Scott Hale, Symmetry healthcare Kristen byrne , DSHS altsa

1. Managed Care & Behavioral Health Update - Barriers to Discharge from Acute to SNF – Issue Review & New Initiatives Scott Hale, Symmetry healthcare Kristen byrne, DSHS altsa

2. Problem Overview:Patients backlogged at acute facilities • Patients remaining at acute facilities beyond acute need – Primarily Medicaid clients • Financial cost to system estimated in millions, however, actual data has not been tracked – burden largely borne by acute facilities • Problem occurring at many community and State hospitals as nursing homes decline to admit high risk Medicaid patients • Washington State Hospital Association seeks relief in 2017 legislation • Legislature commissions a report to analyze potential barriers and consider solutions

3. Legislative Mandate from Senate Bill 5883 “The authority and the department of social and health services shall convene a work group consisting of representatives of skilled nursing facilities, adult family homes, assisted living facilities ………” “The work group shall identify barriers that may prevent skilled nursing facilities from accepting and admitting clients from acute care hospitals in a timely and appropriate manner” “The work group shall consider what additional resources are needed to allow for faster transfers of enrollees including those with complex needs.”

4. AcuteAdministrative Days:The hidden costs of a system without incentives • Patients who remain at acute facilities beyond the date that acute services are no longer required result in payment of the Administrative Day Rate (ADR) of approximately $180 per day to the hospital (Avg NF rate) • The ADR rate is grossly inadequate in covering the true costs of care for the resident at the acute hospital – the difference between the true acute rate and the ADR rate is the hidden cost to the system • MCO responsibility for payment of only the ADR rate results in a potential disincentive to pay competitive skilled rehab rates at the nursing facility during a rehab period • Once determined ‘custodial’ or long term care the MCO may not be responsible for the costs at the acute facility

5. Background - what does the data show • 2016 analysis of managed care and fee-for-service Medicaid hospital admissions. • Difficult-to-discharge residents represent .7 percent of total inpatient hospital admissions • “High risk” group for MCOs, hospitals and particularly for SNFs • 179,306 admissions • 136,896 MCO-paid • 42,410 fee for service • 174,982 discharges to home, transferred for additional inpatient care, leaving against advice of dying • 2.5 percent – 4,323 clients transferred to SNF, AFH or ALF for additional care

6. Potential Cost Example: • Based 2016 Data • Admissions 179,306 • Percent Diff to Place .7% • ____________ • Total 1,255 • Acute/Admin Rate Var $1,000. • ____________ • $1,255,000. • Avg Delay per admit 14 • ___________ • Annual System Hidden Cost. $17,500,000.

7. SNF/Acute Care Hospital Work Group • 2017 Legislature required a report to the Legislature from these stakeholders: • SNF representatives • Adult family homes • Assisted living • Managers of in-home LTC • Hospitals • Managed health care systems (MCOs) • Identify barriers that prevent SNFs from accepting acute care hospital clients in a timely and appropriate manner • Consider resources necessary to allow for faster transfer of enrollees, including those with complex needs

8. Process • Three one-day meetings to: • Identify barriers to discharge from a community hospital • Propose solutions to those barriers • Identify resources needed to implement solutions • Prioritize the solutions • Diverse Group of Stakeholders • Session Methodology

9. Difficult-To-Place Patients • “These difficult-to-discharge residents present unique clinical, economic, and psychosocial placement barriers which differentiate them from the average Medicaid client. While a relatively small segment of the total Medicaid population, their issues and complications can place them in a “high risk group” for MCOs that are financially responsible for their care, for acute care facilities where they reside long after acute services cease, and especially for skilled nursing facilities where post-acute care is desired but for whom significant risk may result.” (Report To The Legislature)

10. Common Themes/Barriers • Mental/Behavioral Health Issues – • Substance abuse • Aggressiveness • Wandering • Refusal of care & self harming behavior • Social Issues • Smoking • Homelessness • Financial self mismanagement • No family or other support structure • Limited resources for post SNF housing options

11. Common Themes/Barriers • MCO Role & Responsibilities – confusion at all levels • Contracting for sufficient provider network • Single Case Agreements vs Group Contract for High Risk Group • Discharge Planning process from acute units • Authorization & Case Management process when in SNF • Discharge planning process from MCO responsibility at SNF • Transition of responsibilities to agencies when dc to lower care setting. • Lack of standardization in all processes between the different MCOs

12. Other Identified Barriers • Regulatory Issues • No exemption from RCS for potential citations • Rates and Financial Issues • Insufficient Rates (MCO/LTC) to mitigate risks • Support Coordination Issues • Agency support for housing and caregivers • Mental Health Service limitations • MCO – Agency – Acute – SNF mixed roles and & responsibilities

13. BARRIER CATEGORIES • Managed Medicaid patients with outlier characteristics • Mental Health Needs • Bariatric • Substance abuse • Western & Eastern State Hospital patients who might be cared for in a lower level of care setting providing specialized mental health services

14. Worst Actual Proposed Barrier Solution (that did not make the final draft) • “It’s obvious that we don’t have enough nursing home beds if facilities are not taking these patient referrals. We need to build more beds so facilities will be more desperate to take these residents.” Name Withheld for Participant Safety

15. Next Steps • Snohomish/King County Hospital Transitions Summit • Mental Health Transformation Project • MCO/SNF Steering Committee • Determine of other potential programs

16. MANAGED MEDICAID:Key Issues – High Risk Referrals • For Nursing Homes, “Managed Medicaid” clients are not true Managed Care, but represent a High Risk Group. • MCO – SNF Contracting – little incentive for group contracting • Most referrals are outliers with high risks • Little opportunity to balance high risk, low rate referrals with low risk, high rate referrals from any given MCO. Each referral must stand on it’s on risk/reward ratio. • Significant risk of client becoming LTC with ongoing risks and requirements at low average DSHS rates • Result: Single Case Agreements for many eventual placements

17. MANAGED MEDICAID:Concept Problems • Multiple MCOs representing a small number of SNF referrals • 4323 total referrals to SNF, AFH or ALF represent approximately 700 referrals per MCO, a fraction of which are SNF referrals. • 1255 unplaced referrals may represent ½ or more of all referrals intended to be placed in nursing facilities. Facilities are only accepting those that meet their increasingly strict criteria or risk/reward ratio. • MCO – SNF Contracting – little incentive for group contracting • Most referrals are outliers with high risks • Little opportunity to balance high risk, low rate referrals with low risk, high rate referrals from any given MCO. Each referral must stand on it’s on risk/reward ratio • Significant risk of client becoming LTC with ongoing risks and requirements at low average DSHS rates • Result: Single Case Agreements for many eventual placements

18. MANAGED MEDICAID:Process Problems & Disincentives • Coverage Criteria – Unclear and frequently changing • No Post Acute Care Benefit – As compared to Medicare, responsibility for coverage in the nursing home is based on “Alternative to Acute Care”. • Significant variation of process between MCOs in areas of: • Contracting • Discharge Planning • Authorization & Reauthorization • Billing & Appeals • Providers report ability to obtain optimal results with any MCO is based on the quality of the MCO Provider Services representative.

19. MANAGED MEDICAID:Why Do It? • Potential For High Rates – Some providers have been able obtain Single Case Agreements with rates comparable with Medicare while also carving out high outlier costs • Local Community Hospital Support – build a relationship with your local hospital by helping them with a difficult-to- place resident

20. MANAGED MEDICAID:Be Proactive To Get Paid • Negotiation BEFORE Admission – Facility leverage disappears once admission • Single Case Agreements • Rate with inclusions/exclusions • Authorization & Reauthorization timeframes – know them and don’t miss them • Claims Submission – Know the required billing format. Follow up promptly on any denial or delay in payment. • Know who your MCO Provider Relations person is • Know Facility and Resident Appeal rights • Know who can help you at the HCA

21. SNF/MCO Steering Committee • Provide clarity and guidance in relationships between MCOs and providers. • Review established barriers to placement of Medicaid clients • Create “Best Practices” recommendations for • Contracting • Placement and Case Management • Program Consistency • Claims Management Process & Appeals • Recommend Data collection, reporting, and clear HCA oversight • Workgroup will not address MCO/HCA contracting. Guidelines to be developed.

22. Bariatric Pilot Program – specialized service example • Program established under WAC 182-531-1600 • 3 Bariatric clients to date • All completed SNF program and returned to a lower level of care facility • Opportunity for higher negotiated rate • Close collaboration with HCS/RCS

23. For Further Information • Skilled Nursing Facility/ Acute Care Hospital Work Group Report • http://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName=HCA%20Report%20-%20Skilled%20Nursing%20Facility%20-%20Acute%20Care%20Hospital%20Work%20Group_08f9d013-7ce3-4ea8-8d7d-e8958c832242.pdf • J. Scott Hale, Symmetry Healthcare Management • jscotth@symmetrycare.com • (206)618-0891