paccr post-acute care center for research home based care & value-based purchasing presented to...
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paccr Post-Acute Care Center for Research
Home Based Care & Value-Based Purchasing
Presented to the American Academy of Home Care Medicine
byBarbara Gage, PhD
Sr. VP, Scientific Research and EvaluationPost-Acute Care Center for Research
May 14, 2015
paccr.org
paccr Post-Acute Care Center for Research
Today’s Evolving HealthCare Environment
Affordable Care Act established the Triple Aim: • Improve quality of care• Improve population health• Reduce cost of care
New focus on patient-centered episodes of care, not silos of service-centered care
Congressional mandate for quality reporting programs for all Medicare services
Innovative payment methods focus on episodes of care and incorporate outcomes in the payment methodology
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paccr Post-Acute Care Center for Research
Payment Innovations in Public and Private Insurance Sectors
Quality adjustments for hospital readmissions in FFS
Value-Based Payment systems for Hospitals, Physicians, SNF, HH, ESRD
Shared savings payments in ACOs, Gainsharing, Medical Homes, and Bundled Payments
Coordinated Care Programs for Dual-Eligible populations
Rebalancing grants for state LTSS programs (BIP, SIM, TEFT)
Carve-out and other innovations proposed in both private and public insurance sectors
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How Are these Innovations Changing The Health Care Marketplace?
Cultural changes incentivizing links between inpatient and community-based services
Coordination across caregivers (both medical and social support)
Communication/education of patient on options and available resources
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paccr Post-Acute Care Center for Research
The Medicare Population, 2010
Of the 47.6 million beneficiaries in the Medicare program: • Under 65 years old -- 16.9%• 65-69 years old -- 25.4• 70-74 years old -- 19.2• 75-79 years old -- 15.0• 80-84 years old -- 11.8• 85 years or older -- 11.8
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paccr Post-Acute Care Center for Research
Medicare Program Expenditures, 2010
National Medicare Expenditures in 2010 = $331B• Inpatient Hospital -- 38.9 %• Physician -- 28.7• Outpatient -- 14.4• Skilled Nursing Facility -- 8.2• Home Health Care -- 5.9• Hospice -- 3.9
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paccr Post-Acute Care Center for Research
What Types of Services Are Being Used In the Medicare Program?
20% of all Medicare beneficiaries hospitalized at least 1/year
• Admitted for a wide range of reasons including medical, surgical, functional diagnoses
Over 40% of the hospital cases will be discharged to PAC
Source: Gage et al. (2009). Examining post-acute care relationships in an integrated hospital system, ASPE, and MedPAC, (2014) June Report To Congress.
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paccr Post-Acute Care Center for Research
Utilization Patterns Following Hospital Discharge
Episode
Pattern1Count
(5% Sample)
Percent of PAC Users
(N=109,236) Cumulative
Percent
Mean Episode Payment
Mean Episode
Length of Stay
AH 25,238 23.1 23.1 $12,696 48.9AS 18,714 17.1 40.2 17,930 44.2ASH 8,474 7.8 48.0 22,208 76.4AO 6,533 6.0 54.0 8,165 40.0AHA 4,909 4.5 58.5 25,035 57.2AIH 3,066 2.8 61.3 30,915 69.3AHO 2,941 2.7 64.0 14,250 88.0ASAS 2,934 2.7 66.7 33,346 81.7ASA 2,092 1.9 68.6 28,106 47.2ASO 1,993 1.8 70.4 18,805 87.1AHAH 1,635 1.5 71.9 26,956 171.5AIO 1,467 1.3 73.2 27,270 79.1AI 1,382 1.3 74.5 25,330 17.4
NOTES:1. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF/
Source: Gage et al. (2009). Examining post-acute care relationships in an integrated hospital system, ASPE
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paccr Post-Acute Care Center for Research
CMS FFS Shifts Focus to Managing Care
2009: CMS ACE Demonstration
2012: ACOs go live; now over 350 Medicare ACOs
2012: Hospital Readmission Penalties instituted; up to 3% by
2015
2013: CBO Re-Scores Bundled Payments;
White House & MedPAC join conversation
2013: Bi-Partisan Bundling Legislation introduced in House 2014: BPCI
programs rollout
2019: Medicare FFS PAC Bundle???
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2014: Rep McKinley
introduces Bundling
Legislation in House
2014: Sen Wyden introduces Better Care,
Lower Cost Act
2014: CMS announces BPCI
expansion
President’s budget
includes PAC bundling savings
CMS releases 2
RFI’s
IMPACT Act becomes Law
Continued momentum and legislative initiatives to transform Medicare FFS reimbursement system, and incentivize more efficiently managed PAC
2005: DRA establishes PAC PRD
Post-Acute Care Reform Momentum Building
2010: ACA passed
paccr Post-Acute Care Center for Research
Mandated a PAC Payment Reform Demonstration to understand costs and outcomes across different PAC sites.
Three components:1. CARE: Standardized patient assessment instrument to measure severity in
hospitals, PAC settings2. Secure, electronic, interoperable standards-based data system for multiple
providers to share essential health information/improve transitions 3. Data collection to analyze costs and outcomes across sites (acute, SNF,
HHA, IRF, LTCH)
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Deficit Reduction Act of 2005
paccr Post-Acute Care Center for Research
ACA of 2010: Codified the Triple Aim- Better Outcomes, Better Population Health, Lower Health Care Costs Patient Centered
Care
Payments
Established new payment models to encourage providers to move to patient-centered care to achieve the Triple Aim:
Accountable Care Organizations – targeted hospitals and physicians• Built on various demonstration projects
o PGP, HCQ, High Cost Clinically Complex
Medical Homes – targeted physicians to coordinate care
Bundled Payments – targeted hospitals and PAC providers, or physicians to coordinate care
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paccr Post-Acute Care Center for Research
ACA of 2010: Codified the Triple Aim- Better Outcomes, Better Population Health, Lower Health Care Costs Patient Centered
Care
OutcomesEstablished Outcomes Analysis Mechanisms
• Hospital Reporting Metrics –• Hospital Acquired Infections – value matters
Broadened hospital responsibility • Established Hospital Readmissions program to account for 30 days post-
dischargeEstablished Quality Reporting Programs for IRFs, LTCHs, Hospice
• Rounds out the Medicare quality reporting programs to include remaining PAC providers
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paccr Post-Acute Care Center for Research
The Evolving National Quality Strategy
Establishment of the National Quality ForumDevelopment of scientific standards for measuring qualityMultistakeholder consideration of quality measures that meet 5 criteria:
important to measure, scientifically acceptable (reliable and valid), feasible to collect, usable/actionable, other related metrics
Stakeholder Prioritization of measure development: NQF workgroups on coordinated care, person-centered care, Alzheimer’s Disease/Dementias, Health Care Quality for the Dual-Eligible, LTPAC populations
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paccr Post-Acute Care Center for Research
What about the political environment combined with the payment and delivery transformation efforts underway made now the time to construct and pass the IMPACT Act legislation for Post-Acute Care?
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2014
paccr Post-Acute Care Center for Research
• Paves the way for “…standardizing post-acute care assessment data for quality, payment, and discharge planning, and for other purposes.”
• All PAC providers including HH, SNF, IRF and LTCH’s included
• Standardized collection on functional status, cognitive function, medical needs and conditions, impairments and other categories deemed necessary by Secretary
• Some data are already submitted by each PAC provider, but varies by type of provider, Act calls for replacing duplicative data collection
• Resource use data also collected to estimate per beneficiary spend
• Includes payment refinement provisions via report from MedPAC to Congress in 2016 based on PAC PRD data and report from CMS
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The IMPACT Act: What does it do?
paccr Post-Acute Care Center for Research
IMPACT Act Timeline for Quality Metrics by PAC Provider
Measure 2016 2017 2018 2019Cognitive function and functional status SNF, IRF LTCH HH
Skin integrity SNF,IRF, LTCH HH
Occurrence of major falls SNF, IRF, LTCH HH
Resource use and other measures SNF, IRF, LTCH HH
Medication reconciliation HH, LTCH SNF, IRF
Ability of a PAC provider to relay health information, and “care preferences” of an individual LTCH SNF, IRF HH
Alignment of claims data with standardized patient assessment data LTCH SNF, IRF HH
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@PAC_CR
Post-Acute Care Center for Research - PACCR
Barbara Gage, PhD, MPASr. VP, Scientific Research and [email protected](202) 697-3358 Post-Acute Care Center for Research
Connect with PACCR!
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