Cale Bradford gave the following speech to the Managed Care Association:
Good Morning. My name is Cale Bradford and I’m the Chief Operating Officer of Pyramid Home Health Services. We’re a state-wide provider of home and community based services including in-home long term care, home health, hospice and pharmacy. I appreciate the opportunity to visit with you today on the topic of a working relationship between home health and an ACO.
My goal is to demonstrate how home and community based services like home health can assist physicians practicing in an ACO structure to build on and make more robust their patient /physician relationships and drive Medicare shared savings and patient satisfaction in the process.
So much of what positively or negatively affects the outcomes associated with any physician’s management and treatment of patent conditions happens outside of their medical office. Where many patients are concerned, particularly those who are elderly or disabled and affected by chronic disease, it happens at home. To follow their doctor’s prescription for diet, exercise, medication compliance, stress management, avoidance of high risk behaviors, or not, is a daily decision for many of the 54 million Americans who receive their health insurance coverage through Medicare. If all of these beneficiaries decisions played out as articulated and agreed to in their physician’s office, surely we’d have a fundamentally healthier society while carving off a hefty apportionment of the $583 billion spent last year by Medicare on these folk’s healthcare- an expenditure that represents approximately 14% of the total national budget.
As a healthcare delivery model, carving off that apportionment is what an ACO has to prove it can do financially. Its physician members have to take currently sicker and more expensive patients and move them toward better health at lower cost. If we take for granted that many patients’ decisions may be bad ones, and that it’s impossible for a physician to physically manifest themself at every intersection of what I should and what I’m going to do, then the question is, what’s the best way to assist physicians to more positively impact these decisions in the aggregate?
Numerous current demonstrations coming out of the CMS Center for Innovation as well as private practice initiatives from around the country, some dating back as far as the 1997 Balanced Budget Act, strongly suggest that home and community based services are the ideal vehicle to deliver physicians a more contemporaneous understanding of the changing factors that influence their patient’s decision making and for delivering physician influence to the point of patient decision making more frequently. Whether we’re talking about the decisions I listed earlier, or choices relating to things like, do these symptoms mean I need an ambulance, or should I take these two medications together, or fill this one, as opposed to that one, because I can’t afford both, the consequences, both health and economic , flowing from these decisions are immense; and the data from these initiatives and demonstrations is showing that easier, more timely access to a physician improves them; and here lays the cornerstone of a working relationship between home health and the physician members of a ACO.
Traditionally home health has been considered a post rehabilitative service, after care relating to an illness, procedure or hospitalization that aides in a patient’s recovery and return to function. However, in the post ACA world, and specifically when working in partnership to an ACO, a home health company’s infrastructure is a powerful tool to aide physicians wishing to extend their positive influence further into their patient’s decision making processes- which is occurring, not in their office, but in their home and community.
When you look at the $583 billion dollars Medicare spent last year, the break down is basically $145 billion, 25%, to Medicare Advantage, hospital inpatient services, 24%, $140 billion, 14% on the combination of part b drugs and services, DME, ambulance, Hospice, outpatient dialysis and lab services, 12% for physician services, or $70 billion, 11% part d drugs, 6% outpatient hospital services, 5% skilled nursing facilities, $29 billion and 3% for home health, $17 billion annually. The key financial question for an ACO has to be; how much of the cost associated with these individual expense categories was avoidable and how do I avoid it in my population of attributed lives going forward? What is the best vehicle for recognizing the opportunity to substitute patient education, less costly technology and timelier, less intensive, interventions for more costly, often avoidable, services?
How about having access to NP, RN, CWCON, LPN, PT, OT, ST, Dieticians, Social Workers, and CNA, 24/7/365; who will deliver, per your order or customized standing protocol, your preferred teaching, technology and intervention to your patient’s home with real time reporting back? That is exactly what a professional relationship between you’re ACO and its home health partner should look like. Further, it should be available at a fraction of the cost associated with an avoidable event stemming from a lack of patient connectivity to your physician’s offices when it’s needed. As a happy aside, it also increases patient convenience and satisfaction.
Consider the average inpatient cost paid by Medicare for the following admission types in Missouri, these do not include any co-pays, deductibles, or other third party payments- COPD $6,300, Pneumonia $8,133, Chest Pain $2,424, Heart Attack $4,344, Hypertension $3,300, Hip fracture $3,912, Diabetes $4,976, UTI $4,540, CVA $4,470. Now consider that the average direct Medicare reimbursement for home health, which includes up to 60-days of aftercare and rehabilitation, inclusive of the cost supplies, and delivered to a patient with an acuity level that prohibits their leaving home without taxing effort is $2,700. In the case of the company I work for, Pyramid Home Health Services, it’s a little over $2,100. How many individuals discharged from an in-patient stay relating to these diagnoses have an elevated risk for re-hospitalization during their first 60-days at home? For those that do, where home health is concerned, for the cost of aftercare and rehab, Medicare is also buying an insurance policy against additional inpatient cost relating to readmission, and for its ACO partner, a better chance of participating in greater shared savings. This assumes of course you’ve working with a home health partner whose outcomes evidence their ability to actually manage that risk.
Medicare Advantage gets it. They’re using the eyes, ears and ability of home health clinicians to accentuate their management efforts as “at risk” entities. Let me give you some examples of how home health is being used by Medicare Advantage and other insurance companies in a way that differs from its traditional rehabilitation and treatment role. These are actual programs that my company, Pyramid Home Health Services, provides under contract to these organizations in a sub-contractual capacity and in support of their own, broader population health management initiatives.
The first of these is Care Transitions Management. Many individuals are discharged to home without a specific need for traditional home health services but, as we’ve discussed, they are still at risk for complications that may lead to unnecessary ER usage or a re-hospitalization. Avoiding this undesirable outcome starts with successfully managing these patient’s transitions from the in-patient setting to the community. So, to do so Pyramid Home Health Services Care Transitions Management program is a 30-day protocol specifically developed to avoid ER usage and hospital readmission post discharge. The program consists of five components.
First, we make an in-person/ in- facility visit to a patient prior to their discharge. We develop a rapport with the patient; evaluate their knowledgeable of their condition, medical record, medications and their personal responsibilities relating to a successful recuperation at home. The also receive a “Transitions Packet” that contains information regarding their condition, warning signs and symptoms, discharge medications and instructions, their physician(s) contact information and follow-up visit dates, a list of the addresses, contact numbers and hours of operation of emergent care clinics nearest their home and 24/7 contact information for Pyramid Home Health Services.
Next, we conduct a pre-discharge assessment of the safety and accessibility of the patient’s home and provide a written report to the patient’s following physician(s), the discharging hospital, and their health plan that identifies safety hazards, barriers to self- care or family assisted care, required home modifications or DME that may be necessary for a successful transition. If required we will coordinate orders and referrals for ancillary services, supplies and pharmacy and ensure supplies, services and medications are there when the patient returns.
We complete a home visit within 48- hours of discharge, or sooner to evaluate the return to the home process, the patient’s satisfaction with it, address health questions, concerns and warning signs and symptoms. We check vitals, review medications and the patient’s knowledge regarding regimen/ dosage(s)/ side effects. If needed, Pyramid Pharmacy can provide Tele-health based MTM (Medication Therapy Management) with a certified pharmacist. We draw requested labs and, if needed, assist to schedule necessary follow-up visits to physicians and other providers including arranging transportation to and from were required.
We offer a 24X7 Nurse Line that makes available a Clinician to provide telephone based response to patient health questions and concerns and to triage alternative care options to the ER after hours. Our response is stepwise and ranges from the least invasive- advice and follow-up telephone monitoring to, if required, referral to the nearest open emergent care clinic or dispatch of a nurse to the patient’s home. All documentation of interactions is provided to the patient’s following Physician(s) and health plan within 24- hours or sooner where appropriate.
Finally, we make weekly check-up calls to the patient to review their stability at home and their satisfaction with the home transition process.
Where we are providing Care Transitions Management to a non-home bound individual, who may or may or may not be a Medicare Beneficiary, the total cost to the payer is $550 for the entire 30-day management period. Where we are providing traditional home health services to a homebound Medicare beneficiary, assuming prior evidenced patient choice and appropriate authorizations, these services are included as a part of the standard Medicare reimbursed home health episode.
Another example of Medicare Advantage’s use of home health as a cost avoidance tool is its use by carriers to monitor, longer term the health of patients with multiple chronic conditions. For patients at a high risk for hospitalization, defined in one contract, as any beneficiary for whom the plan has incurred expenses in excess of $60,000 in the previous year, and who has at least one chronic condition, home health is proving very effective. For this particular company we provide no less than three at home visits with an LPN monthly, more and with alternatively credentialed staff if necessary, and weekly phone contact for a flat fee of $400 per month. Best case scenario there is a 12 to 1 positive ratio between the carrier’s additional home health expenditure and their historical cost outlay for these particular qualifying beneficiaries. So, where the past would be prolog with respect to these patient’s outcomes the odds are overwhelming in favor of the carrier’s additional expenditure on home health driving substantially greater cost avoidance.
There was a great article in the Washington Post in April of last year. The title was, “If this was a pill you’d do anything to get it.” It was regarding the impact of Health Quality Partners in Doylestown Pennsylvania on Medicare expenditures. HQP is a demonstration program that was actually implemented as a part of the 1997 Balanced Budget Act. It, and 15 other sites nationally, enroll Medicare patients with at least one chronic illness and one hospitalization in the prior year in a program that sends a nurse to see them every week to month, whether they’re healthy or sick. The HQP demonstration has used the gold standard of experimental design: randomized-controlled trials. Some seniors enrolled are included in the program and some left out. The assignment is random and the group’s similar, allowing researchers to be certain that whatever differences they’ve seen between the groups are attributable to the care each received rather than the company’s success at signing up healthier seniors. Health Quality Partners’ results have been extraordinary; according to independent analysis by consulting firm Mathematica, HQP has reduced hospitalizations 33 percent and cut total Medicare costs for demonstration enrollees by 22 percent. I think it’s fair to say that those same metrics would no doubt be of great benefit to any ACO capable of accomplishing the same on its population of attributed lives.
One interesting point about the demonstration in which HQP participated is that many of its Medicare beneficiaries were dual eligible or qualifying for both Medicare and Medicaid. When we think about home health more broadly, as a home and community based service, and include both those rehabilitative and treatment services commonly associated with it as a Medicare service but also include those lower acuity professional and paraprofessional services designed to maintain beneficiary independence at home under Medicaid, the result is an even more dynamic partner for an ACO.
There are 10.2 million dual eligible Americans, 7.4 million of whom are full dual eligible, those actively receiving services from both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. There are 168,229 full dual eligible in Missouri and these patients represent a tremendous opportunity for an ACO to have a fundamentally positive impact on the health of the communities it serves and drive major Medicare savings.
Consider this, because Medicare and Medicaid pay for different slices of a dual eligibles’ care this group’s services have been largely uncoordinated. The cost of investments designed to lessen overall spending, if done, is often borne by the state and Medicaid with the benefits accruing to the Federal government and Medicare. For example, reducing avoidable hospitalizations is a direct benefit of better coordinated care. CMS says 45 percent of hospitalizations transferring from skilled nursing facilities last year we’re avoidable. To reduce those hospitalizations requires investments in programs like fall prevention; which when implemented through HCBS reduce the need for and occupancy of SNF and therefore the number of individuals transferring from a SNF to the hospital because of a fall. The cost of expanding these programs is roughly 40% born by the state under Medicaid but the financial savings from reduced hospitalizations and SNF rehab accrue to Medicare and the Federal government. \
As an ACO you’re in a partnership with the Federal government and Medicare. The same Affordable Care Act that ushered in ACO’s also created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make these two programs work together more effectively. They are charged with testing new approaches to care coordination which permits states to share in the Medicare savings resulting from their management efforts; just like those of you operating in an ACO environment get to participate with Medicare in the shared savings resulting from your management efforts. The biggest of these initiatives is the Financial Alignment Demonstration which is predominantly testing two models, fully capitated managed care and healthcare homes. Due to time constraints we can’t go through all the nuances of each of these models but, what’s important is, just like a state that can drive its participation in shared Medicare savings through more effective use of Medicaid services, so too can you as an ACO. Where your ACO has attributed lives represented by dual eligible individuals, those individuals likely represent the group for whom you can drive the greatest Medicare savings. If your home health partner has the experience and ability to assess qualifying need, eligibility and assist these patients to access these Medicaid programs, these long term supports will dramatically reduce Medicare hospitalization and skilled nursing facility cost, and drive your ACO shared savings. That said, this is task that has to occur in the homes and communities of your patients and it’s not equally available from all home health partners.
Given I’m pretty close to my 20 minute mark I should probably summarize the points I’d like to leave you with today. 1st and most importantly, a good partnership between an ACO and Home Health is good for patients; it helps physician’s gain more granular insight into the influencing factors of patient’s lives and helps them empower patient’s to make better healthcare decisions; 2nd in doing so it drives cost savings for Medicare and improves the profitability of the ACO. 3rd, it’s important to partner with a home health provider that offers a full scope of home and community based services under Medicare and Medicaid with comparatively better and verifiable hospitalization and emergent care outcomes rooted in claims data. Believe me; it’s much easier to stand here and describe what a good partner looks like than it is to actually be one, the time you spend investigating yours is well spent; and we at Pyramid Home Health Services would love the opportunity to prove to you why we’d be a good choice of partner.
Thank you so much for having me here today.