Association Annual Meeting October 24, 2016 Jade Gong and Associates @ JadeGongRN