Service Innovations and Assisted Living

1. Service Innovations and Assisted Living Deanna Ludlow Mitchell RN, BSN, MSBA Executive Director – Senior Care Resources Senior Vice President – LeadingAge Michigan

2. The American Health Care System50 Years Old - 2015

3. 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

4. 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 - Medigapinsurance brought under federal oversight 1981 - Freedom of Choice Waivers (1915b/c); states required to provide hospital DSH payment

5. 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

6. 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.

7. 2003 Medicare Modernization Act Medicare Drug Benefits – Donut Hole Medicare Part D Plans

8. 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

9. Seniors were most likely to be living in poverty/50% had insurance Medicare Medicaid

10. 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

11. 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

12. 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 Medicaid

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Medicare Advantage Plans Bundled Payment Groups Medicare Special Needs Plans The Triple Aim Medical Health Homes Threatens the Status Quo Health System Current Provider Behavior is Destructive of the Triple Aim Accountable Care Organizations Dual Eligible Integration Projects

20. 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

21. 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

22. 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

23. 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

24. 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 Patient Centered Medical Homes – Foundation of High Performing ACOs BCBS Michigan Reports Savings of $155 Million (Milbank Memorial Fund Report – 2012-2013)

25. 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

26. 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

27. 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

28. Medicare Advantage Plans In Michigan Total Michigan Medicare Advantage enrollment = 558,082 May 2014 Data Humana

29. Michigan Counties With Highest Medicare Advantage Enrollment

30. Medicaid Managed LTSSMI Health Link

31. 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

32. Values and Expectations Seamless access Health promotion/prevention/ chronic disease Elimination of barriers to home and community based services Transparencyof cost and quality information Evidence-based guidelines Self determination and person-centeredness

33. KFF MI Occupancy = 85% 2011 24th out of 51 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

34. 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)

35. Regional Roll Out 16,107/91,204= 18% 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)

36. 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

37. MAPs ICOs and MAPs ICOs CoventryCares Meridian United Healthcare Molina Healthcare of Michigan AmeriHealth / BCBS of Michigan Midwest Health Plan FidelisSecureCare of Michigan Humana United Health Care Blues Health Plus Priority Aetna

38. 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

39. 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 …

40. 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

41. 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.

42. 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

43. Risk Hospital Nursing Home HHA Michigan Bundled Payment Initiatives MI Health Link MAPs Readmission Penalties RISK

44. 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

45. 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

46. Assisted Living Innovations The Oregon Model Affordable Assisted Living – Huron Woods Level of Care Challenges Collaborations with PACE Programs/Green Houses

47. 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

48. 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

49. 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

50. 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