Tag: Medicare fee-for-service

How Skilled Nursing Facilities Need To Prepare For Value-Based Care

By Kathleen Riordan and Apurva Subramanian, healthcare experts, PA Consulting.

Over the next decade one in five US residents will be over the age of 65, over 70 percent of whom will require some form of Long-Term Services and Support (LTSS) as they continue to age. The resources required to meet the care needs of our senior generation will triple by 2040.

The industry is reaching a tipping point and CMS – the primary payer for these services – is going to look for innovative ways to curb costs while maintaining high-quality, patient-centric care. Value-based payment models in other health service organizations incentive providers to do just this.  Historically, LTSS have been left out of value-based care payment arrangements; however, with the increase in use and cost of LTSS, CMS is gradually incorporating value-based care models in this industry to nudge providers into more innovative ways of delivering care.

For example, in 2019, skilled nursing facilities began receiving quality-adjusted payments for all Medicare Fee-For-Service (FFS) patient-stays. CMS is now withholding 2 percent of all Medicare FFS payments and giving facilities the opportunity to earn this back through an assessment of its performance on the 30-day all-cause hospital readmission quality measure. Recent results show that 73 percent of nearly 15,000 skilled nursing facilities reporting data received payment penalties for performance on the hospital readmission measure, with 20 percent receiving the maximum penalty of the entire 2 percent withholding.

Now is the time for long-term care organizations to act, as the initiatives CMS is proposing will significantly affect the industry. On the agenda for CMS is a range of payment incentives including:

The payment models in both skilled nursing and home health represent a shift that CMS is making to include all ancillary providers into the value-based care arena. Long-term care organizations can learn from hospitals and physician groups who proactively approached this coming wave of value-based payment reform. Organizations that are collecting and acting on data in a timely manner, establishing efficient cost-reducing processes, and integrating effectively within the care continuum will thrive in the new financial environment.

So how can long-term care providers implement an effective value-based care model? Follow these four steps.

  1. Understand value-based program requirements and determine the necessary people, processes, and technologies needed to adjust operations to achieve program success. The challenging part for long-term care is going to be in operationalizing new value-based care program requirements. Those organizations that can effectively arrange the right people, processes, and technology stand to soar above the rest. Advancements in technology have enabled organizations to progress further, faster. Currently, many vendors in the market offer telemedicine technologies and remote patient monitoring applications to care for high-acuity patients in more effective ways. For example, long term care providers can use telehealth to provide support to elder patients allowing them to stay in their homes longer. A great example is the Argenti care technology program in the UK that placed a configured Amazon Echo device in on-demand senior care services, the pilot was highly successful and improved outcomes and reduced cost. Some skilled nursing facilities are even investing in putting in motion detectors in patient rooms to assess movement anomalies to ensure patients get the right care when they need it. Investing in the right technologies to ensure a high-quality care experience can accelerate a LTSS provider’s ability to adapt to value-based care models.
  2. Use data and processes improvement methodologies to recognize and reduce unnecessary costs and develop best-practice processes. Long-term care service providers should already be collecting and using data to generate insights to inform best-practices in both the cost and delivery of care. The Visiting Nurses Association of New York, the oldest nonprofit home and community-based health organization, is already using robust data analytics to drive clinical and operational decision-making by creating a model to proactively predict when a patient may benefit from a different or higher level of care. For those organizations without a robust data analytics strategy, steps can be taken to capture, track, and analyze clinical and claims data to understand population-based characteristics and care needs. In doing so, LTSS organizations can establish benchmarks and reporting to create the drive toward more clinically and cost-effective approaches to care.
  3. Build relationships with providers across the care continuum to create open lines of communication and develop smooth processes for patient care transitions. Crucial to the success of long-term care organizations in transitioning to value-based models is the ability to develop clear processes and means of communication with providers along the patient care continuum to ensure smooth transitions in and out of care and a streamlined flow of information among providers. Currently, NYU Langone Health is partnering with 11 high-quality skilled nursing facilities to create a preferred network where organizations are coming together to improve care transitions by openly sharing quality, readmission, and length of stay data. In doing so, these organizations are learning from one another to improve their own performance standards and proactively prepare for additional upcoming incentives created through value-based care payment models. The transition to a culture of continuous improvement is often a challenge for organizations, as employees at all levels have to recognize and work to overcome the ineffectiveness in largely entrenched processes and procedures. However, in building a culture of continuous improvement where all employees have the capacity and ability to step outside of their daily whirlwind of job demands and look for efficiencies ultimately leads to innovative and productive ways of thinking and acting. 
  4. Partner with local community organizations to enhance your current service offerings. Value-based care models are intended to keep costs down while ensuring patients continue to receive high-quality medical care. The elderly population is a vulnerable population and requires additional support systems in place to have all their health care needs met. Building connections with local community organizations to help patients as they transition out of nursing care to their home or while receiving in-home care can set your organization up for success. Local area agencies on aging can connect long-term care providers with the right community resources to support their patient populations. Local community organizations can provide support with social care needs like transportation, fall-risk assessments, nutrition and meal preparation, community-based engagement, all of which have been shown to not only reduce hospital readmission rates, but also improve the health and well-being of the elderly. 

Long-term care service providers need to invest time and budget into comprehensive data collection and analysis, implementation of process improvement methodologies, and advanced technological devices to proactively adjust to payment reform. Navigating the integration of value-based care models for long-term service and support organizations can seem like a dauting journey. But we have seen that organizations that prepare effective strategies for implementing the four activities outlined above are more likely to experience a smoother transition.

HHS Aims To Deliver Value-Based Transformation In Primary Care

U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announce the CMS Primary Cares Initiative, a new set of payment models that will transform primary care to deliver better value for patients throughout the healthcare system. The CMS Primary Cares Initiative will aim to reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall healthcare costs, HHS said in a statement.

Image result for HHS Secretary Alex Azar
Alex Azar

“For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision,” said HHS Secretary Alex Azar. “Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before. These models can serve as an inflection point for value-based transformation of our healthcare system, and American patients and providers will be the first ones to benefit.”

Empirical evidence shows that strengthening primary care is associated with higher quality, better outcomes, and lower costs within and across major population subgroups. Despite this evidence, primary care spending accounts for a small portion of total cost of care, and is even lower for patients with complex, chronic conditions, HHS said.

CMS’s experience with innovative models, programs and demonstrations to date have shown that when incentives for primary care clinicians are aligned to reward the provision of high-value care, the quality and cost effectiveness of patient care improves, the organization cited.

CMS Administrator - Seema Verma
Seema Verma

“As we seek to unleash innovation in our health care system, we recognize that the road to value must have as many lanes as possible,” said CMS Administrator Seema Verma. “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.”

Administered through the CMS Innovation Center, the CMS Primary Cares Initiative will provide primary care practices and other providers with five new payment model options under two paths:

Primary Care First and Direct Contracting.

The five payment model options are:

  1. Primary Care First (PCF)
  2. Primary Care First – High Need Populations
  3. Direct Contracting – Global
  4. Direct Contracting – Professional
  5. Direct Contracting – Geographic

The Primary Care First (PCF) payment model options will test whether financial risk and performance based payments that reward primary care practitioners and other clinicians for easily understood, actionable outcomes will reduce total Medicare expenditures, preserve or enhance quality of care, and improve patient health outcomes. PCF will provide payment to practices through a simplified total monthly payment that allows clinicians to focus on caring for patients rather than their revenue cycle. PCF also includes a payment model option that provides higher payments to practices that specialize in care for high need patients, including those with complex, chronic needs and seriously ill populations (SIP).

Both models under PCF incentivize providers to reduce hospital utilization and total cost of care by potentially significantly rewarding them through performance-based payment adjustments based on their performance. These models seek to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus and screening for colorectal cancer. PCF will be tested for five years and is scheduled to begin in January 2020. A second application round is also planned for participants starting in January 2021.

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BPCI Advanced: Ensuring Successful Participation

By Win Whitcomb, MD, chief medical officer, Remedy Partners.

Win Whitcomb

The Bundled Payments for Care Improvement (BPCI) Advanced initiative is a new advanced alternative payment model (APM) that will go live October 1, 2018. The successor to the 2013 BPCI program, BPCI Advanced is CMS’ most significant episodic payment reform proposal to date, indicating the government’s commitment to transitioning to paying for healthcare value rather than volume.

BPCI Advanced, a bundled payment model for Medicare fee-for-service beneficiaries, is a voluntary program in which acute-care hospitals and physician group practices may participate as “episode initiators.” As such, they will assume clinical and financial risk for patients during the episode. BPCI Advanced encompasses 32 bundles, or episodes, that include an inpatient hospitalization and the following 90-day period (save for three outpatient procedure bundles that include the procedure and 90-day follow-on period).

Applicants can choose one or more of the 32 bundles and then commit to participate with these bundles for the first five quarters of the program, at which time they can change their selected bundles. The bundled payment is carried out retrospectively where Part A and Part B claims are summed; if total payments are less than an episode initiator-specific target price, initiators keep the difference; if total payments exceed the target price, initiators must pay back overages. Performance on seven claims-based quality metrics impacts incentive payments. Episode initiators may go it alone or participate with a “convener,” which may provide services such as care-management technology, analytics and reporting, care-redesign expertise, access to post-acute provider networks, and financial risk sharing.

CMS recently distributed to applicants historical claims and target pricing data that contains Medicare Part A and B claims for each applicant, at the individual hospital-level, mapping to the 32 bundles and a target price for each bundle. Applicants can see total spending represented by all bundles and the total number of episodes. They can also see, in aggregate and for each bundle, major areas of spending during an episode, such as anchor hospitalization, readmissions, skilled nursing facilities, inpatient rehabilitation facilities, and spending tied to home health agency services, physician services, durable medical equipment, etc.

How to Succeed

Applicants should evaluate areas of high spending, high variation or both. Since BPCI Advanced is a pay-for-improvement program, applicants should select and prioritize bundles in which there is opportunity for improved performance over the baseline period (2014-2016).

Practices that improve care coordination will do well with BPCI Advanced. But keep in mind that BPCI Advanced episodes last for 90 days following anchor hospital discharge, so any readmissions occurring during this window will affect success. The best way to address this issue is to provide longer term follow-up with patients’ key physicians and other providers. One example of this is selecting the optimal discharge destination (e.g., to home without services, home with services, or post-acute facility) based on each patient’s profile. This can help improve the use of post-acute services, which account for substantial spending during an episode.

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