Value-Based Payment Educational Webinar Series: #1 What .

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 201526 Medicare ACOs in NY:Nine Started in 2014 or 2015ACO/HIE NameAccountable Care Coalition of Greater New York, LLCAccountable Care Coalition of Mount Kisco, LLCAccountable Care Coalition of Syracuse, LLCAccountable Care Coalition of The North Country, LLCAdirondacks ACO, LLCAsian American Accountable Care OrganizationBalance ACOBassett Accountable Care Partners, LLCBeacon Health Partners, LLP ACOCatholic Medical Partners-Accountable Care IPA, Inc.Chautauqua County Health NetworkChinese Community Accountable Care OrganizationCrystal Run Healthcare ACO, LLCHartford HealthCare Affordable Care Organization, Inc.Healthcare Provider ACO, Inc.HHC Health And Hospitals Corporation ACO, Inc.Institute for Family Health, TheMontefiore Pioneer (Bronx) ACOMount Sinai HospitalNew York State Elite (NYSE) ACO, Inc.New York Quality CarePrimary PartnerCare Associates IPA, Inc.ProHEALTH Care Associates LLPRichmond Quality, LLCRochester General Health System ACO, Inc.WESTMED Medical Group PC ACOFirm TypeMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Pioneer ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOMedicare Shared Savings ACOSource: Defhc.com, February 2015CityBrooklynMount KiscoSyracuseCantonPlattsburghNew YorkNew YorkCooperstownManhassetBuffaloJamestownNew YorkMiddletownNew YorkGarden CityNew YorkNew YorkBronxNew YorkEast MeadowNew YorkLake SuccessLake SuccessStaten IslandRochesterPurchase HDG 2015Start 20147/1/2012December 16, 201522How ACO Shared Savings WorksCurrentaverage percapitaspending forMedicarepatients inmarket areadeterminedfrom claims forpast 3 yearsPatientassignedbased onwhere majorityof physiciancare receivedACOLaunchedSpendingtargetdetermined byCMSProjectedTargetActualShared savings to bedistributed among ACOdoctors, hospitals, partnersAdapted from Brookings Institute 2015 Health Dimensions GroupIf actualspendinglower thantarget, savingsare shared—IFqualitytargets alsoachieved HDG 2015December 16, 20152312

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015CMS Adopted Changes Designed to DriveGrowth in ACOs CMS finalized changes in May 2015,including provisions that:– Create Track 3,which includes higher ratesof shared savings, prospective assignmentof beneficiaries, and opportunity to usenew care coordination tools– Streamline data sharing– Establish waiver of 3-day stay SNF rulefor beneficiaries prospectively assignedto ACOs under Track 3– Refine policies for resetting ACO benchmarks CMS also implementing Next Generation ACOs to experimentwith new ways to share risk HDG 2015December 16, 201524Medicare ACO Performance Resultsin the News Recently Medicare ACOs qualified for more than 422 million in shared savings in 2014 bymeeting quality standards and savings threshold:– 11 of 20 Pioneer ACOs earned 82 million in shared savings,(Banner 29 million, Montefiore 13 million) while 3 owed 9 millionin losses– 92 of 333 Medicare Shared Savings Program ACOs earned morethan 341 million in shared savings Maturation key—ACOs with three years of experience in theprogram were twice as likely to earn savings than those with one“Officials at both organizations [Montefiore and Banner ACOs] saidperformance was boosted by attention to post-acute care costs andquality. Banner Health's ACO developed a preferred network of skillednursing facilities and recommends those facilities to patients.”(Modern Healthcare, August 25, 2015)Source: CMS Press Release. August 25, 2015. Fact-sheets/2015Fact-sheets-items/2015-08-25.html HDG 2015 2015 Health Dimensions GroupDecember 16, 20152513

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Case Study ACOs and Post-acute:Franciscan Alliance Pioneer ACO (Indiana) Narrowed network of PAC providers through thoughtful process,initially by using a survey and then by monitoring metrics:– Achieved significant reductions in post-acute LOS and readmissions– Improved family and patient satisfaction with discharge care ACO/PAC relationship more collaborative by focusing on:– Customer service and transitions improvement– Two-way communication using EMRs– INTERACT and risk stratification protocols implementation– Patient activation and health literacy improvement Acuity of referrals to institutional post-acute increasing HDG 2015December 16, 201526Case Study on ACOs and Post-acute:Monarch Pioneer ACO (California) Developed post-acute network, which includes targetedcare management strategy based on risk stratification Actual medical cost declined2.8% in first year– Driven by lower SNF cost– Inpatient and physicianexpense both declinedyear over year Key drivers of success:– Post-acute network selection– Performance-based incentivesSource: Norris Vivatrat, MD, Pioneer ACOs, A Review of the GrandExperiment, January 2014– Targeted care management HDG 2015 2015 Health Dimensions GroupDecember 16, 20152714

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Medicare Advantage Growing Nationallyand in NYS?MedicareAdvantage (MA)penetration grewby more than30% in the last5 yearsMost growth isconcentrated in15 states NYSis one of them,with 11 upstatecounties over50% MApenetrationSource: HDG analysis of CMS.gov files as February 2015Despiteenrollmentgrowth, MAremains a “blackbox” to manypost-acuteproviders HDG 2015December 16, 201528Medicare Advantage Plans May BecomeNext Frontier for Value-Based Payment As Medicare Advantage penetration grows, plans willincreasingly copy FFS payment initiatives like bundling andother alternative payment strategies– Medicare Advantage plans are accorded significant payment flexibilityunder federal law– Special Needs Plans (SNPs) likely to be early adopters of value-basedpayment strategies– Fully Integrated Dual Eligible (FIDA) plans have value-based paymentrequirement in their contracts, but so far have had significant problemsachieving scale (only 7,540 enrollees as of November 2015) Value-Based Insurance Design (VBID): CMS recentlyannounced that MA plans in 7 states will be offered flexibility inbenefit design (reduce cost sharing or offer extra benefits) sothat beneficiaries with certain chronic conditions can beincentivized to pursue high-value treatmentsSource: Medicare.gov, October 2011–2015 2015 Health Dimensions Group HDG 2015December 16, 20152915

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Examples of Institutional Special NeedsPlans (I-SNPs) Value-Based ContractingI-SNP AI-SNP B Waives 3-day prior hospitalstay and treats resulting skilledstay as Part A stay Pays reduced rate for Part Astay according to 4 rate tiers Inserts nurse practitioners intofacility Provides quality incentivepayments and upside sharedsavings Waives 3-day hospital stay, butauthorizes limited Part A days Pays PPS rates and hasIntensive Service per diem addon Does not provide nursepractitioners, but paysadministrative fee for additionalchronic care management,credentialing, quality activities Shares higher percentage ofsavings; also requires facility toshare in losses HDG 2015December 16, 201530Health Plans Are Now ImplementingLarge-Scale Shared Savings Programs Accountable cost and quality arrangement (ACQA)—ACO look-alike Mechanism to organize physicians and operate acrosspayers (e.g., Medicare Advantage and commercial plans)This exampleoperates inupstate NY HDG 2015 2015 Health Dimensions GroupDecember 16, 20153116

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Providers Looking at Clinical IntegrationStrategy for Value-Based Care Primary purpose:– Integrate members’ efforts to improve clinical care quality & efficiency– Must integrate clinical decision making or financial risk– Must demonstrate benefit to payers and members Can negotiate reimbursement structures with MCOs, other risk-bearing entitieson behalf of its members that reward quality and efficiencyClinically Integrated CarePillar 1:CollaborativeLeadership Governancebody Compliant legalstructure Payer strategy Culture changePillar 2:Aligned Incentives Physiciancompensation Programinfrastructure PhysiciansupportPillar 4:TechnologyInfrastructurePillar 3:Clinical Programs Diseaseprograms Care protocols Clinical metrics Populationhealthmanagement Healthinformationexchange Patientlongitudinalrecord Disease registry Patient portalSource: ician-relationships/the-4-pillars-of HDG ital-physician-collaboration.htmlDecember 16, 201532Post-Acute Care Providers Are FormingNetworks and Integrating Care Cincinnati-based clinical integration model, LLC entity formedby 3 founding members, with 7 additional SNF participants Centered on value-based shared savings reimbursement:– Medicare bundled payment convener– Negotiating performance-based reimbursement with MedicareAdvantage and MyOhio duals plans Any traditional reimbursement contracts will be messengermodel HDG 2015 2015 Health Dimensions GroupDecember 16, 20153317

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Number of Bundling ModelsContinues to GrowMedicareComprehensiveCare for JointReplacement (CJR)Medicare BundledPayments for CareImprovement(BPCI)MedicaidCommercialMedicare ManagedCare HDG 2015December 16, 201534Bundling Comes in Many Shapes and FormsCan be triggered by presence of chronic condition or occurrence of acuteevent Medicaid and Commercial payers tend to focus on bundling for chronic careconditions Medicare has focused on episodes after an acute hospitalization(e.g., BPCI is triggered by 1 of 48 hospital events)Can be prospective or retrospective Prospective means that the bundler must figure out how to pay other providers inthe bundlesCan have varying episode lengths (30, 60, 90, annual)Often factor out unrelated conditions and have ways to mitigate risk HDG 2015 2015 Health Dimensions GroupDecember 16, 20153518

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Medicare Bundled Payments for CareImprovement (BPCI) InitiativeTypes of Services Included in BundleInpatient hospital and physicianservicesModel 1Acute HospitalStay OnlyModel 2Acute Hospital Post-Acute RetrospectiveRetrospectiveProspective4210Related post-acute care servicesRelated readmissionsOther services defined in bundle(Medicare Part A & Part B)Target to performance paymentNumber of NY participantsRetrospectiveModel 3Post-AcuteCare OnlyModel 4Acute Hospital Readmissions Established as 3-year, voluntary demonstration programby Center for Medicare & Medicaid Innovation (CMMI) HDG 2015December 16, 201536Second Application Period Grew BPCISignificantlyEpisode Initiators by Provider Type723 SNFs20151,618organizations415 Hospitals305 Physician Groups2013214organizations103 HHAsCMS has indicated thatanother round of bundlingis possible after evaluationof current participants Source: CMS BPCI newsletter November 2015, Ed. 7 2015 Health Dimensions Group9 IRFs1 LTCH HDG 2015December 16, 20153719

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015At-Risk Bundlers in NYS:42 Model 2 (13 PGPs)PGP Organization NameRockland Orthopedics & SportsMedicine#1AirmontOrthopedics New York, LLP1Albany7AmherstExigence Hospitalist Medical Servicesof Hornell, PLLCUHS - United Health Services MedicalGroup17Binghamton5East Syracuse35Lewiston1Nanuet1Nanuet1New CitySyracuse Orthopedic Specialists, PCExigence Hospitalist Medical Servicesof Lewiston, PLLCAdvanced Orthopedics & SportsMedicine, PLLCNortheast Orthopedic & SportsMedicine, PLLCPremier Orthopaedics of Westchesterand RocklandCityOrangetown Orthopedic Associates1OrangeburgSt Joseph's Physician Health PC18SyracuseSt. Joseph’s Medical PC1SyracuseClarkstown Orthopedics1West Nyack# Number of diagnostic categories at riskOrganization NameAlbany Memorial HospitalSt. Peter's HospitalSouthside HospitalUnited Health Services HospitalsMontefiore Medical CenterNYU Lutheran Medical CenterThe Brooklyn Hospital CenterBuffalo General Medical CenterCorning HospitalArnot Ogden Medical CenterFlushing Hospital Medical CenterHuntington HospitalJamaica Hospital Medical CenterNorth Shore University Hospital (Nsuh)Winthrop-University HospitalLong Island Jewish HospitalHospital for Special SurgeryLenox Hill HospitalMount Sinai Roosevelt HospitalNew York University Hospitals CenterThe Mount Sinai HospitalSouth Nassau Communities HospitalCanton-Potsdam HospitalHighland HospitalStrong Memorial HospitalSt. Joseph's Hospital Health CenterSamaritan HospitalSeton Health (St. Mary's Hospital)Saint Anthony Community Hospital#432182118642221202111323412212461 HDG 2015CityAlbanyAlbanyBay ElmiraFlushingHuntingtonJamaicaManhassetMineolaNew HydeparkNew YorkNew YorkNew YorkNew YorkNew TroyWarwickDecember 16, 201538At-Risk Bundlers in NYS:10 Model 3 (1 PGP)PGP Organization NameUHS - United Health Services MedicalGroup#2CityBinghamton# Number of diagnostic categories at riskOrganization NameVisiting Nurse Service of New YorkHome Care#2New YorkVillage Center for Care13New York6New Hyde Park6Lake Poughkeepsie1Port WashingtonParker Jewish Institute for HealthCare and Rehabilitation (SNF)Parker Jewish Institute for HealthCare And Rehabilitation (CHHA)UHS - Twin Tier Home Health Care VestalUHS - United Health ServicesMedical GroupBelair Nursing & RehabilitationCenterHuntington Hills Center for Health &RehabilitationThe Pines at Poughkeepsie Centerfor Nursing & RehabilitationSands Point Center for Health &Rehabilitation HDG 2015 2015 Health Dimensions GroupCityDecember 16, 20153920

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Bundlers Were Required to SelectDiagnostic Families by October 1, 2015(48 “Clinical Episodes” Possible)Diagnostic Families(aka Clinical Episodes)Percentage ofPercentage ofModel 2 (Hospital/PGP)Model 3 (Post-Acute/PGP)Bundlers Selected Episode Bundlers Selected EpisodeMajor joint replacement of thelower extremity68%58%Congestive heart failure35%41%Simple pneumonia andrespiratory infections34%47%Chronic obstructive pulmonarydisease, bronchitis, asthma32%39%Hip and femur procedures exceptmajor joint27%36%Top 5 DRG Groups Are Bundled byBoth Acute Model 2 and Post-Acute Model 3Source: CMS analytic file, October 13, 2015; CMS BPCI newsletter November 2015, Ed. 7 HDG 2015December 16, 201540Roles for Post-acute in Model 2 & 3 BPCI:Vendor or EIP Until Another Round of BPCI PermittedModel 2Model 3 Episode IntegratedProvider to Model 2hospital or physician grouppractice (PGP), preferablywith gainsharing Preferred Vendor toModel 2 hospital or PGPby accepting referrals andeffectively managing care BPCI Awardee(accept risk, control gains) Episode IntegratedProvider to Model 3awardee (e.g., SNF orHHA to Model 3 PGP) Preferred Vendor toModel 3 PGP or PAC(e.g., HHA to SNF) HDG 2015 2015 Health Dimensions GroupDecember 16, 20154121

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Care Redesign Is Integral to Value-BasedTransformationCare RedesignGain and RiskSharingReinforcesInformsQuality andPerformanceMeasurementData SharingSupports all Activities and ExchangesSource: CMS, Contracting for Bundled Payment, 2011 HDG 2015December 16, 201542Early Results: Medicare Bundling WillChange Post-acute Care Utilization First CMS evaluation of BPCI for small numberof ortho bundlers showed that institutional PAC(SNF, LTACH, IRF) fell by 30%; use of HHAstayed about the same Cleveland Clinic Model 2 BPCI results formajor joint replacement showed that dischargesto SNFs dropped by 45% while discharges to home/home withHHA increased by 75%; Montefiore Model 2 BPCI results similar Recent letter to JAMA about NYU’s Model 2 BPCI program shows49% and 34% reductions in discharges to institutional PAC forcardiac valve and joint replacement episodes, respectivelyCaution: Early results are heavily influenced by ortho bundles and possibleselection bias; nonetheless, the results and our experience with bundlingindicates that bundling can drive market shiftsSource: CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 1 Evaluation & MonitoringAnnual Report, The Lewin Group, February 2015 HDG 2015 2015 Health Dimensions GroupDecember 16, 20154322

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015Waivers Offer Opportunities for ChangingCare and Increasing Value Proposition Modification of 3-day qualifying stay forMedicare SNF:– Allows SNF coverage for 1-day or 2-day prioracute stay for Model 2 bundlers– Allows direct admission to qualifying SNFproviders for Pioneer ACOs Post-discharge home visits:– Allows billable visits monthly throughout episode, which canbe delegated by physicians to other clinicians Telehealth:– Waives geographic restrictions on telehealth providing that allother Medicare coverage requirements apply HDG 2015December 16, 201544Gainsharing in VBP Context: ExpansionWill Take Time Gainsharing in a bundling and ACO contextexecuted through waivers and will becomemore widespread after excess capacity issqueezed out first Policy on gainsharing is rapidly evolving asalternate payment approaches flourish In general, gainsharing arrangements must:– Have strong quality component,preferably using evidence-basedguidelines– Not be created to directly or indirectlyinduce referrals– Not harm beneficiaryOctober 3, 2014Federal Register HDG 2015 2015 Health Dimensions GroupDecember 16, 20154523

LeadingAge New YorkValue-Based Payment Educational Webinar Series: #1What Value-Based Payment Means to Post-Acute and Long Term CareDecember 16, 2015New CMS Bundling Program:Comprehensive Care for Joint Replacement (CJR)CJR MandatoryLocationsFinalized for April 1, 2016,implementatio

Accountable Care Coalition of Greater New York, LLC Medicare Shared Savings ACO Brooklyn 1/1/2014 . Balance ACO Medicare Shared Savings ACO New York 7/1/2012 Bassett Accountable Care Partners, LLC Medicare Shared Savings ACO Cooperstown 1/1/2015 Beacon Health Partners, L