Growing PACE While Navigating Competition National PACE Association Annual Meeting October 24, 2016 Jade Gong and Associates @ JadeGongRN 1 GROWING PACE WHILE NAVIGATING COMPETITION NATIONAL PACE ASSOCIATION ANNUAL MEETING OCTOBER 24, 2016 PANEL PRESENTATION AND DISCUSSION 2 PACE in the World of Value- Based Care Jade Gong, RN, MBA Principal, Jade Gong & Associates Edo Banach, JD Partner, Gallagher, Evelius & Jones PACE Innovation With and Without Innovation PACE Expansion at Trinity Health PACE Anne Lewis VP, Trinity Health PACE
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GROWING PACE WHILE NAVIGATING COMPETITION · Growing PACE While Navigating Competition National PACE Association Annual Meeting October 24, 2016 Jade Gong and Associates @ JadeGongRN
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Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 1
GROWING PACE WHILE NAVIGATING
COMPETITION
NATIONAL PACE ASSOCIATION ANNUAL MEETING
OCTOBER 24, 2016
PANEL PRESENTATION AND DISCUSSION
2
PACE in the World of Value-
Based Care
Jade Gong, RN, MBA Principal, Jade Gong & Associates
Edo Banach, JDPartner, Gallagher, Evelius & Jones
PACE Innovation With and
Without Innovation
PACE Expansion at Trinity
Health PACE
Anne LewisVP, Trinity Health PACE
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 2
3
TARGET MARKETSERVING THE 8.2 MILLION DUAL ELIGIBLES WHO
ARE NOT NOW IN ORGANIZED SYSTEMS OF CARE
Source: Bipartisan Policy Center, Delivery System Reform: Improving Care for Individuals Dually
Eligible for Medicare and Medicaid, September 2016, page 18
8.2M
2.1M
Dual Eligibles
Not in System of Care In System of Care
* Includes enrollment in MMP, FIDE and PACE in 2015
4
• Center of gravity for patients,
families: where patients want to be
• Most illness, suffering, coping,
caregiving take place in the home
• Failure of home care environment
leads to hospitalization as care of
last resort
• Less than 3% of total health care
spending, but…
• 50% of total health care effort
- Very little research or medical
education in this setting
- Little-to-no professional medical
attention
PAYOR FOCUS ON CARE @ HOME
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 3
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EMERGING RISK-BASED PAYORS NEED
ASSISTANCE WITH LONGITUDINAL CARE
MANAGEMENT @ HOME AND ACROSS SETTINGS
Home PCP SNF HHAOther PAC
Home
Hospital
Current Focus
Lily Tomlin
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The tipping point is that
magic moment when an idea,
trend, or social behavior
crosses a threshold, tips,
and spreads like wildfire.
Malcolm Gladwell
Author, The Tipping Point
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 4
SCALING “CLASSIC” PACE AND NEW PACE
Traditional
PACE
Accelerants
• Flexibility with primary care, community-
based physicians and core assessment
team (proposed)
• Telehealth and home-based technologies
• For Profit PACE / Venture Capital
• New populations allowed by Innovation
Act (PD/IDD, under age 55, not yet NH
eligible)
Scaled
PACEFor Traditional and
Expansion Populations
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• Grow “classic” PACE and consider “new” PACE
• Partner with other plans taking risk for high
cost/high need populations
• Consider other innovative models such as
MediCaring Communities
• You growth plan should assess:
- Where are the emerging opportunities in your
local market?
- Where can PACE infrastructure and expertise
add value and improve care?
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DEVELOPING YOUR GROWTH PLAN
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 5
INNOVATION: PACE AS A MEDICARING
COMMUNITY
Source: Gretchen J Lynn, MediCaring Communities: Getting what We Want and Need in
Frail Old Age at an Affordable Cost. Altarum Institute, 2016. Available on Amazon.com
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VALUE-BASED PAYMENT ACCELERATES
CMS Target 50% of FFS
payment through APMs
by 2018
Health Care Transformation Task Force Target of 75% through
Value-Based Payment by 2020
MACRA Physician Payment Report APM Incentives
begin in 2019
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Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 6
MEDICARE ALTERNATIVE PAYMENT
MODELS IN 2018 AND BEYOND
Medicare 2016
69 % FFS
34 % Alternative Payment
ACOs Bundled Payment
34% FFS
31 % Medicare
Advantage
CMS has
already
reached its
2016 target of
30%
alternative
payment
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NEW PHYSICIAN PAYMENT 2019
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Beginning in 2019, physicians will receive a 5 % bonus if a
significant proportion of revenue from APMs
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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Fully Integrated Dual Eligible Special Needs
Plan (FIDE SNP)
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COMPETITORS – DUAL ELIGIBLE PLANS
PACE
Medicare and Medicaid Plan (MPP)
Financial Alignment Demonstration
Medicare ACOs
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COMPETITORS AND COLLABORATORS
Medicare Advantage
Plan
D SNP MLTSS
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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• An ACO should have a financial incentive to reduce the total costs of care for a Medicare beneficiary and manage care across settings
• However, most ACOs have not accepted downside risk(about 5 %)
• Complex care management is not a priority for ACOs that do not have downside risk
• There are more Physician Group Practice sponsored ACOs that hospital sponsored ACOs; more PGP sponsored ACOs achieved shared savings
• Substantial ACO growth in models with downside risk expected due to MACRA incentives on physicians
**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.
***Includes multiple locations for Trinity Home Health Services, Trinity Senior Living Communities and PACE facilities.
Our 22-State Diversified Network
Home Care & Hospice Locations Serving 116 Counties47 Continuing Care
Facilities59PACE CenterLocations14
Hospitals* in 20 Regional Health Ministries**92 Mission Health
Ministries4Employed Physicians 5,300
Affiliated Physicians23,900National Health
Ministries***3
Trinity Health
• Dr. Richard Gilfillan, CEO of Trinity Health (TH) and past director of CMS Center for Innovation
• As the Innovation Center's first leader, Dr. Gilfillan was instrumental in ushering in new payment and delivery models such as Medicare ACOs and bundled payments and is using his vision to change how TH operates
“Continue to be the sponsor of the largest number of PACE organizations in the country”
Program State City Date Opened October 2016 Census
Catholic Health LIFE New York Buffalo 1-Nov-09 227
Eddy SeniorCare New York Schenectady 1-Oct-96 190
LIFE at Lourdes New Jersey Camden 1-May-09 235
LifeCircles Michigan Muskegon 1-Feb-09 292
LIFE St. Francis New Jersey Trenton 1-Apr-09 325
LIFE St. Joseph of the Pines North Carolina Fayetteville 1-Apr-11 280
LIFE St. Mary Pennsylvania Langhorne 1-Mar-10 244
Mercy LIFE (AL) Alabama Mobile 1-Jan-12 169
Mercy LIFE (MA) Massachusetts Springfield 1-Mar-14 177
Mercy LIFE (PA) Pennsylvania Philadelphia 1-Oct-98 718
Saint Francis LIFE Delaware Wilmington 1-Feb-13 195
Mercy LIFE –West Philadelphia Pennsylvania Philadelphia 1-Oct-98 454
Saint Joseph PACE Indiana South Bend 1-Aug-16 4
Total 3,510
Trinity Health PACE Organizations
TH PACE has experienced over 125% census growth since 2012
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
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Trinity Health PACE Operating Model
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• Trinity Health PACE (TH PACE) was formed in early 2015 to manage and support Trinity Health System's PACE assets including Trinity Health owned PACE organizations (PO) and POs operating under TH PACE ownership and management.
• TH PACE aligns with TH’s Continuing Care strategic initiative to expand services in the care of the dual eligible and service to the poor and underserved by:• Developing an infrastructure to support the delivery of services to the
PACE population• Leveraging the expertise of PACE Interdisciplinary Teams to manage
the dual eligible population in Non-PACE expansion programs• Developing new PACE through the operating company• Utilizing the combined strength of the PACE operating company to
shape industry and regulatory direction
As a National Health Ministry, TH PACE has multiple functions:
• Operator with direct ownership of PACE plans
• Manager of non-owned plans
• System level support to Trinity Health System PACE plans
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TH PACE Functions
TH PACE
Operator ManagerSystem Support
Mercy LIFE of AlabamaMercy LIFE – West Philadelphia
Saint Joseph PACE
Future OpportunityTrinity System PACE
Organizations
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
@ JadeGongRN 19
•Expansion into Albany CountyEddy SeniorCare – New
York
•Expansion into Burlington CountyLIFE at Lourdes – New
Jersey
•Expansion into mid Bucks CountyLIFE St Marys –Pennsylvania
•Replacement Center in Bordentown
•Expansion into Middlesex County
LIFE St Francis – New Jersey
•Expansion into Montgomery CountyMercy LIFE SEPA –
Pennsylvania
•New center in existing service area St Francis LIFE – Delaware
•Existing center expansion
•Expansion into additional countiesLIFECircles – Michigan
New Growth Opportunities: Partnership with Religious Organizations New York, Pennsylvania and Indiana
Growing PACE While Navigating Competition
National PACE Association Annual Meeting
October 24, 2016
Jade Gong and Associates
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• LIFECircles, a partnership between Porter Hills, Mercy Health (Trinity Health), and Senior Resources
• Based on success of LIFECircles, an innovative model TANDEM 365 was developed and included collaboration between four CCRCs and an ambulance company help older adults with complex health needs navigate the complicated health care system
• Provided services not typically reimbursed by insurance companies and working directly with individual primary care providers, team members develop a comprehensive care plan for individuals age 55 and over who don’t necessarily qualify for nursing home care
• The PACE Innovation Act provides an opportunity for using the PACE Model of Care and lessons learned from TANDEM365 as a foundation to create a MediCaring Community which is aimed at meeting the needs of at-risk, Medicare-only beneficiaries