Post-Acute Care Collaborative
Building the High-Value Skilled Nursing Facility Securing an Essential Role in the Market
Jared Landis Practice Manager The Advisory Board Company
[email protected] 202-266-6925
2
The Advisory Board is Uniquely Positioned to Help Research and Relationships at the Intersection of a Dynamic Industry The Advisory Board Difference
Hospitals Post-Acute and Long-Term Care Providers
Physician Groups
We are … Willing to challenge conventional wisdom Devoted to exceeding member expectations at every turn
And we offer … Insurers
Nursing Leaders
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Suppliers
3,000+ Hospitals and Health Systems
200+
1,500+
Independent Physician Post-Acute Care Facilities and Practices Agencies
Unique visibility into provider CXOs’ world – challenges, priorities, vendor perceptions Direct access to over 500 in-house health care experts
200+
5,000+
Health Care Product and Service Companies
CXO Relationships Across the Care Continuum
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Addressing the Key Questions of Post-Acute Providers
Navigating the Future of Post-Acute Care
Industrywide Relationships Offers Unparalleled Perspective on the Value-Based Post-Acute Environment Building the Seamless Post-Acute Network
Forging a Sector-Specific Value Proposition
•
• What role should each post-acute sector assume in a value-based delivery system to meet evolving delivery system demands?
How can post-acute providers create a seamless post-discharge solution that appeals to referrers and payers?
• What partnerships, mergers or affiliations should be considered to align the right set of offerings?
Becoming the Post-Acute Partner of Choice
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• How do post-acute providers build a care management infrastructure to manage patients across settings?
• What are the patient populations that should be prioritized for specialty program development? • What services and clinical factors differentiate an organization from competitors?
Generating a Consistent Referral Stream
Developing Meaningful Clinical Capabilities
• What are the latest trends with regards to post-acute network development?
• What are the clinical competencies that best meet emerging market demands?
• How are hospitals and physician groups approaching the creation of post-acute scorecards?
• What quality tracking and information technology investments are required to build a best-in-class care infrastructure?
• Where are patients going following discharge from the hospital setting?
• How can we upskill our nursing staff and engage them in key clinical priorities?
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©2013 The Advisory Board Company
Road Map
1
SNF Medicare Volume Transformation
2
Strategies to Create System Value
3
Coda: Emerging Payer Partnership Approaches
5
Factors Disrupting SNF Medicare Volumes
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Range of Factors Disrupting SNF Medicare FFS1 Environment
Decreasing Hospital Admissions
Shifting from Inpatient to Outpatient Services
Growing Observation Stay Visits
Substituting PAC Settings (e.g. HHA for SNF)
Emerging Population Health Management Activity
Increasing Medicare Advantage Enrollment
1) Fee for service.
Source: Post-Acute Care Collaborative interviews and analysis.
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Two Drivers of Medicare Inpatient Volume Decline Increasing Use of Observation Stay Visits
Shift from Inpatient Admissions to Outpatient Services
Cumulative Change in Medicare Outpatient Services and Inpatient Discharges
Substantial Growth in Medicare Observation Stays
68% Percentage increase in number of Medicare observation stay visits from 2006 to 2011
Per FFS Beneficiary, 2005-2011
Outpatient Services
30%
28%
25% 18%
20% 15% 10% 10% 5%
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0% 0% 2005
2007
2009
2011
-5% -1% -10%
-5% -8%
Inpatient Discharges Source: “A Data Book: Health care spending and the Medicare program,” MedPAC, June 2013, available at www.medpac.gov; Post-Acute Care Collaborative interviews and analysis.
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Inpatient Admissions Impacting SNF Admissions? Discharges and Admissions Rising Despite Anticipated Decline Number of Patients Coded for Discharge from Inpatient to SNF
Number of FFS Medicare-Covered Admissions in SNF, by Year
All Payer Discharges, in Thousands
In Thousands
3105 2993 2900 2830
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2578
2008
2009
2010
2011
2008
2546
2009
2568
2010
2596
2011
Source: “Report to the Congress: Medicare Payment Policy,” MedPAC, March 2013, available at www.medpac.gov; “Medicare and Medicaid Statistical Supplement, 2013 Edition,” Centers for Medicare & Medicaid Services, available at CMS.gov; Healthcare Cost and Utilization Project, “Nationwide Inpatient Sample,” 2011 dataset, Agency for Healthcare Research and Quality, available at hcup-us.ahrq.gov; Post-Acute Care Collaborative interviews and analysis.
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Beyond CMS Data, Public Companies Report Impact Anecdotally, Large SNF Chains Report Medicare FFS Volume Softening Excerpts from Publicly Traded Companies’ 2012 Annual Reports
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“Our Medicare average daily census for 2012 decreased 5.4% compared to 2011, resulting in a decrease in revenue of $4.9 million.”
“We continue to experience a decrease in Medicare patient days offset by an increase in our managed care patient days in 2012.”
“For 2012, Medicare skilled nursing center average daily census declined by 13% [compared to] 2011.”
“[S]ame facility patient days declined 3% in 2012 and 2% in 2011 compared to prior periods as a result of declines in admissions in 2012 and Medicare average length of stay in both 2012 and 2011.” Source: 2012 Annual Reports, Kindred, available at kindredhealthcare.com, Extendicare, available at extendicare.com, Diversicare, available at dvcr.com, and Skilled Healthcare Group, available at skilledhealthcaregroup.com; Post-Acute Care Collaborative interviews and analysis.
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Technology Enabled Care Utilization Management Health Plans, Hospitals Tap External PAC Utilization Manager NaviHealth’s Post-Acute Management Process 1
15-30%
2
Standard reduction in post-acute care spending Functional assessment of patient conducted in hospital to identify 90-day PAC needs
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4 Results inform analytics, PAC provider preferred performance tracked network against episode expectations to identify high-performing providers
Algorithm used to develop longitudinal treatment protocol; place patients across PAC settings
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NaviHealth nurse case managers round in PAC facilities to assess patients, manage progress along pathway
Case in Brief: NaviHealth
• PAC benefit manager that partners with health systems and health plans to manage PAC costs, maximize functional outcomes • Serves as BCPI convener, external manager of postacute networks performance
Source: Terry K, “Post Acute Care Manager Promises Lower Costs,” InformationWeek, May 2, 2013, available at: www.informationweek.com; Post-Acute Care Collaborative interviews and analysis.
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Impending Post-Acute Medicare Payment Reform Medicare Incentives Designed to Force Greater PAC Accountability Emerging Post-Acute Incentives 30 Days Referrer Payment Efficiency
90 Days Tied to PAC
PAC Payment Tied Episodic Performance
to
• 30-day mortality (PN, AMI, HF)
• SNF 30-day readmission penalties
• MedPAC proposed 90-day mandatory bundled payment
• 2015: 30-day readmissions (TKA, THA, COPD)
• Proposed site-neutral payment
• Multi-site 30-day readmission quality reporting
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• 2015: 30-day efficiency
Current Post-Acute Incentives • 30-day readmissions (PN, AMI, HF)
• Post-acute prospective payment
• Bundled Payments for Care Improvement
• Accountable Care Organizations • PACE1
1) Program of All-Inclusive Care for the Elderly.
Source: Post-Acute Care Collaborative interviews and analysis.
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Technology Enabled Care Utilization Management Health Plans, Hospitals Tap External PAC Utilization Manager NaviHealth’s Post-Acute Management Process 1
15-30%
2
Standard reduction in post-acute care spending Functional assessment of patient conducted in hospital to identify 90-day PAC needs
©2013 The Advisory Board Company
4 Results inform analytics, PAC provider preferred performance tracked network against episode expectations to identify high-performing providers
Algorithm used to develop longitudinal treatment protocol; place patients across PAC settings
3
NaviHealth nurse case managers round in PAC facilities to assess patients, manage progress along pathway
Case in Brief: NaviHealth
• PAC benefit manager that partners with health systems and health plans to manage PAC costs, maximize functional outcomes • Serves as BCPI convener, external manager of postacute networks performance
Source: Terry K, “Post Acute Care Manager Promises Lower Costs,” InformationWeek, May 2, 2013, available at: www.informationweek.com; Post-Acute Care Collaborative interviews and analysis.
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Impending Post-Acute Medicare Payment Reform Medicare Incentives Designed to Force Greater PAC Accountability Emerging Post-Acute Incentives 30 Days Referrer Payment Efficiency
90 Days Tied to PAC
PAC Payment Tied Episodic Performance
to
• 30-day mortality (PN, AMI, HF)
• SNF 30-day readmission penalties
• MedPAC proposed 90-day mandatory bundled payment
• 2015: 30-day readmissions (TKA, THA, COPD)
• Proposed site-neutral payment
• Multi-site 30-day readmission quality reporting
©2013 The Advisory Board Company
• 2015: 30-day efficiency
Current Post-Acute Incentives • 30-day readmissions (PN, AMI, HF)
• Post-acute prospective payment
• Bundled Payments for Care Improvement
• Accountable Care Organizations • PACE1
1) Program of All-Inclusive Care for the Elderly.
Source: Post-Acute Care Collaborative interviews and analysis.
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©2013 The Advisory Board Company
Road Map
1
SNF Medicare Volume Transformation
2
Strategies to Create System Value
3
Coda: Emerging Payer Partnership Approaches
14
Thriving in a New SNF Medicare Environment 10 Strategies for Skilled Nursing Providers to Create System Value
2
3
Build the Essential Value Foundation
Provide the Cost-Appropriate Solution
Secure Network Position
1.
Augment Care Team Composition
4.
8.
Motivate Network Collaborators
2.
Implement Next-Level Clinical Protocols
Create Path for Financially Untenable Patients
9.
Amass the Post-Discharge Network
5.
10. Become the Full (Rural) Network
Target Vital Efficiency Improvements
Develop Needed Cross-Continuum Programs
6.
Build the Super-Specialty Destination
7.
Substitute for Acute Care Stays
3.
©2013 The Advisory Board Company
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Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #1: Augment Care Team Composition
Scaling Staff Investments to Improve Care Quality Options to Improve Care For Increasingly High-Acuity Patients Linking with Physicians
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Level of Clinician Capability
High •
Partner with independent physicians or hospitalist groups
•
Strategically select medical director
•
Partner with hospital- or physician groupbased physicians
•
Employ physicians
Escalating Nurse Practitioner Use •
•
Low
Mostly LPNs and CNAs Low
Partner with independent NP groups
Increasing RN and Therapist Staff Mix
•
Upgrade existing staff capabilities
Partner with acute care-owned NPs
•
Partner with payer-owned NPs
•
Employ NPs
•
Hire RNs
•
Hire therapists
Level of Patient Acuity
High
Source: Post-Acute Care Collaborative interviews and analysis.
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Increasing Skilled Staff Mix North Shore-LIJ’s Process for Converting LPNs to RNs Analyze Feasibility
Determine financial and operational impact of shift to allRN model
Provide Staff Support
Carve Out Time for Study
Alleviate financial burden of return to school by providing funding when possible
Work one-on-one with staff to create realistic plans to balance work and study
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Benefits of Increased Skilled Staff Mix
Provide Higher Skill Level of Care
Improve Skill and Performance of Other Staff
Increase Frequency of Patient Visits
Source: North Shore-LIJ Health System; Post-Acute Care Collaborative interviews and analysis.
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Nurse Practitioners a Key Resource Multitude of Benefits Enable Care for Higher Acuity Patients Prestige Care’s Expanding Partnership Centered Around UHC’s1 NPs2 Hosted UHC’s NP-Led Care Model, Optum
Developed Partnership Through NP Program
Negotiated NP Expansion, Increased Referral Volume
NPs See All Prestige Patients
NPs See Only Optum Patients
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•
•
Model designed to increase patient access to NP-delivered ongoing primary care NPs help reduce disruptive, costly hospitalizations for long-term care patients
1) UnitedHealthcare. 2) Nurse Practitioners.
•
NPs, SNF staff foster close relationships
•
•
•
NPs offer ongoing performance, skill mentoring to SNF staff
UHC valued Prestige’s willingness to collaborate and dedication to reducing hospitalizations
•
NP-staff collaboration improves care quality, reduces readmissions
Prestige negotiated with UHC and secured expansion of NP model to their non-Optum skilled patients
•
Partnership generated increased volume of UHC referrals
Source: Prestige Care, Inc.; Post-Acute Care Collaborative interviews and analysis.
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Tactic #2: Implement Next-Level Clinical Protocols
Boosting Protocols to Reduce Readmissions Layering Additional Systems onto INTERACT-based Standards Industry Standard INTERACT1 Tool-Based Approach
Next-Level Protocol Enhancements 1
2
SNF-Based Palliative Care Facilitators
Data-Driven “Step-Up” Response Unit
Goals of INTERACT Program: 1.
Prevent conditions from worsening with early detection of change in status
2.
Improve advance pare planning and palliative care access
3.
Manage appropriate patients safely in nursing home
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Rehospitalizations from SNF a Cost and Quality Concern
25%
Patients discharged from hospital to SNF were rehospitalized within 30 days
1) Interventions to Reduce Acute Care Transfers.
$14.3B
Cost to Medicare of these patient re-hospitalizations from SNF (2011)
Source: “Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring,” Office of the Inspector General, November 2013, available at oig.hhs.gov; Post-Acute Care Collaborative interviews and analysis.
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SNF-Based Staff Improve Palliative Care Access Hillard’s1 Continuum of Compassionate Care Model
Medical Director of Palliative and End-of-Life Care Integrates palliative care and hospice across system
Senior Living
Hospital
SNF
Home Health and Hospice
Physicians
SNF’s Role in Compassionate Care Model
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SNF-based staff are trained to incorporate these new protocols:
Patient Assessment Understand criteria for identifying patients at risk of deterioration in status 1) Pseudonym. 2) Physician’s Orders for Scope of Treatment.
Palliative Care Integration Collaborate with palliative care specialists to ensure access to efficient, patient-centered support
POST2 Form Discussion Gain comfort broaching advanced care planning and POST forms with patients Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #3: Target Vital Efficiency Improvements
Assembling a Value-Focused Approach to Episodes Four Drivers of Efficiency: Lessons from Value-Based Initiatives
Patient Assessment Protocol Key ingredient: Comprehensive patient assessment protocol assists clinicians in determining appropriate PAC site of care
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Information Sharing, Data Tracking Key ingredient: Data visibility requires investment, but enables patient monitoring and real-time adjustments for cost-saving
Transitions Navigators Key ingredient: Transition navigators guide patients through full episode of care, from inpatient through to post-PAC-discharge
Outcomes Focused Care Plan Key ingredient: Longitudinal care plan tailored to individual’s conditions and needs ensures appropriate amount, level of care
Source: Post-Acute Care Collaborative interviews and analysis.
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Efficient Placement a Persistent Challenge Facility-Specific Capabilities Underrepresented in Discharge Decision
”
Proportion of Medicare Patients Placed in an Avoidably High-Cost Setting Study Findings By Post-Acute Setting
Specialty Service Availability Often Unconsidered
42% 11%
“The case manager is going to place patients based on the last time they heard a presentation, or they’ll ask their colleague ‘Hey, who takes trachs?’ or they will remember from the last liaison who bought them a cup of coffee. There’s no good rhyme or reason.”
30%
20%
18%
14%
31% 15%
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9% 5% HHA
Appropriate Setting
SNF
OP Therapy
Continuity of Care Director, Large Health System
3% IRF
HHA
LTACH
SNF
IRF Source: Dobson, DaVanzo and Associates, “Clinically Appropriate and Cost Effective Placement,” available at www.healthreformgps.org/wp-content/uploads/cacepreport.pdf; Post-Acute Care Collaborative interviews and analysis.
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Informing the Right Level of Care Patient Placement Innovation Requires Incentive Structure Redesign Dorsia Rehabilitation’s1 Patient Placement Redesign Essential Design Features Dorsia System Placement Tool
Hip Fracture Placement Factors:
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• Cognitive status • Weight bearing status • Prior level of function • Age • Caregiver status
Engages Physicians
Referring
• Developed through referring physician input, chart review, clinical research
Preserves Liaison Critical Thinking • Does not automate setting placement, centered critical thinking
preserves patient-
Matched Liaison Liaisons rewarded for Dorsia system referrals rather Incentives than IRF2 referrals
1) Pseudonym. 2) Inpatient rehabilitation facility.
Source: Post-Acute Care Collaborative interviews and analysis.
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Equipping Care Navigators with System Visibility Universal Metrics Support Navigator Placement Efficiencies Key Features: Dorsia1 Care Compass
Navigator Placement Methodology Care Compass Patient Measures
Longitudinal Clinical Measures • Tracks a set of DRG-specific, standardized clinical measures across all Dorsia care settings
Green
Segments patients into risk tiers2
Yellow or Red
Care Navigator Data Feed
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• Alerts care navigators to important changes in patient metric set warranting intervention
Non-Clinical Navigator (Telephonic Visits)
1) Pseudonym. 2) Patients can switch between navigator types should their risk level change.
RN Navigator (Home Visits)
Source: Post-Acute Care Collaborative interviews and analysis.
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Thriving in a New SNF Medicare Environment 10 Strategies for Skilled Nursing Providers to Create System Value
2
3
Build the Essential Value Foundation
Provide the Cost-Appropriate Solution
Secure Network Position
1.
Augment Care Team Composition
4.
8.
Motivate Network Collaborators
2.
Implement Next-Level Clinical Protocols
Create Path for Financially Untenable Patients
9.
Amass the Post-Discharge Network
5.
10. Become the Full (Rural) Network
Target Vital Efficiency Improvements
Develop Needed Cross-Continuum Programs
6.
Build the Super-Specialty Destination
7.
Substitute for Acute Care Stays
3.
©2013 The Advisory Board Company
1
Source: Post-Acute Care Collaborative interviews and analysis.
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Meeting System Gaps to Secure Network Role
Steps to Securing a Seat at the Table
Strategically Select Initiative
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Identify key acute care needs and secure necessary funding
Implement HighQuality Program
Prove and Secure Network Role
Acquire equipment, enhance staff capabilities, and develop protocols to handle new patient population
Demonstrate quality care, flexibility, and ability to meet acute partners’ needs and solve system gaps
Leverage System Value
Use demonstrated value to secure new program partnerships and more favorable terms
Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #4: Create Path for Financially Untenable Patients
Unique Solutions Unlock Partnerships Signature’s Unfunded Patient Transfer Partnership with Lockton Hospital1
Partner Selection Lockton selected Signature and other participating SNFs due to flexibility and willingness to accept difficult-to-place patients
Patient Transfer Signature collaborates with Lockton to provide care coordination and share patient data
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Lockton Benefits
1) Pseudonym.
Cost-Effective Care Signature’s SNF setting enables care provision at lower cost, directly reimbursed per patient by Lockton
Signature Benefits
Bed made available for emergent or reimbursable patients
Sustainable financial compensation for transferred patients
More cost-effective to transfer patient to Signature’s SNF
Closer partnership and prospect to discover, meet other Lockton needs Source: Signature HealthCARE; Post-Acute Care Collaborative interviews and analysis.
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Tactic #5: Develop Needed Cross-Continuum Programs
Leveraging Partnership for Development Support
…Unlocks Specialized Program Implementation Support
Ralston House’s1 Partnership with McQuay University Health System2…
LVAD3 Training
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Close Existing Relationship •
McQuay physicians, NPs, and medical directors serve Ralston
McQuay trains Ralston staff to facilitate program development.
•
Ralston hosts McQuay geriatric fellows
Sample Training Topics:
•
Participate in jointly created programs (for example, specialty hip and knee orthopedic program)
•
Coding for LVAD patients
•
Red flags for patients in need of return to hospital
•
Transportation protocol
Additional Implementation Steps Develop Aligning Specialty Began initiative to mirror McQuay’s LVAD program
1) Pseudonym. 2) Pseudonym. 3) Left ventricular assist device.
•
Create centralized LVAD wing
•
Increase concentration of staff for closer patient monitoring
Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #6: Build the Super-Specialty Destination
Taking On Unique, Very High-Acuity Patients Laclede’s1 Intensive, Specialized Model Expands Target Patients and Conditions Traditional SNF Patient Type
Elderly
Core Services
Standard skilled
Laclede Pediatric
Catastrophic injury
Key Success Factors for Model Implementation
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Funding •
•
Classified as “intensive skilled nursing provider” by state Medicaid
•
Allows higher Medicaid rates
•
1) Pseudonym.
Facility Upgrades
Skilled Staff Search for staff experienced in specific area needed, such as pediatrics
•
Buy equipment such as vents
•
Build medical gases directly into rooms
Provide ongoing training
•
Partner with acute lab
LTACH Partnership •
Collaborate with local LTACH on optimal patient placement
•
Take LTACH patients who have used all acute Medicare days
Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #7: Substitute for Acute Care Stays
Expanding Options for Direct-to-SNF Programs Implementation Processes Still in Early Planning Stages for Many 3-Day Hospital Stay Waiver Program Requirements
Implementation Considerations
1 Direct-to-SNF Transfer Agreement Informed clinicians direct patients to SNF in lieu of acute care as clinically appropriate
2
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3 3-Day Hospital Stay Waiver
Preferred Partnerships
Range of waivers available via: MSSP, Pioneer ACOs, plans, bundle initiatives
Participation often limited to narrow range of SNF partners
4
Proper Patient Identification Create common patient assessment protocols to ensure appropriate patients selected for diversion Joint Process Mapping Map transfer processes with referring partners to enable smooth patient transitions from any site 24-7 Admissions Availability Bolster systems, staffing and medication supply to allow rapid patient acceptance at any time Enhance Clinical Capabilities Increase capabilities to care for and stabilize patients without preceding hospital stay Source: Post-Acute Care Collaborative interviews and analysis.
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Thriving in a New SNF Medicare Environment 10 Strategies for Skilled Nursing Providers to Create System Value
2
3
Build the Essential Value Foundation
Provide the Cost-Appropriate Solution
Secure Network Position
1.
Augment Care Team Composition
4.
8.
Motivate Network Collaborators
2.
Implement Next-Level Clinical Protocols
Create Path for Financially Untenable Patients
9.
Amass the Post-Discharge Network
5.
10. Become the Full (Rural) Network
Target Vital Efficiency Improvements
Develop Needed Cross-Continuum Programs
6.
Build the Super-Specialty Destination
7.
Substitute for Acute Care Stays
3.
©2013 The Advisory Board Company
1
Source: Post-Acute Care Collaborative interviews and analysis.
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Who’s Driving the Network Aggregation? ACOs and Health Systems Already Creating SNF Networks Midwest ACO Brings SNFs Together Around ACO Objectives Regular Collaborative Meetings
Quality Improvement Projects
• SNFs offer input into health system discussions • ACO representatives share updates about ACO progress
• ACO organizes support for SNFs with improving care quality
ACO’s SNF Collaborative
• Initial efforts focused on reducing readmissions via INTERACT tools
Data Reporting
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• ACO requires SNFs to report data on key metrics • SNFs that improve quality metrics can earn shared savings Sample Metrics SNFs Must Report Readmission Rates
Length of Stay
Outcomes Data
Staffing Ratios
Admissions Processes
Patient Satisfaction Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #8: Motivate Network Collaborators
Solidify Hospital Partnership with New Joint Venture Mesker1 Gains Predictable Referral Relationship in Competitive Market
Hospital
Mesker
JV New SNF
• 49% ownership stake
• 51% ownership stake
• Three board seats
• Two board seats
• Clinical quality control
• Operational control Strategic Benefits of JV for Each Party
Hospital
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• Savings from improved inpatient efficiency, share of profits from SNF • Control over quality, clinical decisions post-discharge through Medical Director oversight, physician rounding
Mesker • Share of profits from SNF • Long-standing, binding relationship with hospital and more predictable referral stream in competitive market
• Ancillary services revenues
• Physician presence and increased clinical capabilities
• Home health revenues from SNF patients post-discharge
• Access to patient information and improved transitions
1) Pseudonym.
Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #9: Amass the Post-Discharge Network
Take Control Downstream by Expanding Footprint Service Expansion Supports Episode Performance Dorsia’s1 Value-Driven Care Redesign Spurred Downstream Expansion as Means to Control Costs and Improve Outcomes
Realized over 30% of hip fracture patients could be safely directed to SNF instead of IRF, for approx. $10,000 savings per case
Additional Expansion?
Redesigned Care
Decided to Build SNFs
Initiated care redesign process and created protocols to aid patient placement in SNF or IRF
Completed one new SNF in July 2013 and plans to build another in 2015
Analyzed Data
Considering home health and senior living expansion
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Advantages of Owning (vs. Partnering with) Downstream Assets Retain ultimate control over costs throughout episode of care
1) Pseudonym.
Monitor and regulate patients’ progress to optimize recovery
Capture revenues from providing downstream services yourself
Source: Post-Acute Care Collaborative interviews and analysis.
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Tactic #10: Become the Full (Rural) Network
Skip Winning Over Partner Altogether Signature’s Rural Hospital Acquisition Unlocks Network Initial Signature Footprint
Signature’s Newly Acquired Network
Medical Offices Critical Access Hospital
Four SNFs
”
©2013 The Advisory Board Company
Rural Health Clinic
Employed Physicians
Six-County Home Health Agency
“We have definitely shifted to a view that we have to position ourselves for the future design of health care, which is more network-driven. And in rural communities, we in fact can be the driver and the builder-up of networks.” Chief Strategic Officer, Signature HealthCARE Source: Signature HealthCARE; Post-Acute Care Collaborative interviews and analysis.
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©2013 The Advisory Board Company
Road Map
1
SNF Medicare Volume Transformation
2
Strategies to Create System Value
3
Coda: Emerging Payer Partnership Approaches
36
Medicare Advantage Replacing Fee-For-Service? Large Plans Control Current Marketplace, Future Enrollment Not Clear Medicare Advantage Enrollment Projections
Medicare Advantage Enrollment
CBO2 and OACT3 Projected Future Enrollment
By Firm or Affiliate, 2013 United Healthcare
20
21%
18 16 14 12
17%
All Others
10 8
BCBS1
33%
6 4 2
17%
0 ©2013 The Advisory Board Company
2013
2014
2015
2016
CBO
2017
OACT
1) Blue Cross Blue Shield affiliates, including 4% in Wellpoint affiliates. 2) Congressional Budget Office. 3) Center of Medicare and Medicaid Services Office of the Actuary.
2018
2019
2020
4%
Aetna
Humana 8%
Kaiser Permanente
Source: Kaiser Family Foundation, ”Medicare Advantage 2013 Spotlight”, available at www.kff.org; Centers for Medicare and Medicaid Services, “Medicare Enrollment, National Trends 1966-2010”, available at www.cms.gov; Congressional Budget Officer, “Medicare Baseline,” May 2013, available at http://www.cbo.gov/sites/default/files/cbofiles/attachments/44205_Medicare_0.pdf, Report to the Medicare Board of Trustees, 2013, available at http://downloads.cms.gov/files/TR2013.pdf, Post-Acute Care Collaborative interviews and analysis.
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Create Executive Level Managed Care Relationships
Establish ExecutiveLevel Partnership
Proactively Raise Risk-Sharing Possibilities
• Create executive level position, e.g. VP of Managed Care Partnerships • Select candidate most capable of holding sophisticated negotiations with executives
• Demonstrate willingness to partner and share risk by taking the initiative to convert FFS contracts to pay for performance or risk-based contracts
• Empower VP to seek creative ways to build partnerships with payers’ executives
• Prepare financial models and bring performance data to create leverage
”
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Keys to Starting Partnership Discussions with Managed Care Payers
“To get our feet, wet we’re looking at capitation for our long-term care population. These folks live in our building, we see them everyday, and we know how to take care of them.” VP of Managed Care Commercial SNF Chain Source: Post-Acute Care Collaborative interviews and analysis.
Preempt Payer Care Management with Own Program
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Genesis and Aetna Partner to Improve Care, Reduce Costs Components of Genesis’ Care Improvement Model Related to Aetna Contract
Enhanced Care Management
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Dedicated staff monitor patient progress, aid transitions and manage care utilization
NP and Physician Presence Genesis-based doctors and NPs provide primary care, prevent readmissions
Intensive Rehab Services Intensive therapy 6 days/week; special programs for orthopedic, cardiac, pulmonary, etc.
Expanded Discharge Planning Care managers give discharge guidance, patient education, and ensure connection to PCP
Anticipated Benefits for Genesis Partners estimate $2 million savings from Genesis’ care management and reduced hospitalizations. Genesis eligible for financial rewards based on achieving target measures of improved outcomes.
Source: Newman E, “Genesis-Aetna alliance may preview ACO deals to come,” McKnight’s Long-Term Care News, October 1, 2011, available at mcknights.com; “Aetna, Genesis HealthCare take aim at reducing hospital readmissions,” Aetna, August 10, 2011, available at aetna.com; Post-Acute Care Collaborative interviews and analysis.
Leveraging Case-Specific Expertise to Grow Business
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Keys to Initiating and Cultivating Payer Linkages Engage Payer’s Medical Leadership
Prove Success with One-Off Cases
• Start dialogue with payer’s clinicians
• Steer negotiations away from unit costs
• Discuss increased reimbursement given patient complexities
• Focus on creative, high-quality solutions
” ©2013 The Advisory Board Company
Focus on Unique Approach
Proactively Seek New Opportunities
• Experiment with creative approaches to patient challenges • Demonstrate success on case-by-case basis
• Given expertise, seek other payers with problems placing similar patient types
I Can Help You With That Patient “I’ve had conversations with providers about building a relationship to handle these high-acuity, high-intensity consumers and we haven’t had one mention of unit costs. Not one.” Rick Fredrickson, SVP Long Term Care Programs, Centene
Source: Centene; Post-Acute Care Collaborative interviews and analysis.
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Questions About Today’s Session? For Additional Information on How the Advisory Board Supports Post-Acute and Long-Term Care Providers
Jared Landis Practice Manager Post-Acute Care Collaborative
[email protected] 202.266.6925
©2013 The Advisory Board Company
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Lead Consultant for Post-Acute Care Collaborative 8+ years experience within the Advisory Board’s Strategic Research Division Areas of expertise include: post-acute and long-term care trends, provider relationship building, referral strategy, and business planning
