Service Innovations and Assisted Living

Deanna Ludlow Mitchell RN, BSN, MSBA

Executive Director – Senior Care Resources

Senior Vice President – LeadingAge Michigan

The American Health Care System50 Years Old - 2015

Title XVIII and XIX of SSA

• Medicare and Medicaid signed into law on July 30 1965 and inaugurated one year later

• Extended health coverage to almost all Americans 65+

• Those receiving SS benefits or railroad benefits

• Health care services to low income children deprived of parents

• Caretaker relatives

• Elderly blind and disabled

• Persons with disabilities

• Seniors were most likely to be living in poverty/50% had insurance

The Problems Can Be Tracked Back to the Very Beginning

Medicare Extended

• 1972 -To individuals <age 65 with long term disabilities and ESRD; Authority to conduct demonstration programs

• 1973 - HMO Act provided for start up grants and loans for HMO development/HMOs meeting federal standards for benefits were given preferential treatment in the market plan

• 1977 - HCFA established to administer the program

• 1980 - Coverage of Medicare Home Health

• 1980 - Medigap insurance brought under federal oversight

• 1981 - Freedom of Choice Waivers (1915b/c); states required to provide hospital DSH payment

More Laws Over Time

• 1982 –TEFRA – tax equity and fiscal responsibility act made it more attractive for HMOs to contract with Medicare. Act expanded quality oversight through PROs

• 1983 – Medicare DRGs

• 1985 EmTala – emergency medical treatment and labor act – appropriate medical screenings and stabilizing treatments

• 1986 Medicaid coverage for pregnant women and infants

• 1987 OBRA – strengthened protections for residents of nursing homes

• 1988 Medicare Catastrophic coverage act – improved hospital and SNF benefits

Balanced Budget ACT 1997• New Medicaid Managed Care Options and requirements

• Requiring CMS to develop and implement five new prospective payment systems for Medicare services (for inpatient rehabilitation hospital or unit services, skilled nursing facility services, home health services, hospital outpatient department services, and outpatient rehabilitation services); RUGs

• Slowing the rate of growth in Medicare spending and extending the life of the trust fund for 10 years;

• Providing a broad range of beneficiary protections;

• Expanding preventive benefits; and

• Testing other innovative approaches to payment and service delivery through research and demonstrations.

2003 Medicare Modernization Act

• Medicare Drug Benefits – Donut Hole

• Medicare Part D Plans

2005(6) Deficit Reduction Act

• Medicaid Integrity Programs

• Proof of Citizenship

• Extended look back periods for Asset Transfers

• Changes Medicaid rules for reimbursing Case Management

Medicare Medicaid

Seniors were most likely to be living in poverty/50% had insurance

After Almost Fifty Years• Medicare FFS: chaotic, disorganized, and duplicative

• Medicare Advantage Plans: selective enrollment, costly, large number of provider denials, no gains in overall health outcomes, some have remarkably increasing beneficiary premiums

• Fragmented Delivery System

• Inconsistent measures across systems and providers

• Medicaid itself even more fragmented, major payer for LTSS but people have to impoverish themselves/restricted access/cost shifting/administrative hurdles

• Program Starts are painful

• If you don’t incentivize coordination of care, you wont get it

• Medicare pays as much or more in the 90 days after discharge as it spends for the initial hospitalization

• 90-Day readmission rates can exceed 40%

• Wide variation in average post acute care spending and setting use

• Utilization will be high for any services that pay well

• Most demonstration programs to date have not reduced Medicare spending

• Reform represents a complex new science

Medicare

Medicaid

• Improving chronic care in Medicaid programs helps the Medicare Program• Enhanced access does not

produce savings• Current program structures

are hard to change and are full of conflicting interests• Institutional Bias• LTC is not something

planned for. …most will still impoverish themselves before accessing• Cost Shifting in NFs to

Medicare

Tragedy of the Commons/ Supply Driven Demand • Economic theory – individual acting independently and rationally

according to each’s self interest, behave contrary to the whole group’s long term best interest

• Hospitals need to fill beds

• If hospitals and nursing homes have beds, they will fill them

• Physician-centric care

• Too little appreciation of system knowledge among clinicians and organizations – leading them to sub-optimize the components of the system with which they are familiar at the expense of the whole

• Make the rational option appropriate for all groups and the whole

Affordable Care Act/2010• End to pre-existing condition discrimination; ends to

limits on care; ends to coverage cancellations

• Offered Medicaid Expansion

• Established Center for Medicare and Medicaid Innovation

• Helps close the donut hole

• Supports Value Based Purchasing/Quality Improvements/QAPI

IHI’s Triple Aim

• Improvement requires the simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing the per capita cost of care

• Integrators (Berwick) – those who partner with individuals and families, redesign primary care, develop population health management, financial management

Congestive Heart Failure

• Most common reason for admission of Medicare patients to the hospital

• 40% return within 90 days. Rate can be reduced by 80% with proper management

• System lacks the capacity to integrate its work over time and across sites of care

• Individual provider pay for performance programs, public reporting do not address the defects in care across the system

Good Integrator Systems

• Recognize that they must constrain two sides of the triangle if all three sides are going to improve

• Accepts responsibility for all three components

• Powerful and visionary insurer

• Large primary care group in partnership with payers

• Hospital with some affiliated physician group

Integrator Activities

• Work with the population served so that they are better informed about health status and risk factors/focus on segmented populations

• Change the more is better culture – transparency, systematic education, communication, shared decision making with patients and communities

• Help guide persons with chronic illness; help interpret

• Strengthen primary care for the population/Medical homes

• Monitor resources and how they are used

• Anticipate and shape patterns of care, rather than respond to emergent issues

• Greater value to monitor and intercept signs of deterioration among the CHF residents of a physician, or those who used the hospital last year

The Triple AimThreatens the Status Quo Health System

Current Provider Behavior is Destructive of the Triple Aim

Bundled

Payment

Groups

Accou

ntab

le

Care

Org

anizat

ion

s

Medical

Health Homes

Dual Eligible Integration

Projects

Medicare

Advantage

Plans

Medicare Special

Needs Plans

What is Population Health?• Population Health Management – design, delivery,

coordination and payment of high quality healthcare services to manage the Triple Aim for a population using the best resources available within the health care system:

• Effective Population Management requires

• new partnerships among payers and providers,

• integrated data support,

• a focus on a non-traditional health care workforce,

• new care management models,

• and a shift from FFS delivery to bearing financial risk for populations served

Population Health Management

• Under PHM most of the work takes place outside the hospital and presents new demands on hospitals

• Organizations now have to assess the health and risk of persons who may not visit the hospital or physician office very often. Care to those not touching the system as often in terms of planned interactions, but also those less likely to be seen. Preventive services, lifestyle coaching, and transitional care programs make an impact

Who will Succeed?• Systems that include the full range of services

• Provide integrated and coordinated care

•Smaller health organizations less likely to meet challenges alone – may have to join a system that can provide comprehensive care

•Move to proactive and continuous from reactive and episodic

Patient Centered Medical Home

Comprehensive Health Services to individuals, families, and communities by at least two health professionals who work collaboratively with patients, family caregivers, community service providers on shared goals, within and across settings, to achieve care that is safe, effective, patient-centered, timely, efficient, and equitable

Patient Centered Medical Homes – Foundation of High

Performing ACOs

BCBS Michigan Reports Savings of $155 Million (Milbank Memorial Fund

Report – 2012-2013)

• Patients are registered in a data base

• Systematic assessment of all patient health care needs – rather than problem focused

• Care is standardized by evidence based guidelines/not physician skill

• Team of professionals coordinates all patient’s care

• Measure quality• Track tests and consultations• Multidisciplinary Team

Total Studi

es

Cost Reducti

ons

ED Visits

Inpatient Admissio

ns

Readmissions

Improved Public Health

Improved Access

Increased

Preventive

Services

Improved

Satisfaction

Research

13 61% 61% 31% 13% 31% 31% 31% 23%

Industry

7 57% 57% 57% 29% 29% 14% 29% 14%

Medicare Advantage Plans • Offering ‘better’ care and broader services in return for

reimbursements that are 14% higher than traditional Medicare reimbursements

• Aim to pare the reimbursement by 200 billion over ten years

• Plan covers more than 15 million seniors, or 30% of all Medicare members

• Only 1/5 of the extra reimbursement gets passed to patients in the form of lower premiums, better care or more services. Insurers pocket a lot of it as pure profit. Some spent on advertising (Study from the Wharton School)

• Higher payments are not related to fewer restrictions on care or better outcomes, more intensive treatments, or any change in health profile, nor more access to specialists, more doctor visits

Medicare Advantage Plan Audits

• Medicare officials impose civil fines for delaying or denying access to care. Insurers usually do not dispute the audit findings, but say the care they provide is superior to that in the traditional fee-for-service Medicare program.

• Over 50% of audits say that beneficiaries and providers did not receive an adequate or accurate rationale for the denial of coverage

• Often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights

• 61% of audits, insurers inappropriately rejected claims for prescription drugs – enforcing unapproved quantity limits and required patients to get permission before filling prescriptions when such prior authorizations were not allowed

• Plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients

Medicare Special Needs Plans

• 9 million of over 48 million beneficiaries are also eligible for Medicaid; have greater health challenges with increased need for care coordination across the two programs

• Medicare DSNPs – MAP required to provide specialized services to needs of dual eligibles as well as integrate benefits or coordinate care

• 9% of dual eligible population is enrolled in 322 Medicare DSNP plans

• Tend to be under 65 and disabled, more likely to be eligible for full Medicaid benefits and more frequently diagnosed with a chronic or disabling mental health condition/ services tend to be things younger disabled are looking for.

• Health status measured by expected cost was similar to other dual eligibles in other plans in 2010

Medicare Advantage Plans In Michigan

AETNA 5.96%BCN & BCBS 13.21%HealthPlus 6.34%Humana 30.33%United Health Care 28.08%Priority 5.19%Midwest Health Plan 4.28%Fidelis 2.86%14 Remaining Health Plans 3.74%

United Health Care

Blues

Total Michigan Medicare Advantage enrollment =

558,082

May 2014 Data

Humana

Michigan Counties With Highest Medicare Advantage Enrollment

Wayne

Macomb

Oakland

Kent

Genesee

Otawa

12 Small (1 t0 2.5%)

All Others Less Than 1%

0 5 10 15 20 25 30

16.78

8.38

11.37

8.06

4.89

4.22

21.91

24.39

Medicaid Managed LTSSMI Health Link

MI HealthLink Update

• Regions 1/4 - enrollment effective April 1; opt in and passive enrollment letters scheduled for December – February 2015

• Regions 8/9 - enrollment effective July 1; opt in and passive enrollment letters scheduled for April – May 2015

• Final Agreements not completed/readiness reviews/final rates

Values and Expectations• Seamless access

• Health promotion/prevention/ chronic disease

• Elimination of barriers to home and community based services

• Transparency of cost and quality information

• Evidence-based guidelines

• Self determination and person-centeredness

Values and Expectations

• Effectiveness through improved care coordination and payment reform

• Administrative streamlining

• Improved access to physical care for persons with long term behavioral health issues/improved access to mental health services for persons with functional/ chronic medical needs

KFFMI

Occupancy = 85%2011

24th out of 51

Program Design

• Federal approval for a 1915b/1915c combination waiver

• 1915b waives the requirement to use all qualified providers – health plans are allowed to develop a preferred provider network and limit the use of providers based on performance and cost

• 1915c waives the requirement that a particular service is available to all (MI Choice). Allows the state to limit the category (Elderly and Disabled, Dually Eligible) and allows the state to limit access (slot limits)

Regional Roll Out

• Region 1: Entire Upper Peninsula with estimated target population of 9,000 (1,795 NH)

• Region 4:  Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, Van Buren Counties - estimated target population of 21,000 (3,546)

• Region 8:  Wayne County including Detroit - estimated target population of 58,000 (7,561)

• Region 9:  Macomb County - estimated target population of 17,000 (3,204)

16,107/91,204= 18%

Payments and Incentives• Savings

• 1% Year One

• 2% Year Two

• 4% Year Three

• Quality Withholds (1, 2, 3% respectively)

• Annual Performance Improvement Projects

• QAPI

• External Quality Review

• HEDIS

• 91 State/CMS Core Measures

ICOs and MAPs

ICOs MAPs

• CoventryCares

• Meridian

• United Healthcare

• Molina Healthcare of Michigan

• AmeriHealth / BCBS of Michigan

• Midwest Health Plan

• Fidelis SecureCare of Michigan

• Humana

• United Health Care

• Blues

• Health Plus

• Priority

• Aetna

Hospital Partnerships

• Partnerships with post-acute care providers through ACO, bundled payment and other initiatives

• Readmissions: Medicare rate penalties of up to 3%

• 433 more hospitals than last year

• Average penalty 0.38-0.63

• 80% of hospitals now working with home care agencies

• Streamlining transitions/early identification

October 1 – New Round of Hospital Readmissions Penalties• Work with LeadingAge Insights to get a picture of your regional

hospital challenges; high readmission hospitals will see total Medicare reimbursements cut by 3%

• What are your local hospital’s readmission rates and length of stay?

• Work to streamline transitions – what projects are in your community

• More follow up of ED discharges …

Bundled Payments• A set price for an episode of care: up to three days prior and up

to 30 days (90) following; generally paid FFS with reconciliation

• Reduced cost per case

• Improve Quality

• Strengthen relationships

• By 2020, bundled payments will represent 35% of the US health systems revenue

• 24% of current health plans are implementing contracts that bundle payments

• Step toward fully Accountable Care

ACO Versus Bundled Payment

• Both move from volume to value

• Shifting risk for cost and quality from payers to providers

• Require collaboration

• Two distinct care management models

• BP: Successful episodic care managers, improving cost and quality of individual episodes: reducing input costs and growing volume = success

• ACO: Focus is on the total cost of care, reducing growth in spending for beneficiaries in the ACO, providers must bill for fewer services over time. Provider internal efficiency does not help.

ACOs• 360 established ACOs serving over 5.3 million Americans

• Beneficiaries have the option of seeing physicians in or outside of the network

• ACOs share with Medicare any savings generated from lowering growth in health care costs when they meet a standard of care

• Puts control in the hands of physicians

• 2014 CMS Quality Report: ACOs Scored high for easy access to care and communication with physicians

• Success at preventing hospitalizations more mixed• Diabetes management a challenge• Patient involvement in health care decisions – challenged• Higher copayments/looking at reduced CMS payments in

future

Risk

Capitated

Managed Care

Acute/PAC Care Bundling

Value Based

Purchasing

FFS Payment Incentive

s

RISK

Readmission

Penalties

HospitalNursing HomeHHA

Michigan Bundled Payment

Initiatives

MI Health Link

MAPs

Assisted Living• Fastest growing residential option

• 31,000+ facilities serving over 1 million seniors

• Conceived as an alternative to nursing homes

• Lifestyle choice among seniors – variety of options

• No federal designation/state regulated

• Some state/federal funding

Strategies

• Abandon the concept that a specific LEVEL OF CARE is tied to a physical location

• Assisted Living is not an easy fit into newer models of care but you may be able to integrate aspects of Population Health and chronic disease management into a proactive model

• Define who you are and what you are good at

• Know and understand your outcomes and value and KNOW what other providers challenges and opportunities are

Assisted Living Innovations

• The Oregon Model

• Affordable Assisted Living – Huron Woods

• Level of Care Challenges

• Collaborations with PACE Programs/Green Houses

Who are YOU?• Mission Based? The goals and vision of the Triple Aim are very much in

alignment with the mission based provider.

• What is your community and what is your role there? Must have a clear understanding of who and where you are along with a defined vision for where you want to be.

• What are your core strengths – who is the population that you are knowledgeable about.

• Define a population geographically, or by health condition

• Can be defined by income, race, ethnicity, Disease Burden

• Or those served by a particular health system

• Work in your region to fully understand the partnerships and projects underway and keep up to date about the changes and implementation of payment and delivery reform

• Seek out partnership with like minded providers or organizations

• Develop and communicate your value proposition – it will define a course for further work

To Create a Value Proposition….Need to Understand Quality

• Need experience data for your chosen population over time (SC/CC variation)

• Gain insight into the relationship between interventions and effect

• Understand the time lags between cause and effect

• Distinguish between outcome and process measures

• Understand the value of benchmark or comparison data

• Mortality, life expectancy

• Health and functional status

• Disease burden (delay of onset, complications) prevalence of chronic conditions

• Risk Behaviors

• Health indicators such as BP, BMI, Cholesterol, blood glucose

• Global satisfaction indicators

• Total cost per member per month/population

• Hospital and Emergency Room Utilization

What to Consider….

• Understand the care pathway for your population

• Know and speak to your outcomes

• Ramp up clinical skills if needed

• Consider your role in care coordination across transitions

• Sharing of medical records and information with other providers

• Identifying issues before they become more expensive

• Help push the patient toward primary services

• Monitor and understand MAPs, ICOs, ACOs, BP

• Make service more than shelter and basic assistance

If You Decide to Foster Real Aging in Place

• Work with your partners to develop evidence based care pathways for the major common chronic diseases

• Monitor all admissions and readmissions/root cause analysis

• Consider partnering relationship with commonly used physicians or plan physician staff

• Consider adopting evidence based tools such as INTERACT

Can You Work With a Health Plan to…??

• Facilitate longer appointment intervals for patients with good chronic disease control

• Use non-provider visits for selected issues – nurse visits to implement stepped therapy for chronic disease control and immunizations

• Better help diagnose mental health issues – routine screening to capture changes in patient’s needs: Effects of unrecognized depression, anxiety, and substance abuse are among the most prominent contributors to poor control of chronic physical illness – historically separate systems…reduce fragmented approach

Different models of integration

• Collaboration of services – between independent primary care entities – share staff, provide services in each setting

• Co-location of services address gaps in continuity and communication that can negatively impact patient care. Duplication of services and costs are unavoidable if separate

• Fully integrated models utilize standard care pathways and real time electronic information systems to coordinate care across all provider groups

Where Do You Fit?Populati

onOpportunity Resources

Frail Elders with Multiple Chronic Conditions

5% Total Redesign of Service

50%

At risk for major intervention/disease

25% Enhanced delivery, consistency, early identification

30%

Healthy Seniors, minor care issues

70% Access, education, risk factors

20%

Thoughts to Leave You With

• Assisted Living may not be much affected by the change in demographic patterns or evolving health care system – you can stay where you are (Medicaid Managed Care)

• You may try to continue to expand your services in a horizontal manner – anticipating that the aging demographic will keep your beds filled – but it is not clear how long private pay for services will hold up

• Keep expanding and look for some new opportunities to come your way

• You can actively develop relationships with providers and the community to identify innovative ways to serve

Risk Reward

Questions??