1. Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in both the public and private sectors. For more information, visit www.altarum.org Transition from Volume to Value Reimbursement, & MediCaring Communities! Joanne Lynn, MD Director, Center for Elder Care & Advanced Illness April 1, 2016 Joanne.Lynn@Altarum.org

2. 2 The Problem(s)  Health care costs are distorting the economy, becoming unsustainable  Patients and families do not trust the care system – are often frustrated, fearful, and angry  Clinicians are also frustrated, fearful, and angry

3. 3 My Mother’s Broken Back

4. 4 “The Cost of a Collapsed Vertebra in Medicare”

5. 5 Why?  Incentives for procedures, more volume  Disincentives to deal with behavioral and supportive services  The American disinclination to accept disability and death  PRICES

6. 6 What’s been tried – and what’s gone wrong  Skin in the game – for patients/families (cut high value as much as low value)  Reducing prices – (hurts current good providers, forces consolidation, encourages concierge)  Sharing in savings  Providers (too little, too late, and often out of their control)  Investors (substantial funds going to investors, not services)  Quality incentives (wrong metrics, small gains and losses) Now – Medicare/Medicaid to be value-based payment

7. 7 What matters to costly patients in Medicare… elders living with illness and disability?  Relationships – family, friends, spirituality  Control, finances, dignity, respect  Familiarity, meaningfulness, significance  Comfort  Confidence  Survival time What do we measure?

8. 8 What do we measure in nursing homes?  Moderate to severe pain  New or worsened pressure ulcers; any pressure ulcers  Flu and pneumococcal vaccine  New anti-psychotic medication; any antipsychotic medication  Increasing need for ADL help  Weight loss  Losing control of bowel or bladder  Urinary catheters  UTIs  Depression  Restraints  Falls with injury

9. 9 What more do we measure in home care?  Improved mobility  Improved bathing  Improved breathing  Improved wounds  Improved understanding of medications  How often the home care team checked on various things  How often – hospitalization, ER use, readmissions  Patient rating of overall care, professionalism, communication

10. 10 What’s missing?  Most of what matters most!  Customization to patient/family priorities  Meaningfulness  Comfort beyond serious pain  Independence and control  Finances  AND a public health perspective – the well-being of frail elders living in a particular community  Why?  What should be done?

11. 11 MIPS and APMs…for FFS Medicare (probably does not affect managed care unless tied to FFS) 4 components to the MIPS score – Quality Cost IT QI All gains for someone are matched by losses to someone else. Every clinician wants out of MIPS – APMs give a reliable 5% bonus. What counts?  Some Patient-Centered Medical Homes (criteria not clear)  Some ACOs (maybe requiring downside risk?)  Some bundles (only with downside risk?)  And…..? The coming of MACRA

12. 12  What counts as value-based purchasing??  What counts as an Alternative Payment Model?  Does it matter? Questions to shape the future

13. 13 A winning strategy  Build a high-reliability model and estimate new expenditures, avoided expenditures and net savings  Find a way to make it sustainable  Align incentives, including pride in work and by community  For frail elderly people – specifically  Integrate long-term supportive services and end of life care  Work within the available funds  Take responsibility for a geographic community  Monitor and improve – build a learning organization

14. 14 The MediCaring Community Model: Core Elements 1.Frail elders enrolled in a geographic community 2.Longitudinal, person-driven care plans 3.Medical care tailored to frail elders (including at home) 4.Incorporating health, social, and supportive services 5.Monitoring and improvement guided by a Community Board 6.Core funding derived from shared savings from current medical overuse (e.g., a modified ACO)

15. 15 Identification of Frail Elders in Need of Medicaring AND one of the following: >1 ADL deficit or Requires constant supervision OR Expected to meet criteria in 1-2Y Unless Opt Out Frail Elderly Want a sensible care system Age >65Age >85 With Opt In

16. 16 Steps in optimal care planning 1.Targeting 2.Care Planning A.Current patient/family situation B.Likely future situation(s) with various strategies C.Patient/family priorities – hopes, fears, values – goals D.Negotiated, patient-driven care plan E.Available to those who need it, promptly 3.Evaluation and Feedback – system learning 4.Care plan use in system management – supply and quality issues for community

17. 17 The Chronic Care Management Code List of Elements “typically included” in a Care Plan  Problem list; expected outcome and prognosis; measureable treatment goals  Symptom management and planned interventions (including preventive care)  Community/social services  Plan for care coordination with other providers  Medication management  Responsible individual for each intervention  Requirements for periodic review/revision

18. 18 Sad Tale #2 – NY Times Sept 28, 2014

19. 19 Mr. Andrey’s Story  Elderly man, living alone, one daughter who must work – mobility problems, multiple hospitalizations, Medicaid aides around the clock  Hospitalization – no home care would take him -- Medicaid managed care  Multiple NHs, pressure ulcers, hospitalizations, medication errors  Finally home with aides, but living long meant discontinuation – and hospice also meant losing aides  Inpatient hospice at the end – no physician, no last rites  Nothing worked – everyone followed the dollars

20. 20 The “bottom line” for Mr. Andrey  Last year included about 4 nursing homes, many more ERs and hospitalizations  Cost >$1million to Medicare and Medicaid  And he did not get his only wish… To be at home.

21. 21 Geriatricize Medical Care  Continuity  Reliability, 24/7 to the end of life  Enabling self-management around disabilities  Respecting and including family and other caregivers  Attend to the burden of medical care  Move services to the home  Prevent falls, wrong actions  Enhancing relationships, activities, meaningfulness  Enduring with persons living with dementia

22. 22 Health Care Spending ≠ Health Status Want your money back? 38% > Swiss spending 81% > avg of other 10 US Rank: 5 OECD Health Stats, 34 Nations #27 Life Expectancy at Birth #31 Infant Mortality #27 Men/Years of Potential Lost Life #31 Women/Years of Potential Lost Life #5 Share of Adult Daily Smokers Average = 29 th (of 34!)

23. 23 But, We Can’t Afford Social Supports, Right? Recall US’s #29 avg. ranking? Sweden’s avg. = 5 th Switzerland is 10 th It’s the ratio! US ratio = 0.75 Avg. of 11 = 1.86

24. 24 “The Ratio” in Our Work—Elder Care The Older Americans Act at 50 – Community-Based Care in a Value-Driven Era (NEJM 2015) Ravi B. Parikh, M.D., M.P.P., Anne Montgomery, M.S., and Joanne Lynn, M.D. The Older Americans Act clearly affirms our Nation’s sense of responsibility toward the well- being of all of our older citizens….Every State and every community can now move toward a coordinated program of services and opportunities for our older citizens. We revere them; we extend them our affection; we respect them. Lyndon B. Johnson, 1965 The ratio is getting much worse! 54% 186% 7%

25. 25 Disaster for the Frail Elderly: A Root Cause Social Services Funded as safety net Under-measured Many programs, many gaps Medical Services Open-ended funding Inappropriate “standard” goals Dysfx quality measures Inappropriate Unreliable Unmanaged Wasteful “care” No Integrator

26. 26 Äldres läkemedelsanvändning i Jönköpings län Jonkoping hospitals and municipalities

27. 27 How could local management arise?  Care Transitions  Age-friendly cities and other urban planning  Local coalition building for healthy communities – CDC- engendered coalitions  Public health  Local aging authorities – commissions, offices  Area Agencies on Aging (and Administration for Community Living)  ACOs  Managed care  And more….

28. 28 Frail Elderly People Need Some New Spending… $ Housing $ Nutrition $ Personal Care $ Caregiver training, respite, income $ New drugs and other treatments Where will it come from?

29. 29 Estimating Potential Savings in Medical Care  Estimate frail as 10% of >64 population in a geographic area  Estimate PMPM total costs (except for unpaid caregiving)  Use CMS HRR and county data for aggregate costs, population, utilization  Use sources in literature for LTC costs and small ancillary costs  Estimate realistic goals of reducing medical care, delaying Medicaid, reducing use of nursing homes - generally, about half of the maximal effect (e.g., 25% reduction in hospital, 5% in LTC)

30. 30 Estimating Potential Savings in Medical Care  Assume it will take 2 years to get to full impact  Adjust for expected deaths, assume no mortality effect  Adjust for inflation  Ignore moving in and out of area (assume balance, and modest)

31. 31 MediCaring Communities Financial Simulation: Utilization Estimates (Akron, OH) Service Category Without MediCaring With MediCaring Percent ChangeAbsolute Change Inpatient Hospital $966$725-25%-$242 Outpatient Hospital $331$36410%$33 Professional Primary Care $270$35130%$81 Skilled Nursing Facility $315$252-20%-$63 Medicaid- covered Long- Term Care $2,307$2,191-5%-$115

32. 32 MediCaring Communities Financial Simulation

33. 33 MediCaring Communities Financial Simulation

34. 34 A Winning Possibility: MediCaring ACOs…  Four geographic communities - 15,000 frail elders as steady caseload  Conservative estimates of potential savings from published literature on better care models for frail elders  Yields $23 million ROI in first 3 years Net Savings for CMS Beneficiaries Yr 1Yr 2Yr 33-Yr Before Deducting In- Kind Costs -$2,449,889$10,245,353$19,567,328$27,362,791 After Deducting In- Kind Costs -$3,478,025$8,463,101$17,629,209$22,614,284 For more on financial estimates, see http://medicaring.org/2013/08/20/medicaring4life/http://medicaring.org/2013/08/20/medicaring4life/

35. 35 NorthStar – What to Aim For  Fully integrated system, with monitoring and management  Honest care plans  Client/family perspective guides system and care  Adequate supply of critical supportive services  Medical services routinely attentive to function, comfort, meaningfulness – available at home, 24/7  Sustainable – to family, community, and country Is it value-based? Is it an APM? Does it achieve the aims, within budget?

36. 36 Engage your representatives!  Encourage allowing innovation – including some local management and control  Require population-based metrics  Demand appropriate measures of quality  Develop language that can enable us to deal honestly and sensitively with frailty and death – join our Party Platform Project (email to info@caregivercorps.org ) info@caregivercorps.org  Talk with every political leader and wannabe about services and finances for elders

37. 37 The MediCaring Reforms

38. 38 The MediCaring Community Model: Core Elements 1.Frail elders enrolled in a geographic community 2.Longitudinal, person-driven care plans 3.Medical care tailored to frail elders (including at home) 4.Incorporating health, social, and supportive services 5.Monitoring and improvement guided by a Community Board 6.Core funding derived from shared savings from current medical overuse (e.g., a modified ACO)

39. 39 We can have what we want and need When we are old and frail But only if we deliberately build that future!