The Delivery System of the Future: Own the Continuumfiles.ctctcdn.com/1e4d6496be/6cff8ebf-bd37-4548-a8a4-fea... · 2016-02-23 · ‒Torrance Memorial Health System 2016 3. Part One

The Delivery System of the Future: Own the ContinuumHEALTH DIMENSIONS GROUP NATIONAL SUMMITJosh Luke, PhD, FACHEMarvin O’Quinn, SEVP and COO, Dignity HealthFebruary 23, 2016

The Health System of the Future Lead. Follow. Or get out of the way.

JOSH LUKE, PH.D., FACHEUniversity of Southern California, Price School of Public Policy

Author, Readmission Prevention: Solutions Across The Provider Continuum

Founder, National Readmission Prevention Collaborative (2013)

Founder, National Bundled Payment Collaborative (2015)

Strategic Adviser, Nelson Hardiman Law/Compliagent

Josh Luke, PhD, FACHE

• SNF Administrator/AL Executive Director‒Kindred, Windsor/SNF Management, Life Care Centers of America

• Hospital CEO ‒Memorial Hospital, Western Medical Center, Anaheim General

• CEO for Acute Rehab ‒HealthSouth Las Vegas Rehab Hospital

• Vice President Post Acute Services ‒Torrance Memorial Health System

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Part One

Why I Became a Patient Advocate

2016 4

52016

1998 - It Was a Very Good Year

1998—It Was a Very Good Year

62016

Career Change

• My grandmother was ill and being juggled through the system

• Entered AIT program for Life Care Centers of America‒The best leadership lessons of my career

‒Discovering empathy: a heart for caring

• Became a hospital CEO two years later

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Part Two: The Fee for Service Free-For-All

From Volume to value: How we got here and where we go from here

2016 8

9

The Fee For Service “Free For All”

2016

Grandma Belva: 1920 - 2002Home $0Hemet Valley Medical Center $48,000LTACH $52,000Nursing Home $12,000Home with Home Health $4,000Hemet Valley Medical Center* $36,000Nursing Home $18,000Assisted Living with Home Health $4,000Hemet Valley Medical Center* $42,000Nursing Home $24,000Hemet Valley Medical Center* $58,000

$298,000

Provider and physician got paid at every stop:

Episode- based reimbursement

Tommy Olmstead v Lois CurtisU.S. Supreme Court Decision, June 1999

“Patients in an acute hospital have the right to be discharged to the least restrictive environment.”

“Continued institutionalization of patients who may be placed in less restrictive environments often constitutes discrimination.”

2016 10

“Operationally, physicians and hospitals must first rule out the least restrictive environment.”

The Transformation of the Acute Hospital: The C-suite Must Take Action

Coordinating care for improved outcomes:

• Hospitals must act likehealth systems

• Health systems must act like managed care organization

• Thus, the hospital must act like a managed care organization as well

• Mandated post acute care plans –October 2015

11

Hospital

HealthSystem

Managed Care

2016

Financial Incentives to Avoid Unnecessary Hospitalization

Welcome to the world of…Admission Prevention

• RAC Audits

• Hospital readmission penalty program

• Accountable Care Organizations

• Bundled Payments

• Medicare Spending Per Beneficiary penalty

• Better, smarter, healthier: In January 2015, HHS announced goal for 30% of Medicare spending in ACO/Bundle by 2016 and 50% by 2018

• Proposed Medicare Spending Per Beneficiary post-acute penalty

2016

Why Hospitals and ACO’s are Engaging No-cost Community Providers to Manage Post Acute Spending and Episodes

7 PROGRAMS & 18 REASONS HOSPITALS ARE FINALLY REACTING

Program/Initiative Revenue Opportunity

Cost Savings Penalty Exposure

ACO Shared Savings Yes - $ ↓ Yes - $Bundled Payments Yes - $ ↓ Yes - $

Value Based Initiatives Yes - $ ↓ Yes - $Readmission Penalty No ↓ Yes - $

Medicare Spending Per Beneficiary

No ↓ Yes - $

Better. Smarter Healthier. (30% in an APM by 2016; 50% in an APM

by 2018)

Yes - $ ↓ Yes - $

Care Plan Act No ↓ Yes - $

2016

What Does This Mean for You?

Hospitals = Last resort

SNF = Second-to-last resort

Home health = Networks will be narrowed

Winners = Home care, private duty, and assisted living

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Story TimeOnce Upon a Time…

15

The Fee-for-Service Free-for-All Era

Post-ACA Era

Old Hospital = 290 bedsNew Hospital =

249 beds

Hospital Bed Capacity

2016

Part Three: Strategies to Succeed in the New Era

Understanding Alternative Payment Models

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Home

SNF

Home Care/ Health

Dr. Office

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Alternative Level of Care Pre-Authorization Required?

Doctor’s Order

Required?

Notes

Observation Floor No Yes High Cost to Hospital; should be last resort

Physician Office/Urgent Care No No

Long Term Acute Care (Alt Acute) No Yes New admission criteria makes this process more challenging but still an option if patient meets STACH criteria

Acute Rehab No Yes Easiest

Skilled Nursing/Sub-Acute No** Yes ** Patients discharged from a hospital or SNF within last 30 calendar days

Assisted Living/Board & Care No No Cash pay; not a covered benefit; discharge delay

Home Health No Yes

Home Care No No Patient pays; not a Medicare covered benefit but no caps or limits on service

Hospice or Palliative No YesAcute Psychiatric Hospital Yes Yes Can vary based state to state

Options for Direct Transfer from Emergency DepartmentPatients with a Medicare benefit can be transferred directly from the Emergency Department to the following levels of care

Luke, Josh, 2016: www.joshluke.org; www.NationalBundledPaymentCollaborative.com

http://www.joshluke.org/

http://www.nationalbundledpaymentcollaborative.com/

Emerging Trends For Health System Revenue Enhancement

Health Systems Revenue Streams1. Home care & private duty

2. Home health services (services capped)

3. Chronic care management- $35 to $45 per month (code 99490)

4. Transitional care management‒Range from $135 to $350 (codes 99495 and 99496)

2016

Post-Acute Opportunities & Expectations

1. Align with hospital based home health and home care

2. SNF’s should be skipping home health upon SNF discharge

3. Deliver data consistently on the 15th each month

4. Prep for disappearance of the 3 midnight rule

5. Prep for criteria/performance-based payment

6. Tools to Implement in facility: POLST ,Interact, Log readmits

7. The Super SNF: Where will the LTACH, IRF and Med Surg patients go?

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Bundled Payment: Competing for the Post Acute Dollar

Hip Replacement Case $40,000 for episode (hypothetical for illustration)

Acute Stay = $20,000 or 75%$18,000 $10,000 $2,000

Hospital Surgeon Anesthesia

Built in Margin For Initiator/Convener = $4,000 or 10%

Post Acute Care (All encompassing) = $6,000 or 15%Includes LTACH, IRF, SNF, Home Health, *home care, *assisted living, palliative and *other

In 2015 app. 42% of joints were discharged from acute to SNF. Projected to be only 20% by 2018.

That leaves 80% for home based providers!

* Not required to be a Medicare participant if application states service

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2016 21

Model 1 Model 2 Model 3 Model 4

Episode All acute patients; all

DRGs

Selected DRG’s, hospital plus post

acute period

Selected DRG’s, post acute period

only

Selected DRG’s, hospital plus

readmissionsServices included in Bundle

All Part A services paid as part of the MS-DRG payment

All non-hospice Part A & B services

during the initial inpatient stay, post

acute period & readmissions


during the post acute period & readmissions


(including the hospital &

physician) during initial inpatient stay& readmissions

Payment Retrospective Retrospective Retrospective Prospective

Severity of Financial Impact of avoidable Hospitalization

Medium High

Note: CCJR most closely resembles

Model 2.

High Severe (reduction in initial episode payment;

impacts health systems immediate

cash flow)

All Bundled Payment Models Impacted by ED Admissions

Source: HIN Reducing Readmission Survey, November 2009

Part Four: Challenges to Transformation

Case managers. Discharge planners. Care Managers…

Should I stay or should I go?

2016 22

Will hospital and post acute discharge planners transform?

Re-program discharge planning

‒Required by Care Management Act

‒First option for all patients is to go home if possible

‒Every post acute dollar spent has financial impact

‒Discharge planners can no longer assume patients are unwilling to pay; many services are capped

2016

The Discharge Planners New Role:Adopt a Home-First Mentality

LTACH AcuteRehab

SNF Home Health

Home Care

Assisted Living

Transit-ional

Care Visit

Chronic Care Man.

HospicePalliative

Degree of Financial and Quality Penalty to DischargingHospital

Severe Severe Moderate Nominal None None Negligible(its less

than 10% of the cost

of home health –and it

covers 30 of 60 days)

Negligible NoneNA

Discharge Level A A LR NR FO FOADH AHD ADWCD NA

Patient Financial Responsibility

Varies Varies 20% after 20 days

Nominal $ $ Nominal Nominal NA

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A – Avoid, LR – Last Resort (if patient is unsafe to go home with resources)FO – First Option and consideration for all patients NR – Only if the patient has No Resources to pay for Home Care, AHD – Order for All Home Discharges ADWCD – Order for All Discharges with Chronic DiseasesFOAHD – First Option After Discharge Home; Assisted Living can cause delays in hospital discharge; engage AL before discharge

My Legacy: Going Purple for My MomRaising $20,000 in 2016 to Fight Alzheimer’s Disease!

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•Passion•Empathy•Fight•Use your gifts•Legacy

Values

2016

Josh Luke, Ph.D., [email protected]

Are you Leading? Following? Or being left behind?

262016

Available at ACHE.org/publications

www.joshluke.org

www.NationalReadmissionPrevention.com

www.NationalBundledPaymentCollaborative.com

Clinical Integration:The Bridge to Accountable CareMarvin O’QuinnSEVP & Chief Operating Officer

February 23, 2016

28

• Introduction to Dignity Health

• Current State of the Industry

– From Volume to Value

– Population Health

• Integrated Delivery Network Strategy

– Clinical Integration (CI)

– Physician Interest & Responsibilities

• The Bridge to Accountable Care

• Bundled Payments

– Model 2

• Dignity Health Partnership with naviHealth

– Post-Acute Network

– Results in the Inland Empire

• Growth Strategy

Overview

29

Who We Are

As of September 30, 2015

21 400+ 9,000 59,000 39 667,000State

NetworkAffiliated

AccessPoints

Affiliated Physicians

Employees Acute Care Hospitals

Attributable Members

30

• On a recent “Face the Nation” episode, there was a panel discussion about former presidents who were skilled at helping their country overcome challenges in the 21st century.

• The discussion noted traits, common to effective leaders:– Resilient

– Inspiring

– Collaborative

– Great communicators

Common Leadership Traits

Health Catalyst. 2014. Top 7 Financial Healthcare Trends and Challenges for 2016.

31

Continued Shift from Volume to Value-Based Care


32

Lead the way:

Continued Shift from Volume to Value-Based Care

Understand clinical measures: healthcare financial leaders need to get a handle on clinical quality and how much it costs to achieve a unit of healthcare outcome and quality.

Develop cost systems to quantify your margins: develop new, automated systems that show costs for activities across all sectors

Create your risk vision: we’ve been under various CMS quality programs for years. If you aren’t improving yet, then you need to prioritize helping your teams improve.


33

• Population health is the recurring theme in a recent interview of healthcare leaders from the 21 winning Healthcare IT News’ 2015 Best Hospital IT Departments.

• Fort HealthCare’s Senior Director of IT effectively summarized the increasing prioritization of population health:

Population Health is a Top Priority

“Population health is 100 times bigger and the road isn’t yet paved; it isn’t just about the data or the tools used by clinicians, it really is about changing the way healthcare organizations think about practicing medicine.”


34

Lead the way:


Get comfortable with blurred lines: provider and payer roles will become less obvious, and we’ll continue to rely less on four-walled structures.

Learn the new terminology: Are you familiar with Return on Engagement? In a PMPM capitated environment, you must budget time and resources for all patients.

Know how to treat a population: and take risk for that population. Load claims data and analyzing physician, diagnosis codes, and treatment pattern data.


35

Lead the way:


Learn new measurements: with 23.5 ACO and 7.8 million Medicare ACO patients, you must know your population to define how to measure success.

Collaborate to improve the care continuum: identify partner organizations and stakeholders you’ll need to collaborate with to achieve a broader definition of care.

Study patient flow: start by identifying the bottlenecks at your hospital or clinic. Use data to study patient movement and focus on improving the admission/discharge process.


36

• Using technology to engage patients will be a focal point of patient engagement conversations in 2016.

• Half of patients hospitalized in the last year started using wearable technology after their hospital stay.

• Lead the way:

Engaging Patients Through Technology

Understand how different patient segments use technology: technology is not a one-size-fits-all solution. Understand how different patient segments use technology.

Attend the International Consumer Electronics Show: CES is a global consumer electronics tradeshow that takes place every January in Las Vegas.


• Leveraging Horizon 2020 strategies to build a system poised to address the demands of accountable care

Dignity Health: Moving Towards Accountable Care

Current

• Episodic Care

• Volume Driven/Fee-For-Service Payment Systems

• Acute Care Provider

• IT Systems in Silos

• Hospital-Physician Centric Interactions

Future

• Population Management

• Bundled Payments/Pay-For-Performance

• Diversified and Integrated Delivery System

• Integrated Information Systems Across Multiple Care Delivery Locations (Acute, Ambulatory, Home Health, Retail)

Horizon 2020 StrategiesGrowth, Cost, Quality, Integration, Connectivity, Leadership

Mission, Vision and Values37

38

Old Model of Stakeholders is Obsolete

HEALTH SYSTEMS DOCTORS HEALTH

PLANS CMS

The New Era Model is Joint Accountability!

39

Integrated Delivery Network Strategy

New payment models

Partnerships• Specific

expertise• Expand

continuum of care

Acute care market infill

Non-acute capacity growth

Clinical integration and other physician alignment

• Patient-Centered

• Aligned Networks

• Improved Outcomes

• Shared Risk

• Managed Populations

Components of Clinical Integration

Clinical Integration

Selective membership

criteria

Commitment to standardized

care

Care coordination infrastructure

Performance management

system

Legal, meaningful

performance-based incentives

Capability to jointly contract

with commercial payors

Adapted from The Advisory Board, “Building the Performance-Focused Physician Network.” 2010.

40

1. Improve quality of care

2. Increase efficiency/reduce cost

3. Provide a structure for independent and aligned physicians to partner with hospitals

4. Gives physicians opportunity to get be rewarded for their hard work via beneficial contracts

5. Facilitate physician buy-in for hospital quality and cost initiatives

Why Clinical Integration?

41

Model ReasonableCost

Includes All

Specialties

Joint Contracting

Employment - + +

Clinical Integration + + +

Co-Management + - -

Bill Clinton at California Association of Physician Groups Conf. 6-8-13 42

Our only hope for the 21st Century is to form a “mass thick network of creative collaborators.”

43

Physician Alignment and Clinical IntegrationFiscal Year End June 30

*IMS, One Medical, and Identity Medical Group

0

1,000

2,000

3,000

4,000

5,000

6,000

FY 12 FY 13 FY 14 FY 15 Q1 16

Partner Aligned groups*

Employed Model MedicalGroups (not in CI)Bakersfield CI

Redwood City CI

Ventura CI

Arizona CI

Inland Empire CI

Nevada CI

Growing Networks with over 5,700 Physicians Multiple Options for Alignment

Obtained Limited Knox Keene License

Health Plan Infrastructure in place

Employed

Aligned

Integrated

44

Momentum in Value Based Contracting

12/31/2009 07/01/14 6/30/2015 9/30/2015

Capitated Contracts

Primary Care Capitation

ACO

Bundled Payment

Narrow Network

Direct 2 Employer

Patient Centered Medical Home

On or Near Site Medical Offices

Other

Agreements

Attributable Lives667,000

596,000544,000

107102

74

105,000

20

45

CI Network Organizational Structure: Physician Led & Physician Driven

MedProVidex CI Program Network

Operating Agreement

Board of Managers

Initiatives Committee

PayerCommittee

Remediation Committee

Management Services Agreement

46

Physician Responsibilities for Membership

• Adopt and adhere to physician-developed standards to improve quality and efficiency

• Collaborate with colleagues to improve performance

• Agree to be measured and to share quality data with the network via technology provided with the program

• Be accountable for compliance with network policies and procedures

• Maintain medical staff privileges at or referring relationship with the local Dignity Health member hospital

5,700 participating providers

50% of Dignity Health’s total medical staff

Dignity Health’s CI program has been presented to the

FTC

47

Clinical Integration: The Bridge to Accountable Care

Fee-for-Service

Accountable Care

Opportunities Shift Towards Population Health

Clinical Integration Program

(Physician Network, Quality & IT Infrastructure)

CommercialPPO ACO Commercial

PPOP4P

MedicareAdvantage

MedicareACO

CMS Bundled Services

Managed Medicaid /

Duals

Patient Centered Medical Homes

Direct to Employer

48

49

CMMI’s Alternative Payment Methodology Focus

> 6,000 organizations participating

600 + ACOs (CMS and Commercial)

Bundled Payments for Care Improvement & ACOs

Bundled Payments for Care Improvement

Primary Care Transformation

Initiatives to Speed the Adoption of Best Practices

Initiatives Focused on the Medicare-Medicaid Enrollees

Initiatives Focused on the Medicaid and CHIP Population

Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models

Comprehensive Care for Joint Replacement (CCJR) Model

Accountable Care

50

BPCI Model 2: Went Live on January 1, 2014

naviHealth Market Presence

Health Plan BPCI Health Plan & BPCI

Enterprise Footprint

Enterprise 75 markets 70 hospitals 1 physician practice 7 BPCI partners 8 MA partners > 100,000 episodes managed 1.5 million MA lives

25 Hospitals 18,528 episodes managed

Dignity

naviHealth is the only company with a proven operating model for managing post acute care at scale across multiple markets

Dignity Health and naviHealth Care Coordination

Pre Admission Acute SNF/ IRF/ LTAC Home Health

Health Services Liaison

• Non-clinical support team

• BPCI patient identified

• Performs Health Risk Assessment (HRA+)

• nH Care Coordinator communicates HRA+ results to care team at patient’s next level of care

Inpatient Care Coordinator (ICC)

• RN, LPN, PT/OT

• Goal to help inform the discharge disposition

• Identifies and educates patient and family on BPCI program

• Performs risk assessment

• Generates OPTTM

• Discussion of Preferred Provider list

• Warm handover to care team at patient’s next level of care

Skilled Inpatient Care Coordinator (SICC)

• PT/OT

• Performs admission and weekly LiveSafeTM to guide discharge planning discussion

• Collaborates with PAC care team to identify patient’s ongoing needs

• Warm handover to care team at patient’s next level of care

High Risk Case Manager (HRCM)

• Performs regular assessments including LiveSafe and other care management assessments

• Performs medication reconciliation

• Interventions tied to risk score

• Actionable interventions

• Risk rounds to move patients through the continuum

• Some markets may be in market resource, others, telephonic

A key value the Coordination Model provides a seamless management of patient care throughout the care continuum.

52

53

Initial Results from naviHealth’s Engagement

Reduction in Readmissions

from PAC

-15%

54

• BPCI patients identification hardwired with 85% accuracy• 74% (target: 80% ) referral rate to participating post acute

providers• 15% improvement in 90-day readmission• Hospital Care Coordinators and naviHealth to drive appropriate

post-acute care placement• Positive feedback from patients – 80-85% Medicare FFS patient coverage

• Volume doubled in Home Health over 3 quarters

Key Performance Outcomes – Inland Empire

55

Grow, Diversify and Expand the Continuum

Our growth strategy is evolving to leverage our

strides in innovative ambulatory care

models, expand our integrated delivery

networks, and grow our footprint

IDN Growth: New Markets

IDN Growth: Existing Markets

Health Plan Partnerships

Strategic Innovation

New Business Verticals

Physician Alignment and Population Health

International Markets

56

Partnerships to Expand Access

JV Partnership JV Partnership

• Innovative micro-hospital model

• Partner in Las Vegas market, branded as Dignity Health care sites

• Evaluating expansion to other markets

• Minority owner in parent company

• Consumer focused urgent care

• Launching partnership in Bay Area

• Co-branded with Dignity Health

• Evaluating expansion in other markets

• Video visit platform• Cost-effective care model• Selected by U.S.

HealthWorks as video visit partner

• Piloting with Dignity Health Medical Foundation

• 2016 Launch

57

Strategic Innovation – Areas of Focus

Chronic disease management

Patient as consumer

Continuum of care

Next generation operations

Opportunistic

58

• Consistent progress on strategic transformation

• Evolution of growth strategy

• Leveraging IDN strategies, diversified assets and partnerships

• Financial resources sufficient to support strategy

• Strong leadership team focused on building capabilities and next generation of leaders

• Delivering on commitment to our communities and our financial stakeholders

Concluding Remarks

Thank You

59

Documents

The Delivery System of the Future: Own the Continuumfiles.ctctcdn.com/1e4d6496be/6cff8ebf-bd37-4548-a8a4-fea... · 2016-02-23 · ‒Torrance Memorial Health System 2016 3. Part One