Contributor: Brian Holzer, WG’05
To learn more about Brian, click here.
Society teaches basic fire escape planning generation after generation, starting as early as preschool. Simple concepts are taught such as:
- Prepare for the event of a fire.
- Install smoke alarms for early fire detection.
- Focus on older family members with mobility limitations.
- Identify an outside meeting place.
Thankfully, many of us may never have to experience a house fire. Yet, we teach our kids to prepare for this unlikely event. The same basic principles are largely ignored when it comes to planned or unplanned hospitalizations. As our loved ones age, hospitalizations are a likely event. Patients and families are not prepared.
Post-hospital (i.e., post-acute) care is currently used by almost 42 percent of Medicare beneficiaries.1 Baby-boomers are aging, and the U.S. population over the age of 80 is expected to triple between 2010 and 2050, according to the UN World Population Aging 2013 report. As hospitals and health systems are increasingly under pressure to limit the length of stay in hospitals, patients and families will need to become more educated consumers on post-hospital care. Education currently occurs during hospitalizations, often amidst immense stress and vulnerability, when retention is unlikely.
Fortunately, high quality and coordinated post-acute care (PAC) models are increasingly becoming a focal point in healthcare. Facility-based providers such as skilled nursing facilities (SNF), long-term acute hospitals (LTACH), inpatient rehabilitation facilities (IPR), or home healthcare (HHA), have a tremendous financial impact on PAC and associated government programs. Medicare and Medicaid, and ultimately federal and state budgets, can be impacted by PAC outcomes. Employers, particularly those that offer retiree coverage, wrestle with the ability to continue to provide benefits to seniors, who are most in need of coordinated care after hospitalizations. It’s imperative that our healthcare system identifies innovative solutions to solve for this less publicized, but increasingly relevant, area of healthcare.
Using the “fire-safety” analogy, private/public payers have started “planning” by pioneering new models of reimbursement that focus on value-based incentives to improve quality and reduce costs. The Affordable Care Act (ACA) of 2010 established the Center for Medicare and Medicaid Innovation (CMMI), which tests such new models of healthcare delivery within Medicare and Medicaid programs. Delivery systems and payment reform are being driven by the 2015 passage of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA links physician payments to quality and value, rather than volume. In the PAC space, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act in 2014; which aims to improve care for Medicare beneficiaries by implementing quality metrics and resources used for tracking by providers, including physicians and hospitals.
Focusing on PAC makes sense, as it’s the component of healthcare with the most variation in care delivery. Clinical transformation and payment reform must occur in parallel in order for PAC to achieve the sustained evolution required. Three key trends will likely drive this transformation:
- PAC silos will need to be replaced with more coordinated continuums of care. Hospitals and health systems will increasingly realize the value of owning, or partnering, with high quality networks of PAC providers. PAC providers will increasingly embrace the need to work together in order to offer end-to-end solutions for hospitals and payers.
- Pressure on hospitals and health systems, including PAC readmission penalties and bundled acute/PAC reimbursement, will further drive integration of the acute and post-acute segments.
- More robust quality data on PAC providers will enable shifts in reimbursement from a fee-for-service model to a quality and outcomes-based value model.
A Potential Solution
HM Home and Community Services LLC (HM HCS) was established in 2016 to address the importance of PAC and its impact on clinical outcomes, patient experience, and overall cost of care. The vision of HM HCS is to transform PAC by removing barriers to collaboration, closing the gaps in uncoordinated care, and transforming quality, service, and value. HM HCS deploys a payer-provider agnostic network management model and acts as a solutions aggregator by optimizing the deployment of various technology partnerships and collaborations. HM HCS leverages data in order to disrupt the PAC model from a financially-driven incentive model, to a quality and outcomes-based incentive model, beginning with a Pennsylvania health plan’s Medicare Advantage program as its first customer.
HM HCS’ management model produces scorecards for SNFs and HHAs based on robust quality and outcomes metrics. These scorecards are used to generate quarterly risk-adjusted rankings that provide transparency to SNFs and HHAs on their performance and how they compare to their peers. HM HCS Network Performance Managers are engaged with SNFs and HHAs to provide scorecards and rankings, with the goal of facilitating collaborative communication and continuous improvement initiatives, including patient quality and reduced overall medical costs. Pay-for-value (P4V) future provisions implemented by health plans will further incentivize high performing providers. And, higher performing PAC provider networks will support health plans P4V contractual provisions to further align incentives and drive sustainable transformation.
HM HCS is transforming the approach to managing PAC, and offers scalable solutions for payers and providers at-risk for spend in PAC. Quality improvement, broad access, and a superior patient experience are both aspirational and attainable for transformative healthcare models in the post-acute care space. HM HCS achieves a win-win-win by implementing “fire-safety” plans that help prepare and benefits patients, payers, and providers across the healthcare continuum.
Despite the unlikelihood of experiencing a house fire, children continue to be taught year-after-year how to prevent and prepare for this type of tragic event. Unfortunately, hospitalizations are much more likely to occur, and families are much less prepared. Education and advocacy for patients and families are of paramount importance. HM HCS is in the process of trialing out-of-the-box solutions and proof of concept initiatives in the post-acute care space. As PAC awareness expands, so will the increased need for “fire-safety” planning.
Contact Brian at:
Brian Holzer MD, MBA
President, HM Home and Community Services
120 Fifth Avenue
Pittsburgh, PA 15237
- Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Chapter 7: Medicare’s Post-Acute Care: Trends and Ways to Rationalize Payments. Washington, DC: Medicare Payment Advisory Commission; March 2015.