good-bye volume; hello value · 2019-10-08 · learning objectives define “value” in healthcare...

Good-bye

Volume;

Hello Valuepresented by

Irving L. Stackpole

Post-Acute Care

Learning Objectives

Define “value” in healthcare and post-acute care

Describe current reasons for high degree of variance in

post-acute care

Identify information & resources that managers can

and should access to establish programs to improve

value

List partners and models to develop and communicate

an effective program

Describe a 7 step process to build cross-continuum

collaborations

1. What is the “value formula”

in healthcare?

1. Value = Lowest Cost × Best

Outcomes

2. Value = Positive Outcomes –

Untoward Outcomes

3. Value = Quality ÷ Payment

(Total Costs)

4. Value = (Outcomes ×

Efficiency) × Patient

Satisfaction

5. Not sure

Audience Question #1

Volume to Value

Volume - Fee for Service

Value

4

Factors driving the shift from

Volume to Value

Healthcare in the US is too expensive

• Poor outcomes

Pressure in society - consumerism

Rising attention by CMS to PAC

• Mandated data analysis to prove effective

and efficient resource use (VALUE)

5

Copyright © 2017 Stackpole & Associates & Ability Network

Pressure for Aging Services

- Federal Debt as Percent GDP

Source: https://en.wikipedia.org/wiki/National_debt_of_the_United_States#/media/File:51129-land-summaryfigure1(1).png

2. Nursing center utilization

among those over 65 has

been increasing.

1. True

2. False

3. Not sure



The Percent of Population 65+ Using / Needing Skilled Nursing Services

5.21% 5.14%

4.71%

4.21%

3.48%3.23%

2.79%

2.35%

0%

1%

2%

3%

4%

5%

6%

1995 2000 2005 2010 2015 2020 2025 2030

Percent of USA Population using SNF age 65+ using a SNF on a daily basis


USA Historic / Current / Projected People in SNFs

1,751,302

1,795,388

1,724,582

1,703,398

1,663,365

1,824,056

1,840,988

1,744,279

1,550,000

1,600,000

1,650,000

1,700,000

1,750,000

1,800,000

1,850,000

1,900,000

1995 2000 2005 2010 2015 2020 2025 2030

Current and Forecast Number of SNF Pts Served Daily in USA


Medicare and Medicaid Nursing Home Expenditures

-$40,000

-$20,000

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

Y1

966

Y1

967

Y1

968

Y1

969

Y1

970

Y1

971

Y1

972

Y1

973

Y1

974

Y1

975

Y1

976

Y1

977

Y1

978

Y1

979

Y1

980

Y1

981

Y1

982

Y1

983

Y1

984

Y1

985

Y1

986

Y1

987

Y1

988

Y1

989

Y1

990

Y1

991

Y1

992

Y1

993

Y1

994

Y1

995

Y1

996

Y1

997

Y1

998

Y1

999

Y2

000

Y2

001

Y2

002

Y2

003

Y2

004

Y2

005

Y2

006

Y2

007

Y2

008

Y2

009

Y2

010

Y2

011

Y2

012

Y2

013

Y2

014

Y2

015

Y2

016

Y2

017

Y2

018

Y2

019

Y2

020

Y2

021

Y2

022

Y2

023

Y2

024

Y2

025

Nu

rsin

g H

om

e E

xp

en

dit

ure

s i

n M

illio

ns (

000)

1966 to 2025 Combined Historic and Projected Medicare and Medicaid Nursing Home Expenditures

Can the growth in funds keep pace with the need?

Medicare & Medicaid total nursing center expenditures are expected to decline as a percentage of overall expenditures.

1. True

2. False

3. Not sure



Nursing Home Care % of Health Expenditures

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Y1

96

6

Y1

96

8

Y1

97

0

Y1

97

2

Y1

97

4

Y1

97

6

Y1

97

8

Y1

98

0

Y1

98

2

Y1

98

4

Y1

98

6

Y1

98

8

Y1

99

0

Y1

99

2

Y1

99

4

Y1

99

6

Y1

99

8

Y2

00

0

Y2

00

2

Y2

00

4

Y2

00

6

Y2

00

8

Y2

01

0

Y2

01

2

Y2

01

4

Y2

01

6

Y2

01

8

Y2

02

0

Y2

02

2

Y2

02

4

1966 to 2025 Medicare/Medicaid Nursing Home Expenditures Percent of Total National Health Expenditures

Nursing Home Care is now and projected to be 2.6% of US Health Expenditures

4. Why are nursing center occupancies low, and declining?

1. Demographics

2. Patient/consumer

preference

3. Regulatory &

intermediary

constraint

4. All of the above

5. Not sure


Stackpole & Associates, Inc.14

2020

Born 1934

85 yoa

2017

Born 1931

85 yoa

2030Born 1945

85 yoa

2045Born 1960

85 yoa

Copyright © 2017 Stackpole & Associates & Ability NetworkCopyright © 2017 Stackpole & Associates & Ability Network

Turbulence in action

• Balance innovation

and value

• Race to the

bottom?

• Protect DSO

• Measurement is

easy outside of the

river

Value – Three Principles

First Principle

• PAC - variance in costs & outcomes =

“waste”

Second Principle

• FFS = misaligned incentives

Third Principle

• Simplify to meet Triple Aim

–Too complex and lacks integration

–No one has responsibility for coordination

16

Increase your value

Integrated care and organized paths!

Integration = coordination and alignment of goals

Integrated environments:

• share clinical data,

• agree on plans of care, and

• collaborate - patient-centered outcomes

Foster care coordination among providers, share

data and track outcomes to measure progress

Technology can help better manage, communicate

and use data

Volume to Value

Volume - Fee for Service

Value

18

Volume or

Value?

The Challenges / WHY?

Volume – Value Shift • High Value Providers thrive

Low occupancy

Declining payments

Three Principles – REMEMBER!

First Principle• Decrease variance & efficiency

Second Principle• Align incentives for best outcomes

Third Principle

• Simplify, integrated care & complexity

21

Steps to the dance…

Leadership

Trust

Shared experiences

Early wins

Inclusive

Data, data, data

“Take your partner by the hand…”

The highest levels of “efficiency” produce the best outcomes for society.

1. True

2. False

3. Not sure


Stackpole & Associates, Inc.24

Efficiency

Technical, Productive, Allocative

– TechnicalMaximum improvement from resources

– ProductiveBest health outcome for given costs or

reduction in cost for the same outcome

– AllocativeBest outcomes for society

Focus for Clinical Integration

Focus e.g., quality improvement,

Care coordination - SNF, HHA & PAC

referrals,

Favor efficient providers

Target high-risk individuals & populations

• disease management

COLLABORATION

25

What reduces value?

Fragmentation

• Services are delivered across an increasing array

of distinct and often competing providers and

entities, each with different objectives, obligations,

and capabilities (Cebul et al., 2008).

• Providers practicing within the same geographic

area, sometimes caring for the same patients,

often work independently from and not

communicating with one another (Bodenheimer,

2008; Shih et al., 2008).

• As a fragmented health care delivery system we

are not equipped to manage the continuum of

health care for an aging population with complex

needs.26

Drive Value

– How can we respond?

27

Short Cut – New Rules

Defend, protect & fortify

Increase Productivity / Efficiency

Innovate

Differentiate

Engage v. Bunker

COLLABORATION

Where do we start

How can disparate actors move

effectively from vision to the

implementation of cross-continuum

collaboration?

When no one actor has all the answers

or the authority, the usual committee of

working group isn’t adequate to the task.

Steps to the dance…

Leadership

Trust

Shared experiences

Early wins

Inclusive

Data, data, data

Focus on end-users

“Take your partner by the hand…”

Leadership

Leadership

• Visibility

• Support

• Focus &

• Endurance

• Leadership – measures

6. Trust is best developed in cross-continuum collaborations through:

1. Aligning payment

incentives

2. One-on-one, personal

relationships

3. Visible, charismatic

leadership

4. None of the above


Trust

One-on-One

• Reliable

• Transparent

• Personal

Shared Experiences

Integration between / among

• “Walk a mile in my shoes…”

• Work-a-Day / Work-a-Week

• Functional v. management

–Trust, personal

–Early “wins”, durable

Early Wins

Focus on 15 – 30 day victories

• delay to start of home care by 12 hours

OR

• Eliminating readmissions

Which is more likely to have “early win”?

Inclusive

Staff the initiative “inclusively”

NOT the usual position-based staff

• Who is likely to have the insight

• Who handles the phone / text / email

Data, data, data

Measure EVERYTHING

• Qualitative

• Quantitative

Buy Excel tutorials for EVERYONE

The end user

Realities

Occupancies are poor• The age qualified markets are declining

• Increased options / choices

• Negative perception (consumerism)

• The economy

• The role of “Intermediaries”

The need for change is URGENT

“Soft” skills are needed

Realities

Continued pressure on payments

Continued pressure on utilization

Efficiencies & productivity are the

keys to effective differentiation

Collaboration is the “new frontier”

QUESTIONS???

Brill, S. America’s Bitter Pill: Money, politics back room deals, and the fight to fix our broken

health care system. New York: Random House 2015

Dent, H. The Demographic Cliff: How to survive and prosper during the great deflation ahead.

New York. Portfolio/Penguin. 2014, 2015

Emanuel, E. Reinventing American Healthcare: How the affordable care act will improve our

terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error -prone

system. New York: Public Affairs. 2014

Hillestad, S & Berkowitz, E. Health Care Marketing Plans: from strategy to action. Gaithersburg:

Aspen. 1999

Moriates, C., Arora, V. & Shah, N. Understanding Value Based Healthcare. New York, McGraw

Hill Education. 2015

Patterson, P. & Spreng, R. “Modeling the relationship between perceived value, satisfaction and

repurchase intentions in a business-to-business, services context: an empirical examination.”

International Journal of Service Industry Management. Vol. 8 No. 5, 1997: 414-434.

Porter, M. “What is Value in Health Care?” New England Journal of Medicine. N Engl J Med

2010; 363: 2477-2481. December 2010

Reichheld, F. The Loyalty Effect: the hidden force behind growth, profits, and lasting value .

Boston: Harvard University Press. 1991

Roth, A. Who Gets What and Why: The new economics of matchmaking and market design.

Boston, Houghton Mifflin Harcourt. 2015

Stackpole. I. & Ziemba, E. Make Your Marketing P-P-P-P-Perfect, Care Management Matters,

April 2008

Stackpole, I. & Ziemba, E. It’s Not What Your Say – It’s What People Hear!, Care Management

Matters, June, 2008

References

Irving Stackpole

Stackpole & Associates, Inc.

1-617-739-5900, Ext. 11

1-617-719-9530

[email protected]

Stackpole & Associates, Inc.

mailto:[email protected]

1. What is the “value formula”

in healthcare?

1. Value = Lowest Cost × Best

Outcomes

2. Value = Positive Outcomes –

Untoward Outcomes

3. Value = Quality ÷ Payment

(Total Costs)

4. Value = (Outcomes ×

Efficiency) × Patient

Satisfaction

5. Not sure
