Regulatory Update Oregon Hospice Association/Washington State Hospice and Palliative Care...

Regulatory UpdateOregon Hospice Association/Washington State

Hospice and Palliative Care Organization

Judi Lund Person, MPHVice President, Regulatory and Compliance

National Hospice and Palliative Care Organization

1

2

Recent regulatory updates

• Effective October 1, 2014 – implementation of:– NOE filing and penalty for non-compliance.– NOTR filing.– Change in attending physician form

• Effective March 31, 2015 – implementation of Cap Self-Report to be sent to MAC – If not filed, payments will be suspended

• Effective April 1, 2015 – CAHPS mandatory participation for all hospice providers

3

What’s in the pipeline?

• Calendar year 2015– Spring 2015: Announcement of Medicare Care

Choices Model awardees– Spring 2015: FY 2016 Hospice Wage Index

Proposed rule• CBSA changes in wage index for hospice • Possible other regulatory changes• More Part D and hospice guidance

– October 1, 2015: ICD-10 implementation

4

UPDATE ON WASHINGTON POLICY ACTIVITY

5

“Doc Fix”

• Sustainable Growth Rate (SGR)• Possible permanent fix• Possible one year adjustment in marketbasket

increase• FY2018• Latest information

6

MedPAC

• March 2015 Report to Congress just released• Recommendations:

– Congress should eliminate the update to the hospice payment rates for fiscal year 2016.

• Margins:– Margins for all hospices in 2012: 10.1%– Predicted margins for 2015: 6.6%

Number of Medicare Certified Hospices

1985 1990 1996 1999 2003 2005 2007 2008 2009 2010 2011 2012 20130

500

1000

1500

2000

2500

3000

3500

4000

4500

Number of Hospices

Source: MedPAC March 2015 Report to Congress

7

Total Medicare Spending on Hospice

2000 2010 2011 2012 20130

2

4

6

8

10

12

14

16

$2.9

$13$13.8

$15.1 15.1

Expenditures by Year

Billi

ons

of D

olla

rs

Source: MedPAC March 2015 Report to Con-gress

Length of Service in Hospice

Average Length of Stay Median Length of Stay0

10

20

30

40

50

60

70

80

90

100

54

17

80

17

83

17

86

17

86

18

86

17

88

18

88

17

2000 2007 2008 2009 2010 2011 2012 2013

Days

of C

are

Source: MedPAC March Report to Congress, various years

10

MedPAC Reports on Levels of Care

11

Shifting from Diagnosis to Prognosis

12

Statutory Definition of Terminally Ill

• Social Security Act - §1861(dd)(3)(A):• Defines “terminally ill” as having a medical

prognosis that the individual’s life expectancy is 6 months or less.

13

Diagnoses in perspective

Terminal diagnosis

Unrelated diagnosis

Related diagnosis

or condition

Primary or Principal diagnosis

Any other diagnosis or condition that is related

to the terminal illness/prognosis

Any other diagnosis that is not related to the terminal illness/prognosis

14

Determining prognosis• Hospice physicians determine prognosis from:

– Records review and lab reports– IDG input– Discussions with referral sources/attending

physicians– Clinical judgment– Examination of the patient (if applicable)– Certification narrative is a good place to explain this

Physician Determines Relatedness15

• Relatedness is not determined by the CFO based on cost to hospice provider

• It is determined patient by patient, case by case, related to the palliative plan of care

Clinical staff collect

information from patient

Hospice physician

reviews all available

information

Hospice physician

confers with attending physician and IDT

Decision Made (subject to revision as

patient conditions

change)

15

If it is related to the terminal prognosis.…

• Hospice covers the cost – Care (services, treatment…) – Medications– DME & supplies

• Documentation should appear in the clinical record that it is related– Physician narrative– Plan of Care– Medication profile

16

16

17

Steps your hospice can take

• Evaluate admission process• Ask the question “Does this diagnosis or condition

contribute to or influence the patient’s terminal prognosis?”

• Review hospice physician documentation of relatedness and unrelatedness

• Review medications for – Related, hospice pays– Unrelated– Related but no longer effective, discontinue or patient pays

• Check diagnosis reporting on claim form

18

NHPCO PROPOSALS TO CMS

19

Prognosis and Parts A, B and D “Leakage”

• Addressing terminal prognosis• Addressing improvements in systems and

practices for hospices – NOE submission– Improved care coordination functions– Identification of physicians and other healthcare

providers actively involved in the patient’s care• Issues for other providers

– Knowledge of the hospice election– Access to Common Working File before claim is

submitted

20

Scope of Benefits and Services Waived

• Section 1812(d)(2) of the Social Security Act establishes the scope of benefits and what the patient waives by electing to receive hospice care.

• The current language has not changed since the Medicare hospice benefit was established as a demonstration in 1983.

21

Waiver Language

• By electing to receive hospice care, beneficiaries waive their right to have payment made for:

“services that are determined (in accordance with guidelines of the Secretary) to be related to the treatment of the individual’s condition with respect to which a diagnosis of terminal illness has been made.”

22

NHPCO Relatedness Work Group

• Meeting weekly for more than one year• A work group of the Regulatory Committee• Clinical expertise, including four physicians• Regulatory expertise for places where the

prognosis language may be appropriate• HUGE discussions about approach • HUGE discussions about clinical practice• HUGE discussions about what makes sense for

patients and families

23

Basic Tenets of Relatedness

• Must be individualized and determined case-by- case• Decisions must be made by hospice physician• Based upon relationship to terminal prognosis and

related conditions• Can be complex- how far down the chain of causality

do you go?– Example: Diabetes and cardiac conditions; dialysis and

heart failure

Medical Director’s Key Role

• It is the role of the hospice medical director to determine whether a diagnosis or medication is related to the patient’s terminal illness and related conditions

• The hospice must ensure that the hospice medical director is involved, reviews medications, and documents relatedness status in the medical record

24

25

Medical Directors’ Decisions

• Diagnoses– Related or unrelated to the terminal prognosis– Case-by-case– Consistent reasoning that staff can understand and

communicate

• Medications– Related, reasonable, and necessary– Clinically useful– Covered by hospice or insurance

26

Regulatory Committee Recommendations

• Changes to CoPs and Interpretive Guidelines• Suggestions for changes in hospice processes

as well as those of other Medicare providers

27

Changes to CoPs or Interpretive Guidelines

– Appendix M is the hospice Appendix for “Surveyor Guidance” used by surveyors in judging compliance with the CoPs.

– Includes “Procedures and Probes” – questions that the surveyor can ask hospice staff to assess compliance with a Condition of Participation.

– Some, but not all recommended changes, will require rule-making.

28

Focus Areas

• Comprehensive assessment– Must reflect health status related and unrelated to terminal prognosis– Updates reflect changes and discontinuation of treatments and

medications• Drug profile – include a list of all drugs, including those

unrelated to the terminal prognosis• Plan of care – include care coordination with other healthcare

professionals actively involved in patient’s care• Hospice medical director

– evidence of training in management of end of life care– Responsible for determining related diagnoses, treatments and

medications

29

Proposed Process Changes for Hospices

– Process changes for hospices Admissions Interdisciplinary team

o Coordination of careo Initial and comprehensive assessmento Medication review

– Comparing hospices to each other– New and ongoing education about hospice

responsibilities for terminal prognosis– Clear guidance about billing requirements

30

Proposed Changes for Other Medicare Provider Types

• Provider knowledge of hospice election• Hospital admission/discharge• Flags in billing for other Medicare providers to

indicate hospice election/revocation/discharge• New and ongoing education for other provider

types about hospice• Provide clear guidance on billing issues for

other provider types

31

Further Study

• Attending physician issues when the physician is– A nursing home medical director– A hospitalist identified by the hospital as the patient’s

attending• Pre-hospice evaluation and goals of care discussion

– Payment currently only for physicians– Could it be expanded to other hospice clinicians or to

the hospice to avoid unnecessary hospitalizations

32

Ongoing Discussions

• NOE• Prognosis/Relatedness• Cap self report and calculation re sequester• Program integrity• MAC medical review• Medicare Care Choices Model• Advance Care Planning

33

DIAGNOSES ON CLAIM FORM

34

Diagnoses on the claim form

• The principal diagnosis reported on the claim is the diagnosis most contributory to the terminal prognosis

• The hospice must report other diagnoses and conditions that contribute to the patient’s terminal prognosis as “other diagnoses”

• Follow coding conventions for ICD-9-CM and then migrate to ICD-10-CM

35

Coding Reminders

• Certain dementia diagnoses may not be used as a primary diagnosis – see NHPCO resources

• Alzheimer’s and dementia – still legitimate hospice diagnoses

• Adult failure to thrive and debility unspecified may not be used as a primary diagnosis

• Can be used as an other diagnosis• Watch use of protein malnutrition as an

alternative

36

CMS Reports Multiple Diagnoses on Claim

36

FY2010 Q1 - 10/1-10/31/12

FY20136062646668707274767880

77.2

72

67

% of claims with one diagnosis

% of claims with one di-agnosis

OFFICE OF INSPECTOR GENERAL ACTIVITIES

37

38

Hospice care in assisted living

• Report released January 2015• Payments in ALFs more than doubled in 5 years,

totaling $2.1 billion in 2012. • Hospice beneficiaries in ALFs often had

diagnoses that usually require less complex care.

• Hospices typically provided fewer than 5 hours of visits per week

• Visit mix was heavily hospice aides

39

ALF Nursing Facility Home Skilled Nursing Facility

0

20

40

60

80

100

120

98

50 45

30

Median Days in Hospice Care by Beneficiary, by Setting

Days

Primary Setting of Hospice Care

Med

ian

Day

s in

Hos

pice

Car

e

40

ALF Nursing Facility Home0%

5%

10%

15%

20%

25%

30%

35%

40%36%

28%

22%

18%

14%

10%

Percentage of Beneficiaries with Long Lengths of Stay, by Setting

181-365 days> 365 days

Primary Setting of Hospice Care

Perc

enta

ge o

f Ben

efici

arie

s

41

Hospice Aide Visits;

2.4

Nursing Vis-its; 1.7

Medical Social Service Visits; 0.3

Visits per Week, 2012

Hospice Aide VisitsNursing VisitsMedical Social Service Visits

42

Monday Tuesda Wednesday Thursday Friday Saturday Sunday0%

5%

10%

15%

20%

25%

20%19%

18% 18%19%

4%3%

Percentage of Visit-Hours Provided to Beneficiaries Receiving Routine Home Care in ALFs by Day of the Week, 2012

Visits

43

OIG Areas of Concern

• 25 hospices reported no visits to their patients in ALFs in 2012 -- $2.3 million in Medicare $$

• 97 hospices relied on ALFs for most of their Medicare patients. More than ½ of Medicare payments they received in 2012

44

OIG Recommendations1. Reform payments to reduce the incentive for

hospices to target beneficiaries with certain diagnoses and those likely to have long stays

2. Target certain hospices for review3. Develop and adopt claims-based measures of quality4. Make hospice data publicly available for beneficiaries 5. Provide additional information to hospices to

educate them about how they compare to their peers.

45

Additional OIG Hospice Focus in 2015

• Review of Hospice GIP – Assess the appropriateness of hospices’ general

inpatient care claims – Review content of election statements for

hospice beneficiaries who receive general inpatient care

– Review hospice medical records to address concerns that this level of hospice care is being misused or overused

46

KEY VULNERABILITIES

47

Key Vulnerabilities

• Live discharges• General Inpatient Care, Continuous Care,

Inpatient Respite• Non Hospice Spending In Medicare Parts A, B

And D: “Leakage”• Visits in last 48 hours of life

48

LIVE DISCHARGES

49

Rates of Live Discharges

2010 Live Discharge rates by state

• CT 12.8%• MS 40.5%

% of Patients Discharged

Alive

Number of Hospices

0 – 9.9% 1,601

10% - 19.9% 1,315

20% - 29.9% 371

30% - 39.9% 133

40% + 282

Hospice claims data from CY 2010-CY 2012 for beneficiaries who were discharged (alive or deceased) in CY 2012

50

Source: Journal of Palliative Medicine, August 7 2014

51

Live Discharge and Readmissions

Hospice Discharge

Hospital Admission

Expensive test/procedure$126 M

Hospital Discharge

Hospice Readmission

Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule

2010 Data

13,770 patients of 182,172 live discharges – 7.5%

52

Live Discharge and Readmission by State – Highest %

MS VA

OK TX

AL NJ

SC GA

MD LA CMS CY 2012; FY2015 Hospice Wage Index Final Rule

$56.0 M (44%) of the hospitalization costs from these 10 states

53

GENERAL INPATIENT CARE, CONTINUOUS HOME CARE, AND INPATIENT RESPITE CARE

UTILIZATION

54

Percentage of days by level of care

Level of Care Percentage of Total Days

Routine Home Care 97.4%

Continuous Home Care 0.4%

Inpatient Respite Care 0.3%

General Inpatient Care 1.9%

55

GIP Utilization

• Patient utilization:77.3% of patients electing hospice did not have a GIP stay during their hospice election

• Hospices providing GIP21.1% of hospices did not bill for a single day of GIP in CY2012


56

GIP Utilization

• National average = 1.9% of days are GIP

• Do not provide GIP?– 66% for-profit

• Provide GIP?– 5-10% = 195 hospices – 10% or more = 46

hospices

Any GIP Provided?

Number of Hospices

No 760

Yes 2,758

Hospice claims data from CY 2010-CY 2012 for beneficiaries who were discharged (alive or deceased) in CY 2012

57

Location of GIP

% of Total0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

68.0%

24.9%

5.5%

1.6%

Hospice Inpt FacilityHospitalSkilled Nursing FacilityMulti


58

Length of GIP Stay by Location

Average Length of Stay in Days0

1

2

3

4

5

6

7

5.5 days6.1 days

4.5 days 4.7 days

AllInpatient HospiceInpatient HospitalSNF


59

Policy Questions

• Was the hospice able to provide GIP?• Was the hospice “cherry picking” patients who

were “less sick?”• Does the hospice comply with COP

requirement for a contract for GIP?• Was quality of care compromised?

60

Non Hospice Spending In Medicare Parts A, B And D: “Leakage”

61

Medicare A and B Outside Hospice BenefitPart A or B Service Percentage of $$

SpentDME 7.1%

Inpatient care 28.6%

Outpatient Part B services 16.9%

Other Part B services (physician, practitioner, labs and diagnostic tests, ambulance transports, and physician office visits)

37.4%

Skilled Nursing Facility Care 5.7%

Home Health Care 4.5%

62

States where Medicare A and B Outside the Hospice Benefit is Highest

WV

FL

TX

MS

SC CMS CY 2012; FY2015 Hospice Wage Index Proposed Rule

63

Part D Expenditures During a Hospice Stay

• CY2012– Total Part D spending: $417.9 million– Paid by Medicare: $334.9 million

64

Highest Part D Expenditures by State

ID

WV

AL

OK

CMS CY 2012; FY2015 Hospice Wage Index Final Rule

65

CY2012 Total Non-Hospice Medicare Spending

For beneficiaries after hospice election

• Parts A & B: $710.1 million • Part D: $334.9• TOTAL: $1.3 Billion dollars

• Note: 51.6 % of $1.3 billion -- 373 hospices

• Average total per beneficiary: $1,289 in non-hospice costs

66

VISITS IN LAST 48 HOURS OF LIFE

67

% of Patients with No Skilled Visits

Days before Death % of Patients

Last day of life 28.9% of patients

Last 2 days of life 14.4% of patients



Skilled visits include nurse, social worker, therapies (OT, PT, Speech). Does not include aide, chaplain, volunteer.

CMS CY 2012; FY2015 Hospice Wage Index Final Rule

68

Lowest % of Patients with No Visits in Last 2 Days of Life

State % with No Visits

WI 5.7%

ND 7.3%

VT 7.5%

TN 7.5%

KS 8.5% CMS CY 2012; FY2015 Hospice Wage Index Final Rule

69

Highest % of Patients with No Visits in Last 2 Days of Life

State % with No Visits

NJ 23%

MA 22.9%

OR 21.2%

WA 21%

MN 19.4%CMS CY 2012; FY2015 Hospice Wage Index Final Rule

70

CMS Commentary

• We further examined hospice utilization data and developed a provider-level file to identify aberrant hospice behavior. The provider level file contains information on beneficiaries who were discharged (alive or deceased) in Calendar Year (CY) 2012 and includes claims data from January 1, 2010 through December 31, 2012.

71

HOSPICE PAYMENT REFORM LATEST ABT INFORMATION

72

Recent CMS Statements

• Considering the analysis from Abt Associates• Not likely to wait until data from the new

hospice cost report is in• Still considering

– Rebasing (reducing) the routine home care rate• Budget neutrality required

– U-shaped curve – or tiered payments• Higher at the beginning (5 days being considered)• Higher at the end

73

Abt Payment Reform Concepts

• Site of service adjustment • Rebasing the routine home care rate • Tiered payment model • Short stay add-on • Skilled visits at the end of life • Live discharge

Abt presentation on Open Door Forum 1/14/15

74

Site of Service Adjustment

• Hospice patients in a nursing facility receive more visits than patients in the home after controlling for patient and provider characteristics.

• Hospice aides may be substituting for, rather than augmenting, nursing facility aides.


75

Rebasing the Routine Home Care Rate

• Due to data limitations, only the labor portion of the base payment rate could be rebased, which represents approximately 70% of the rate.

• Using just the labor information, it was found that rebasing using current cost information would result in a reduction in the FY 2014 RHC payment rate of 10.1% ($1.6 billion).


76

Tiered Payment Model

• Unintended Consequences of a simple U-Shaped Payment System – Could encourage extremely short stays– Could increase live discharges – How would level of care transfers be handled (GIP

to RHC?)– Could reduce frequency of services in response to

decreased reimbursement


77

Tiered Payment Model

• Different payments for characteristics that might be associated with the cost of the stay. – Would have features of a U-Shaped Model. – Could also pay for

• Extremely short stay hospice users (who tend to have high average resource use)

• Hospice users who do not receive skilled care at the end of life.


78

Tiered Payment ModelGroup RHC Days Days of

HospiceImplied Weight

New Base Payment Rate

Group 1 RHC Days 1-5 2,800,144 2.3 $337.25

Group 2 RHC Days 6-10 2,493,004 1.11 $162.76

Group 3 RHC Days 11-30 7,767,918 0.97 $142.23

Group 4 RHC Days 31+ 65,958,740 0.86 $126.10

Group 5 RHC during last 7 days, skilled visits during last 2 days

2,832,620 2.44 $357.78

Group 6 RHC during last 7 days, NO skilled visits during last 2 days

476,809 0.91 $133.43

Group 7 RHC when hospice LOS is 5 days or less and discharged dead

510,787 3.64 $533.73

Total 82,840,022 1 $146.63


79

Short Stay Add-on

• Background: – Stays that are 5 days or less (25% of beneficiaries

in 2011) are less U-shaped because there is not a lower cost middle period between the time of admission and the time of death.

– A potential reform would be to only increase payments for the shortest stays through an add-on that would be paid for through a reduction to payment for long stay beneficiaries


80

Skilled visits at the end of life

• There is considerable variation in the probability of receiving skilled visits at the end of life that may be related to certain characteristics of the hospice stay.

• These characteristics include – The day of the week a beneficiary died – Which state the beneficiary is located in– Which specific hospice a beneficiary receives

services fromAbt presentation on Open Door Forum 1/14/15

81

CAP REPORTING

Cap self-reportPS&R

Inpatient cap

82

Cap Determination Notice

§ 418.308 Limitation on the amount of hospice payments.

(c) The hospice must file its aggregate cap determination notice with its Medicare contractor no later than 5 months after the end of the cap year (that is, by March 31st)

• Use data no earlier than three months after the end of the cap period, or January 31

• If hospice fails to file, payments will be suspended in whole or in part until cap report is filed

• Overpayments will be due when cap report is filed. An Extended Repayment Schedule (ERS) is available.

• The MAC will continue to issue final cap determination letter

83

2013 Cap Reports

• For 2013, cap letters will come from MACs• Timing in question, could be up to one year

84

Inpatient days cap & non-compliance risk

• MACs will continue to calculate the inpatient days cap

• If hospice fails to file the aggregate cap report, payments will be suspended in whole or in part until cap report is filed

IMPACT ACT

Hospice SurveysMedical Review

Hospice Aggregate Cap

85

86

IMPACT Act

• Stands for:Improving Medicare Post-Acute Care Transformation Act of 2014 (“IMPACT Act”)

• Impacts post acute providers including:– home health agency– skilled nursing facility– inpatient rehabilitation facility– long-term care hospital

87

Hospice Provisions in IMPACT Act

• Three provisions:Hospice surveys every 36 months

• Implementation date: April 6, 2015• Surveys conducted by state survey agency or

accrediting organization• No change in process except frequency• State determined implementation• In place for the next 10 years

88

Hospice Provisions in IMPACT Act

Increased medical review for long lengths of stay• Technical correction to the Affordable Care Act• Intended for hospices who have a high percentage of

patients with a length of stay >180 days• What is the “high percentage?”

– CMS will set the number – in the 40-60% range

• Implementation date: CMS can begin the process at any time. CMS reports that they are gathering data on the issue to make a decision

89

Hospice Provisions in IMPACT billHospice aggregate cap

• Aligns the inflation increase for the aggregate cap and the hospice rate increase

• Implementation date: FY2017 (Payment year beginning October 1, 2016)

• Example of when cap amount and rates increase at same rate:

ExampleCap for year

ending October 31, 2014

Marketbasket Increase

Example of Cap Amount for Coming Year

10/31/2014 $ 26,725.79 1.70% $ 27,180.13

90

QUALITY REPORTING

91

Quality Reporting Reminders

• Hospice CAHPS survey:– Every hospice must participate in at least a one

month dry run between January 1 and March 31– Mandatory participation begins April 1

• HIS data submission:– ended for 2014 – ongoing for 2015

Moving Hospice Upstream

Expanding the Use of Hospice Skills within the Healthcare Continuum

November 2014 NHPCO Consulting Services 92

NHPCO Consulting Services 93

Hospice Use by Medicare Decedents, 2012

47%

53%

Received hospice careNo hospice

November 2014

Source: A Data Book: Healthcare Spending and the Medicare Program, Medicare Payment Advisory Commission (MedPAC), June 2014, p. 187.


Transferrable Hospice Skills

• Managing patients under a risk-based payment method – controlling costs

• Managing patients with high needs and high levels of frailty

• Managing patients with complex, life-threatening illness

• Managing patients in a home or home-like setting

• Managing patients out in the community

November 2014


Hospice Saves Medicare Significant Costs

1-7 Days 8-14 Days 15-30 Days 53-105 Days$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$2,650

$5,040

$6,430

$2,561

November 2014

Source: Amy S. Kelley, et al., “Hospice Enrollment Saves Money for Medicare and Improves Care Quality Across a Number of Different Lengths of Stay,” Health Affairs, March 2013.


JAMA, November 12, 2014:Medicare patients with poor-prognosis cancers who received hospice care had:

– Lower rates of hospitalization– Fewer ICU admissions– Fewer invasive procedures– Significantly lower health care costs

November 2014

Source: “Use of Hospice Care by Medicare Patients Associated with Lower Rate of Hospitalization, ICU Admission, Invasive Procedures and Costs,” press release from JAMA, November 11, 2014.


Upstream Care Types

• Advanced illness management (AIM) programs• Community based palliative care• Post-acute transitional care• Pre-hospice programs

November 2014


Upstream Partners for Hospices in Washington and Oregon

Seeking those at risk for health expenses:• Hospitals and health systems (at risk under

exchanges and all-payer systems)• ACOs in your service area• Medicare Advantage plans• Commercial Insurers• Large self-insured employers (including hospitals)• Insurers

November 2014


How likely is the following by 2019?

Formal mechanisms will be in place in your service area to ensure seamless coordination across the care continuum

Your hospital will be partnering with community organizations to support population health management initiatives

0% 20% 40% 60% 80% 100%

51%

76%

42%

22%

Very Likely Somewhat LikelySomewhat Unlikely Very Unlikely

November 2014

Source: “Futurescan 2014: Healthcare Trends and Implications 2014-2019,” Society for Healthcare Strategy & Market Development and the American College of Healthcare Executives, 2014.

98%

93%



Your hospital or health sys-tem will enter into a partner-ship or affiliation with another provider or payor organization to expand services or realize

efficiencies

0% 20% 40% 60% 80% 100%

53% 41%


November 2014


94%



Your hospital's strategic plan will have a goal of reducing unnecessary

admissions

0% 20% 40% 60% 80% 100%

74% 22%


November 2014


96%


Making the Case to Your Partners: Benefits of Upstream Palliative Care/Patient

Management

• Patients have better quality of life• Patients are more likely to use hospice, less

likely to use expensive hospital care• Patients cost less to care for (when

appropriately selected)• They may even live longer

November 2014

Sources: Jennifer Temel, MD, et al., “Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer,” NEJM, August 19, 2010; K. Eric De Jonge, MD, “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,” JAGS, October 2014.


Business Planning for Upstream Programs

1. What population will you serve?2. How will you manage your patients?

– What clinical model will you use?– What administrative support will you need?

3. How will you be paid?– Who are your business partners and payers?– What are their needs? How can you help them?

4. What will you measure?– What measures will you track before and after the

program?November 2014

#1 What Population Will You Serve?



High Cost Population Is Not All at End of Life

November 2014

High-Cost Population18.2 Million People

High-Cost End-of-Life Population2 Million People

Low-Cost End-of-Life Population0.5 Million People

Source: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (IOM), The National Academies Press, Washington, DC, 2014, Appendix E, p.27.

High Cost Population Not All Old

Age <6586%

Age 65+14%

Total Population, by Age

Age <6560%

Age 65+40%

High-Cost Population, by Age


Source: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (IOM), The National Academies Press, Washington, DC, 2014, Appendix E, p.27.


The Top 5% of Patients Account for 50% of All Healthcare Spending

Top 1% Top 5% Top 10% Top 25% Top 50%0%

20%

40%

60%

80%

100%

22.7%

50.0%

66.0%

86.7%

97.3%

Percentile Ranked by Health Care Expenditures, 2012

November 2014

Source: Steven B. Cohen, Ph.D., “The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2012,” Statistical Brief #455, AHRQ, October 2014.

108

Functional Limitations Greatly Increase Likelihood of High Expenditures per Patient

Everyone

No Limita

tion, no ch

ronic

illness

Chronic

illness

only

Functi

onal limita

tion only

1+ Chronic

3+ Chronic

Chronic

+ Functi

onal limita

tion

ADL/IA

DL

ADL/IA

DL + Chro

nic

ADLIADL +

3 Chronic

10.2

0.8 0.81.8

3.64.3

6.16.6

7.7

Relative Risk of Being in Top 5% of Health Care Spenders

Source: Lewin Group Analysis of 2006 Medical Expenditures Panel Survey, from “Individuals Living in the Community with Chronic Conditions and Functional Limitations,” report to HHS, January 2010.


Ways to Identify the Target Population

• Computer algorithms analyzing patient records within an insurer database

• Documentation of functional limitations and chronic illness in a health system EHR

• Routine documentation of answers to the “surprise” question: “Would you be surprised if the patient died in the next 12 to 24 months?”

• Physician referralNovember 2014


Top Five Most Costly Medical Conditions

1. Heart disease2. Trauma-related disorders3. Cancer4. Mental disorders5. COPD/asthma

November 2014

Source: Steven B. Cohen, Ph.D., “The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2012,” Statistical Brief #455, AHRQ, October 2014.


Clearly Define Your Target Population

• Biggest savings will accrue only if you get the population right– cost differences are highest only among the sickest and frailest

• If healthier, lower-risk population is included, costs can easily outweigh the benefits of intensive management

November 2014


Start Simply, Start Small

• Begin with the low-hanging fruit: Start with your best program initiative, that promises the greatest savings with a limited population

• Grow over time: Expand later, after success is demonstrated

November 2014

#2 How Will You Manage Your Patients?


Target Population = High Risk Patients

• Functional limitations• Multiple chronic conditions• Dementia• Serious (life threatening)

illness• Uncontrolled symptoms• Recent discharge from

hospital• Caregiver breakdown

• Home safety assessment• Patient and family

education• Medication reconciliation• Diet counseling• What to do in crisis• Planning – Care goals• Visits• Telephonic support


Patients May Have Upstream Care May Involve


Formal Mechanisms Support Care Coordination

• Documented handoffs when patient transfers to another care setting

• Integrated health information portals• Patient navigators and case managers• Strong social support care• Telephonic and urgent care support

November 2014


Ensure Your Savings Will Outweigh Your Costs of Caring for This Population• Care coordination can be very expensive

– North Shore-Long Island Jewish Health System reports that new admits to its care coordination program (Care Solution) cost $400 per member per month

• 2015 Medicare physician fee schedule permits $40.39 per month per qualifying patient for care coordination management (codes 99487-99489)

• Most experienced providers suggest starting small to make sure volume and costs don’t overwhelm the fledgling program

November 2014

Sources: Kristofer Smith, MD, “Working within Value-Based Contracts to Support Community-Based Palliative Care, presentation to CAPC, September 24, 2014; Donna Marbury, “2015 Medicare fee schedule offers new care coordination, telehealth codes,” Medical Economics, November 3, 2014.


Plan for the Fact that High Savings Are Reserved for Highest-Risk Patients

Lowest frailty Moderate frailty Highest frailty$0

$20,000

$40,000

$60,000

$80,000

$22,611

$42,223

$56,589

$19,146

$43,353

$76,840

Medicare Costs by Frailty Category

ManagedControl

November 2014

Sources K. Eric De Jonge, MD, “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,” JAGS, October 2014.

#3 How Will You Be Paid? (Who Will Your Business Partners Be?)



Financing Upstream Services(In Order of Level of Support)

• Full support from partnering health system• Per visit payment• Case rate payment• Palliative care billing for allowed clinical services

(only partially offsets cost)• Risk-based payments (per member per month)• Shared savings (as with an MSSP ACO)

November 2014


Types of Risk-based ContractsType Description

Pay for performance

Provider receives incentive payments for meeting certain quality or cost efficiency targets (usually both)

Shared savings Provider may receive a portion of any savings incurred through cost avoidance relative to a pre-determined budget

Shared risk Providers shares upside and downside risk with insurer/payer relative to a pre-set target

Full risk or capitated

Provider gets all or a portion of the premiumFlat payment per covered person, no matter what the utilization

November 2014


High-Impact Target Areas for ACO Initiatives

1. Prevention and wellness2. Chronic disease3. Reduced hospitalizations4. Care transitions5. Multi-specialty care coordination of

complex patients

November 2014

Source: Accountable Care Guide for Hospice & Palliative Care, Toward Accountable Care Consortium, Raleigh, North Carolina.


Shared Savings Distributions AnewCare Collaborative, Tennessee

• Aggregate Performance Year One: $6.9 Million Savings

• Distribution Plan:– ACO administration gets $10 pmpm off the top– Reinvest in infrastructure = 50% of remainder– Distribution to participants = 50%

• Physicians get 64% of participant share• Hospitals get 36% of participant share

November 2014

Source: AnewCare Collaborative, Johnson City, TN, from website anewcare.org, accessed November 2014.

CMS Hospital Compare Can Help Target Your Efforts


Source: http://www.medicare.gov/hospitalcompare, accessed November 13, 2014.

#4 How Will You Measure Success?



Measure and Report Your Success

• Be sure to collect baseline data – demonstrate savings and quality improvements made under your

management• Work with your business partners to determine what

measures are most meaningful to them:– Hospital admissions/re-admissions– Emergency department utilization– Falls– Patient and family satisfaction– Cost reductions/cost avoidance– Lab, imaging, drug costs– chemotherapy use in last month of life

November 2014

Models and Resources



@HOMe Support, Michigan

• Hospice of Michigan in partnership with BlueCross BlueShield of Michigan

• 80% of patients ultimately transition to hospice

• Outcomes:– 9% decrease in ED use– 33% decrease in hospital admissions– 57% decrease in hospital re-admissions– High patient and family satisfaction scores

November 2014

Source: “Improving Access to High Quality Hospice Care: What is the Optimal Path?” Melissa Aldrige and Jean Kutner, Health Affairs Blog, September 9, 2014.


Aetna Compassionate Care Program

For the 1% of Medicare Advantage members enrolled in the program:

– An 82% hospice election rate– An 81% decrease in acute hospital days– An 86% decrease in ICU days– High member and family satisfaction– Total cost reduction of $12,000 per enrolled

member

November 2014

Source: A Palliative Care Toolkit and Resource Guide, CAPC and the National Business Group on Health, 2014.


Hospice Care of California• Community based palliative care program serving 6 different risk-

bearing IPAs in California• Services include telephonic support from an RN and also visits from

an interdisciplinary team:– MD– RN– Social worker– Chaplain

• HCC receives a per-visit payment and also a small per member, per month admin fee

November 2014

Source: A Palliative Care Toolkit and Resource Guide, CAPC and the National Business Group on Health, 2014.


Use Available Resources for Planning an Upstream or Palliative Care Program

• NHPCO• IPAL: Improving Outpatient Palliative Care (CAPC)• CSU: The Institute for Palliative Care at The

California State University• Toward Affordable Care Consortium

www.tac-consortium.org• IOM – “Dying In America” (September 2014)

November 2014

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Always remember who we serve ---

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NHPCO members enjoy unlimited access to Regulatory Assistance95% of questions received a response in < 24 hours in 2014

Feel free to email questions to [email protected]

mailto:[email protected]

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Regulatory/ Compliance Team at NHPCO

Judi Lund Person, MPHVice President, Regulatory and Compliance

Jennifer Kennedy, MA, BSN, CHCDirector, Regulatory and Compliance

Email us at: [email protected]

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mailto:[email protected]

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Resources and References• ICD-9-CM Official Guidelines for Coding and

Reportinghttp://www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08-09_sm.pdf

• Hospice Quality Reporting Program– https://www.cms.gov/Medicare/Quality-

Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/index.html

• Hospice CAHPS Survey– www.Hospicecahpssurvey.org

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References• The Centers for Medicare & Medicaid Services (CMS)

Medicare Hospice Wage Index Final Rule and Medicare hospice payment rates for fiscal year (FY) 2015

– http://www.ofr.gov/OFRUpload/OFRData/2014-18506_PI.pdf

• Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance

• Medicare Hospice Conditions of Participation• OIG FY 2015 Work Plan

– http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf

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