Fred Benjamin - AHCA/NCAL Deck.pdf · Fred Benjamin AHCA/NCAL Regional Multifacility Council Chair President LTC Division, Lexington Health Network

Fred BenjaminAHCA/NCAL Regional Multifacility Council Chair

President LTC Division, Lexington Health Network

The Two Big Unfixables – Aging and Dying. A Discussion about Being Mortal

Is More Better? Prolonging Life At The

Expense Of Quality Of Life

David Gifford, MD MPH

Senior Vice President for Quality & Regulatory Affairs

1. Mor et al., 20102. CMS NHC site3. Commonwealth 20114. Jencks NEJM 20095. Analysis of SNF Claims

Churning at End of Life

Home

Assisted Living

Nursing Home

DeathER

Hospital SNF

23%1

50%2

20%1

19%4

20%3

5%5

45%2

2.2M Medicare admissions

A third use LTC but account for 87% of Costs

Costs of Long-Term Care Services 2007

Elderly want to stay in their home1

▪ Surveys of community elderly show a strong aversion to nursing home; • in a study of a large sample of seriously ill persons >70 years

old, 29% indicated that they would rather die than enter a nursing home.7

▪ In contrast, “Families often opt for nursing homes because they fear leaving their relatives at home where some untoward event may occur.”1

1 Kane RL & Kane RA. What Older People Want From Long-Term Care, And How They Can Get It. Health Affairs, 20, no.6 (2001):114-127

WRAPPING OUR CHILDREN IN BUBBLE MAY PROTECT THEM FROM INJURY BUT AT WHAT EXPENSE?

Rehospitalization Marker of Increased Mortality

Hospitalized beneficiaries who have an early hospital readmission nearly 3 times more likely to die within 1 year (one-year mortality = 38.7 % vs patients who were not readmitted = 12.1 %; p<0.001). Lum et al. J Gen Intern Med 2012; 27(11): 1467-74.

Mobility levels following hospitalization

hospitalized for major surgical procedurehospitalzed for non-surgical reasons

Ann Intern Med. 2009 Mar 17; 150(6): 372–378.

6 month Survival after ICU care

Guidet B. et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France A Randomized Clinical Trial JAMA. 2017;318(15):1450-1459.

ICU admission Rate Controls vs Intervention

34% vs 61%

intervention

Control

Five Questions to Explore

1. What is your understanding of where you are and of your illness?

2. What are your fears and worries for the future?

3. What are your goals and priorities?

4. What outcomes are unacceptable to you? What are you willing to sacrifice and not?

5. What would a good day look like?

From Atul Gwande’s book: “Being Mortal”

Play the film - http://www.pbs.org/wgbh/frontline/film/being-mortal/

10-Minute Break

Gail SheridanChief Clinical Operations Officer

Tealwood Senior Living

BEING MORTAL

PHIL FOGG

AGING

DYING

UNFIXABLES

AGING

DYING

PATIENT vs PERSON

L IFE JOURNEY

CHAMPION OF EACH JOURNEY

CHAMPION OF EACH JOURNEY

L I V E T H E B E S T

R E S T O F T H E I R

L I V E S

W H E R E H A V E T H E Y C O M E F R O M ?

L I V E T H E B E S T

R E S T O F T H E I R

L I V E S

H O W D I D T H E Y G E T H E R E ?

W H E R E A R E T H E Y N O W ?

H O W D O T H E Y W A N T T O L I V E T H E

B E S T R E S T O F T H E I R L I F E ?

P O S I T I V E E M O T I O N

E N G A G E M E N T

P O S I T I V E R E L A T I O N S H I P S

M E A N I N G + P U R P O S E

A C C O M P L I S H M E N T

HAPPINESS vs

WELL-BEING

P R O G R A M S TO S U P P O R T W E L L - B E I N G

I - S N P

M A N A G E D C A R E F O R

L O N G - T E R M L I V I N G P O P U L A T I O N

I N L O N G T E R M C A R E

H E A LT H P L A N

PA T I E N T | R E S I D E N T H I S T O R Y

E N D O F L I F E P L A N N I N G

F O C U S O N H E L P I N G I N D I V I D U A L

L I V E B E S T R E S T O F T H E I R L I V E S

N E W C H A P T E R S

A S P I R A T I O N A L R E H A B

R E C O V E R Y

R E - E X P E R I E N C E

B U C K E T L I S T

V I TA L L I F E

F O U N D AT I O N

B A C K PA C K T O S C H O O L

J O U R N E Y O F H E R O E S

M E M O R I E S I N T H E

M A K I N G

M U S I C + M E M O R I E S

V I TA L V O L U N T E E R S

INTENTIONAL FOCUS

E A S I E R W H E N YO U

R E A L LY K N O W S O M E O N E

Phi l Fogg, Sr

“ THE BEST REST OF YOUR L I F E ”

HAS UN IQUE MEAN ING

TO EACH PERSON

CHAMPION

OF EACH

JOURNEY

L I V E T H E B E S T

R E S T O F T H E I R

L I V E S

Risk Bearing OpportunitiesCleo Kitt, Director of Special Projects-Operations and

Executive Director of LifeWorks Advantage Jason Lee, CEO, Arkansas Superior Select/Tribute Health Plans

David Norsworthy, CEO, Central Arkansas Nursing Centers,

Risk Bearing Opportunities: I-SNP Operations

Risk Bearing Opportunities: I-SNP Operations

From the LifeWorks Advantage Perspective

Cleopatra Kitt, MPHDirector of Special Projects-OperationsExecutive Director of Lifeworks AdvantageMedical Facilities of America, Inc.

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AGENDA

LifeWorks Advantage

Risk and Rewards

Operations

39

LifeWorks Advantage

LifeWorks Advantage is a Medicare Advantage Instutionalized Special Needs Plan (I-SNP)

LifeWorks Advantage is limited to Medicare beneficiaries who are long-term residents in one of our nursing centers throughout the Commonwealth of Virginia

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Lifeworks Advantage

Service Area

41

Goals of the Plan 42

Position MFA to access premium dollar directly

Own and control data

Leverage MFA Model of Care to drive better outcomes for

patients

Superior growth opportunity and financial model

Transformation platform: proprietary technology + change

management protocols

✔

✔

✔

✔

✔

Risks and Rewards

Market Summary

Provider Networks

Medicare Advantage Regulations

Star Ratings

Integrations with Current Systems

43

Skilled Nursing Facilities 44

Industry

Pressures

Gov’t Reimbursement

Spend Margin

Medicare $29.8B 12.6%

Medicaid $46B 1.60%

Variation in Medicare Margins

• 75th percentile: 21%

• 25th percentile: 2.4%

Skilled Services Under Pressure

• Primary focus of bundles is

SNF spend

• CMS dropping therapy as element

of Medicare reimbursement

• Significant utilization decrease

due to cumulative impact of MA

growth, bundles, ACOs, MSSP etc.

Managed Care Environment

• Government programs will

continue to expand

• Medicaid Managed Care Expansion

• Medicare Advantage Growth

Industry Response

✔✔ Experience diminishing

returns of current market forces

- Continue to invest in skilled

services and referral streams

- Manage cost basis for long

stay patients

✔✔ Utilize political influence with

new administration and state

decision makers

✔✔ Pursue SNP Model

Industry Pressures

SNF Market Snapshot

Long Term Care Industry is Poised for a Significant Shift to Value-Based Care

Government Goals- 90%of Medicare payments link to quality/value by 2018

- Significant focus on reducing post acute spend

Payer Goals - Medicare Advantage poised for growth; “safe haven”

- Focus on Medicaid managed care expansion

Population Growth

Provider Goals

Projected Market for Long Term Care Value-Based Care Services

$9.4B+Total Addressable Market

✔ 2.7 million long term care residents

✔ $98B in healthcare spend

✔ Available market at 9-10% of spend

- Increase in 85+ population accelerates in 2020

- Alzheimers/Dementia comprises 1/3 of 85+ population

- Invest to control own destiny

- Capture value from care coordination

45

Operations

Infrastructure

Policies

INTERGRATION of Systems

Resource Requirements

Financial Plan

Metrics to Measure

Performance

46

Financial Plan

Outline a high-level financial plan that defines your financial model and assumptions.

Enrollment Projections

Bureau of Insurance

License

Medical Loss Ratio (MLR)

Catastrophic loss

47

18 Month Application:

Transformation Cycle

Thru Feb

2016

June

2016

June-

December

January

2017

48

July

2015

Policies and Integration of

Systems

Current System Policies

Clinical

Model of Care

Pharmacy

Information Technology

Billing

49

Resource Requirements

Resource Requirements:

Personnel

Technology

Finances

Marketing

Professional Fees

Services

50

Metrics to Measure

51

- - - - - - - - - - - - - - - - - - - - -

Lifeworks Advantage Executive DashboardExecutive Summary

Period: 1/1/2017 thru 6/30/17 Data as of 11/1/17

Superior Demonstrated Outcomes 52

VALIDATION

53

MFA’s Goal is to Capture and Create Value54

Benefits of an Effective

Compliance Program

Promotes patient safety and ensures the delivery of high

quality patient care

Helps ensure proper submission and payment of claims

Reduces billing mistakes

Improves outcomes from Medicare claims reviews

Reduces potential for Fraud, Waste and Abuse

55

Key Issues

Near term

Identify if you need a partner to help develop a D-SNP or

I-SNP based on your organizations assessment

Understand CMS Guidelines for Medicare Managed Care

Special Needs Plans

Identify the project lead times

Prepare financial assumptions

56

LifeWorks Advantage Partner:

AllyAlign Health

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✔ Unique offering across clinical and financial continuum for LTC residents

✔ Full continuum of data and proven outcomes

✔ Physician/NP/SNF-owner driven MOC for high risk institutional population

✔ Performance-driven network alignment

✔ Purpose-built shared services model

Key Issues

Long-term

Understand the impact on the care of your patients

across the long-term care continuum

Understand the risk and rewards on your company’s

financial health.

58

The Road Ahead 59

Requisite for Growth

Buy into Model at Facility Level

Care Team Formulation

Demonstrated outcomes; Gain share distributions

Follow on wave of membership

✔

✔

✔

✔

60

Resources

www.lifeworksadvantge.com

www.allyalign.com

www.cms.gov

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Questions & Discussion

Cleo Kitt, MPH

Executive Director of LifeWorks Advantage

[email protected]

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