VAMDA – 2014 Verna Sellers, MD, Medical Director Geriatric Services and Centra PACE

1. The Future Impact of the Patient Protection and Affordable Care Acton Post Acute and Long Term Care VAMDA – 2014 Verna Sellers, MD, Medical Director Geriatric Services and Centra PACE Lynchburg, Virginia

2. Speaker Disclosures: Dr. Sellers has disclosed that she has no relevant financial relationship(s).

3. Learning Objectives • Explain the essential components of the 9 titles in the PPACA • Discuss the goals of PPACA and the implications for Long Term Care • Identify strategies for medical directors, physicians and other long term care professionals to navigate new wave of healthcare reform utilizing lessons learned from capitated programs • Describe the Medical Director’s role in maintaining the financial solvency of the nursing Facility.

4. Drivers for Change: Healthcare Delivery System Reaches Financial Tipping Point Medicare & Social Security Income & Cost Rates As a % of taxable payroll Medicare From 2011 Social Security & Medicare Board of Trustees Annual Report… [The HI fund fails the test of short-range financial adequacy, as projected assets drop below one year’s projected expenditures early in 2011] [The fund also continues to fail the long-range test of close actuarial balance. Medicare’s HI Trust Fund is expected to pay out more in hospital benefits and other expenditures than it receives in income in all future years. The projected date of HI Trust Fund exhaustion is 2024, five years earlier than estimated in last year’s report] Source: http://www.ssa.gov/oact/TRSUM/index.html

5. The majority of our healthcare dollars are spent on healing as opposed to prevention

6. The Patient Protection & Affordable Care Act 1 2 3 4 5 6 7 8 9

7. Necessity is the Mother of Invention: Time for Innovation Innovate Next 5 – 10 Years

8. What is Accountable Care? A New Delivery Model? Major Risk Shift from Payor to Provider Capitated Payments Predictive Modeling Information Systems: H.I.E. Patient Centered Preventive Emphasis Coordinated Care Chronic Disease Focused

9. 1970 New model • 1983 PMPM • 1986 Replication? • 1990 Waivers • 1994 11 PO in 9 states • 1997 BBA • 2000 PACE Expansion • 2006 Rural Expansion • 2007 42 PO in 22 states • 2013 98 PO in 31 states

10. http://www.chqpr.org/accountablecareorganizations.html

11. Health Coaches or Care Managers monitor near time patient data Major Investments in Information Technology: Investing in the exchange of health information and targeted care management Accesses various care levels for more immediate preventive care Home & Ambulatory Care Transitional Care Inpatient Care

12. A New Set of Core Competencies Will Be Required for Provider Success Physician Integration Care Coordination/ Management Infrastructure Financial Strength and Capital Capacity Post Acute-LTC Information Technology Sophistication Payer Relationship Management Service Delivery System Rationalization Risk Management Market Essentiality Cost Effectiveness 12

13. A New Set of Core Competencies Will Be Required for Provider Success

14. Medicare Bundled Payments 450 Bundled Payment Plans From The Advisory Board, December 23, 2013 Medicare's bundled payment program overtakes its ACO models “More than 450 health care organizations in February joined fourCMS bundled payment initiatives, seeking to determine whether paying lump sums for episodes of care will lower health care costs without harming care.” Becker’s Hospital Review, December 20, 2013 From Becker’s Hospital Review, January 6, 2014 62 Hospitals Participating in CMS' Advanced Bundled Payment Model  In Model 4, hospitals agree to an upfront price on the specific DRGs, and CMS pays that specific bundled price to the hospital, which then pays other physicians and caretakers. In essence, Model 4 is the epitome of what bundled payments are to be in the future. Rep. Diane Black (R-Tenn.) and Rep. Richard Neal (D-Mass.) proposed legislation that would expand bundled payments within the Medicare program.

15. Clinically Integrated Networks From Becker’s Hospital Review, September 13, 2013 CINs are a way for hospitals and physicians to work together in managing the health of a population of patients. They are networks of hospitals or health systems and providers that collaborate to develop and sustain clinical initiatives within the CIN. Participants use evidence-based guidelines and share data and patient information in order to coordinate and manage care efficiently. Additionally, the ability to contract as one network with a payer is important for CINs. Becker’s Hospital Review Article Link: http://www.beckershospitalreview.com/hospital-physician-relationships/9-keys-for-hospitals-building-effective-clinically-integrated-networks.html

16. Care Transformation - Financing & Care Delivery Must Evolve Together Global Capitation Episodic or Bundled Payments Amount of Payment At Risk Pay For Performance Arrangements Basic Fee-for-Services Care Delivery Transformation – System Maturity

17. Care Delivery Transformation Future Emergence of the Triple Aim Improve the health of the overall population Focus on the experience of care: * Safe * Effective * Timely * * Efficient * Patient Centered * * Equitable 3. At the lowest per-capita cost Care Navigators Community-based delivery systems Information Techology PAST Maximize Utilization – Fee For Service Fragmented care delivery Limited electronic patient data Competing financial incentives between providers Financial rewards for higher utilization Focus on sick care (recovery)

18. Right Place at the Right Time?

19. A Focus on Preventive Medicine and Acute Care Avoidance Urgent Care Emergency Care Patient Centered Medical Home Acuity Home monitoring & Home Care Transitional Care Cost of Care

20. Centra - A regional not for profit integrated health system serving communities in central Virginia Acute Care Post Acute Care • 3 acute care facilities • 650 licensed beds • 125,000 annual ER • visits • 160 employed • physicians • 450 active medical • staff • 7,000 employees • Level 2 trauma center • Clinical leadership in • all major service lines Long Term Acute Care Hsptl Palliative Care & Inpatient Hospice Home Health & Hospice Services Senior Living Facilities Inpatient Rehab Facility Free Standing Skilled Nursing Facilities P.A.C.E. Emergency Mental Health Inpatient Child/Adol Adult Geriatric Residential Treatment: Child/Adol Chemical Dep Rivermont Schools Outpatient Psychiatric Services

21. Centra’s 2013 Capitated or At-Risk Populations Financial Mechanisms Moving to Value Based Care • Centra Employees & Dependents • Medicare 30-Day Readmission • Penalties: CHF, MI, Pneumonia • CMMI Bundle II: CHF, Elective • Hip/Knee Replacement • PCHP Medicare Advantage Plan • Inpatient Medicaid & Indigent • Patients • Commercial payor P$P models • P.A.C.E. – Lynchburg & Farmville • Hospice – Lynchburg & Farmville Self Insured - $30 Mill - 8,500 lives Penalty Avoidance - $600k – 1,500 lives Modified Capitation – 900 lives Modified Capitation – 900/2700 lives Cost Avoidance – 3,000 lives Shared Savings Full Capitation – 200 lives Modified Capitation – 350 lives

22. Bundled Payments

23. CMS Initiative 2011Quality Assurance and Process Improvement (QAPI) • The Patient Protection and Affordable Care Act (ACA) • Many provisions for which CMS is responsible for implementing. • Survey and Certification Group • Section 6102 • Establishment of standards relating to quality assurance and process improvement. • Purpose of program is to strengthen current requirements and promote accountability for resident care and safety by nursing facilities.

24. Multiple Payment Reform Initiatives Point Towards… $ COST $ New payment models incentivize hospitals to reduce patient utilization in higher cost settings Acute Care LTACH Inpatient Rehab Skilled Nursing Fac • Health Systems are building functionality that will reduce acute care admissions • NCQA Patient Centered • Medical Homes • Chronic Disease Clinics • System Care Navigators • Home monitoring Assisted Living Home Health Primary Care

25. PA-LTCImplications • Who’s patient is it? Multiple providers with differing patient agendas…CIN or hospital-based care management may interfere with SNF medical director. • SNFs need to take patients directly from ED, earlier from inpatient hospital, keep them a shorter time in SNF, while reducing readmission %. • MD/SNF contracting with local CIN and/or hospital for triple aim based care models • SNF MD…how to touch more patients?

26. What are the Potential SNF Plays? 30-90 Day Avoidable Readmissions • Understand your own 30-90 day readmission history • Meet with your health system(s) to understand their • readmission issues • Consider co-developing clinical pathways with both • referring health systems and quality home care • providers • Expand your scope of knowledge beyond SNF discharge • Consider opening a second front door SNF Avoidance or Shorter SNF LOS #1 SNF Hospital Admissions Non-Acute Admissions Increased Transition Management Potentially Avoidable Admissions

27. References • The Patient Protection and Affordable Care Act, 2012 Accessed at http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf • McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29:982–990 • Helton MR, Cohen LW, Zimmerman S, van der Steen JT. Reply to the Letter to the Editor by Bellelli JAMDA - June 2011 (Vol. 12, Issue 5, Page 388, DOI: 10.1016/j.jamda.2011.03.003)

28. Thank you