1. Home Based Care & Value-Based Purchasing
paccr.org
Home Based Care & Value-Based Purchasing
Presented to the American Academy of Home Care Medicine by
Barbara Gage, PhD
Sr. VP, Scientific Research and Evaluation
Post-Acute Care Center for Research
May 14, 2015

2. Today’s Evolving HealthCare Environment
Affordable Care Act established the Triple Aim:
Improve quality of care
Improve population health
Reduce cost of care
New focus on patient-centered episodes of care, not silos of service-centered care
Congressional mandate for quality reporting programs for all Medicare services
Innovative payment methods focus on episodes of care and incorporate outcomes in the payment methodology

3. Payment Innovations in Public and Private Insurance Sectors
Quality adjustments for hospital readmissions in FFS
Value-Based Payment systems for Hospitals, Physicians, SNF, HH, ESRD
Shared savings payments in ACOs, Gainsharing, Medical Homes, and Bundled Payments
Coordinated Care Programs for Dual-Eligible populations
Rebalancing grants for state LTSS programs (BIP, SIM, TEFT)
Carve-out and other innovations proposed in both private and public insurance sectors

4. How Are these Innovations Changing The Health Care Marketplace?
Cultural changes incentivizing links between inpatient and community-based services
Coordination across caregivers (both medical and social support)
Communication/education of patient on options and available resources

5. The Medicare Population, 2010
Of the 47.6 million beneficiaries in the Medicare program:
Under 65 years old %
65-69 years old
70-74 years old
75-79 years old
80-84 years old
85 years or older

6. Medicare Program Expenditures, 2010
National Medicare Expenditures in 2010 = $331B
Inpatient Hospital %
Physician
Outpatient
Skilled Nursing Facility
Home Health Care
Hospice

7. What Types of Services Are Being Used In the Medicare Program?
20% of all Medicare beneficiaries hospitalized at least 1/year
Admitted for a wide range of reasons including medical, surgical, functional diagnoses
Over 40% of the hospital cases will be discharged to PAC
Source: Gage et al. (2009). Examining post-acute care relationships in an integrated hospital system, ASPE, and MedPAC, (2014) June Report To Congress.

8. Utilization Patterns Following Hospital Discharge
NOTES:
1. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF/
Source: Gage et al. (2009). Examining post-acute care relationships in an integrated hospital system, ASPE

9. Post-Acute Care Reform Momentum Building
Continued momentum and legislative initiatives to transform Medicare FFS reimbursement system, and incentivize more efficiently managed PAC
CMS FFS Shifts Focus to Managing Care
CMS releases 2 RFI’s
2014: CMS announces BPCI expansion
2014: Sen Wyden introduces Better Care, Lower Cost Act
2013: Bi-Partisan Bundling Legislation introduced in House
IMPACT Act becomes Law
2014: BPCI programs rollout
2014: Rep McKinley introduces Bundling Legislation in House
2012: Hospital Readmission Penalties instituted; up to 3% by 2015
2013: CBO Re-Scores Bundled Payments; White House & MedPAC join conversation
President’s budget includes PAC bundling savings
2012: ACOs go live; now over 350 Medicare ACOs
2010: ACA passed
2019: Medicare FFS PAC Bundle
???
2009: CMS ACE Demonstration
2005: DRA establishes PAC PRD

10. Deficit Reduction Act of 2005
Mandated a PAC Payment Reform Demonstration to understand costs and outcomes across different PAC sites.
Three components:
CARE: Standardized patient assessment instrument to measure severity in hospitals, PAC settings
Secure, electronic, interoperable standards-based data system for multiple providers to share essential health information/improve transitions
Data collection to analyze costs and outcomes across sites (acute, SNF, HHA, IRF, LTCH) 10

11. Accountable Care Organizations – targeted hospitals and physicians
ACA of 2010: Codified the Triple Aim- Better Outcomes, Better Population Health, Lower Health Care Costs  Patient Centered Care
Payments
Established new payment models to encourage providers to move to patient-centered care to achieve the Triple Aim:
Accountable Care Organizations – targeted hospitals and physicians
Built on various demonstration projects
PGP, HCQ, High Cost Clinically Complex
Medical Homes – targeted physicians to coordinate care
Bundled Payments – targeted hospitals and PAC providers, or physicians to coordinate care 11

12. Established Outcomes Analysis Mechanisms Hospital Reporting Metrics –
ACA of 2010: Codified the Triple Aim- Better Outcomes, Better Population Health, Lower Health Care Costs  Patient Centered Care
Outcomes
Established Outcomes Analysis Mechanisms
Hospital Reporting Metrics –
Hospital Acquired Infections – value matters
Broadened hospital responsibility
Established Hospital Readmissions program to account for 30 days post- discharge
Established Quality Reporting Programs for IRFs, LTCHs, Hospice
Rounds out the Medicare quality reporting programs to include remaining PAC providers 12

13. The Evolving National Quality Strategy
Establishment of the National Quality Forum
Development of scientific standards for measuring quality
Multistakeholder consideration of quality measures that meet 5 criteria: important to measure, scientifically acceptable (reliable and valid), feasible to collect, usable/actionable, other related metrics
Stakeholder Prioritization of measure development: NQF workgroups on coordinated care, person-centered care, Alzheimer’s Disease/Dementias, Health Care Quality for the Dual-Eligible, LTPAC populations

14. 2014
What about the political environment combined with the payment and delivery transformation efforts underway made now the time to construct and pass the IMPACT Act legislation for Post-Acute Care?

15. The IMPACT Act: What does it do?
Paves the way for “…standardizing post-acute care assessment data for quality, payment, and discharge planning, and for other purposes.”
All PAC providers including HH, SNF, IRF and LTCH’s included
Standardized collection on functional status, cognitive function, medical needs and conditions, impairments and other categories deemed necessary by Secretary
Some data are already submitted by each PAC provider, but varies by type of provider, Act calls for replacing duplicative data collection
Resource use data also collected to estimate per beneficiary spend
Includes payment refinement provisions via report from MedPAC to Congress in 2016 based on PAC PRD data and report from CMS

16. IMPACT Act Timeline for Quality Metrics by PAC Provider
Measure
2016
2017
2018
2019
Cognitive function and functional status
SNF, IRF
LTCH HH
Skin integrity
SNF,IRF, LTCH
Occurrence of major falls
SNF, IRF, LTCH
Resource use and other measures
Medication reconciliation
HH, LTCH
Ability of a PAC provider to relay health information, and “care preferences” of an individual
Alignment of claims data with standardized patient assessment data