Mobile Integrated Healthcare: The Payer’s Perspective

Some of the most common questions in the development of a Mobile Integrated Healthcare (MIH) strategy relate to financial sustainability. Yes, it is the right thing to do for the patients and it’s necessary to meet the Institute for Healthcare Improvement’s Triple Aim (improved patient outcomes, improved population health and reduced cost of care), but without a sustainable economic model the programs are difficult to sustain.

 

Thankfully, innovative economic models are flourishing. This comes as a result of healthcare financing changes within the Affordable Care Act (ACA) that seek to align incentives to help make the entire healthcare delivery system more financially sustainable. We are also seeing implementation of some long-standing, but stagnant finance reforms.

 

Some of the more recognized finance changes–such as bundled payments, risk-sharing arrangements, enhanced managed Medicare and Medicaid programs and, of course, Accountable Care Organizations (ACO)–are ways the ACA is transforming our healthcare delivery models. However, programs such as 1115 Medicaid waivers, managed Medicare and Medicaid, and traditional fee-for-service models are rapidly recognizing MIH provides a valuable service in which they should be investing.

 

This is the first of four columns that will focus on the financing and economic models for MIH services that hospitals, Medicare and Medicaid, commercial insurers, integrated delivery systems, ACOs, hospice agencies and even home health agencies are funding and, more importantly, why they are funding them.

 

The question for this first article: What is motivating hospitals today to work with other agencies to actually reduce the inappropriate use of their in-patient facilities?

 

Value-based purchasing

 

One of the efforts to improve quality and reduce healthcare costs in the ACA is an initiative called value-based purchasing (VBP). Under VBP, hospitals are eligible for bonuses or penalties of up to 1.25% of their total Medicare payment based on quality metrics in 2014. That percentage will increase over the next three years to 2%. It’s worth emphasizing that this bonus or penalty is applied to all Medicare payments a hospital receives, not just payment for admissions on which they did not score well. By way of example, for a hospital with annual Medicare payments of $500 million, a 0.5% VBP penalty can amount to $2.5 million. VBP process metrics and clinical guidelines include considerations such as:

 

“¢ Percent of heart attack patients given medication to avert blood clots within 30 minutes of arrival at the hospital

 

“¢ Percent of heart attack patients given percutaneous coronary interventions within 90 minutes of arrival

 

“¢ Percent of heart failure patients given instructions upon discharge about how to take care of themselves

 

 

The second domain of evaluation is the much talked about patient satisfaction measures.1 These are measures such as:

 

“¢ How well nurses communicated with patients

 

“¢ How well doctors communicated with patients

 

“¢ How clean and quiet the hospital room and hall were

 

The patient’s experience of care comprises 30% of the total VBP calculation. Consequently, hospitals pay very close attention to the patient’s perception of the hospital both during inpatient care and post-discharge (see article in February JEMS2 ). This has increased the hospital’s focus on the patient’s transition from the hospital to the home environment, not only to help reduce preventable readmissions, but to enhance the patient’s perception of the hospital’s concern about the patient post-discharge.

 

The third area evaluated for VBP is mortality rates among Medicare patients admitted for heart attack, heart failure or pneumonia.

 

Hospitals could also be interested in programs that reduce ED visits for low-acuity patients. These patients often have long wait times in the ED, resulting in an unfavorable experience of care. When those patients receive patient satisfaction surveys, there is potential that the rating will be low, thereby impacting the 30% patient experience score. Further, decongesting the ED may have a positive impact on the experience for other ED patients through potentially reduced wait times, thereby possibly improving satisfaction scores. In the MedStar system, all four hospital systems are jointly funding the 9-1-1 nurse triage system to help navigate low-acuity callers to safe alternative care sources for exactly that reason.

 

EMS-MIH Opportunity: Hospitals may be willing to invest in EMS-based safe transition programs to enhance patient perceptions about the transition.

 

Readmissions

 

Another quality measure being applied to hospitals is the 30-day readmission rate for three specific diagnosis-related groups (DRGs): congestive heart failure, myocardial infarction and pneumonia. The reason these three were selected is the cost to Medicare for these conditions, as well as the tendency for these DRGs to have high readmission rates. In October 2014, COPD and hip and knee replacements will be added to the list of DRGs. Hospitals are eligible for bonuses or penalties up to 2% of their total Medicare payments based on their 30-day readmission rate. The readmission criteria is currently an “all cause readmission,” meaning that if a CHF patient who is discharged from the hospital readmits for a fall two weeks later, that counts as a readmission.

 

Two-thirds of the nation’s hospitals are being assessed a readmission penalty.3 For some, the fnancial incentive to reduce high readmission penalties may outweigh the actual payments they receive for the admission. A recent article in Modern Healthcare reported that Michigan-based Henry Ford Health System’s system-wide fnancial penalty for preventable readmissions was estimated at $2.2 million in 2013, and $4.3 million in 2014.4 The financial incentives for hospitals to reduce readmission penalties may lead them to be receptive to EMS-based MIH programs to reduce potentially preventable readmissions. This is likely the reason that the Henry Ford Health System is actively working with, and paying for, its ambulance provider Medstar Ambulance’s program to reduce preventable readmissions.

 

EMS-MIH Opportunity: Hospitals may be willing to invest in EMS-based CHF readmission prevention programs. Examples of such funded programs are MedEx Ambulance and the University of Chicago Medical Center; Christian Hospital EMS in St. Louis and the Christian Hospital System; Green Bay Fire Department and the Bellin Health System; and East Baton Rouge EMS and Lane Regional Health System.

 

Public reporting

 

In addition to the fnancial incentives, hospital readmission rates and patient experience ratings are now published by Centers for Medicare & Medicaid Services (CMS) on their Hospital Compare website (www.medicare.gov/hospitalcompare). Hospital administrators working with MedStar have indicated the public reporting of patient satisfaction and subsequent perception of poor clinical care due to high readmission rates is even more of an incentive to improve satisfaction ratings and reduce readmissions than the current financial incentives.

 

Medicare spending per beneficiary

 

Looming on the horizon for hospitals in 2015 is a new measure to which CMS will hold hospitals accountable: Medicare spending per beneficiary. 5 This measure will be part of the VBP bonus or penalty and will be based on the amount of money Medicare spends for a patient’s care–preadmission, during admission and post-discharge. This may change the economic incentive for hospitals to discharge patients to high-cost services such as long-term acute care (LTAC), skilled nursing facilities (SNF) or even home health. It may also lead them to look to EMS for programs to reduce length of stay for inpatient care.

 

 

EMS-MIH Opportunity: Hospitals are looking for more cost-effective post-acute care, not only to reduce readmissions, but also to reduce the overall Medicare spending per beneficiary in the post-acute setting.

 

Shared risk

 

More hospitals are becoming part of risk-sharing arrangements with payers. The most talked about model is an ACO. In an ACO, the hospital shares in the potential savings in caring for a defined population of patients. In other words, they gain an economic advantage if the cost of caring for the patients in the defined population is less than anticipated. As such, it’s possible that the hospitalization of a patient in this type of program could actually cost them money.

 

Perhaps it’s for this reason that the Presbyterian Health System, an innovative integrated delivery system in Albuquerque, N.M., launched its “hospital in the home” project. In this program, patients are “admitted” to the hospital, but the care is provided in the patient’s home. Hospital beds, IV pumps, cardiac monitors and all equipment and supplies needed to care for the patient are brought to the home. Doctors and nurses “round” on the patient several times a day, or are continuously at the bedside. Their experience was that the patients had shorter length of stays and higher satisfaction scores with this arrangement. And, the cost of providing the care was reduced.

 

Another example of a funded program to reduce unnecessary ED visits is the program Mesa Fire Department and Mountain Vista Medical Center are conducting in Mesa, Ariz. Mountain Vista provides a nurse practitioner and Mesa Fire provides a paramedic captain in a transitional response vehicle. This unit responds to low-acuity calls in the system to assess, treat and navigate patients

 

UNLAWFUL TO COPY WITHOUT THE EXPRESS PERMISSION OF THE to the most appropriate care setting, thereby preventing an unnecessary ED visit. And, as an added bonus, since services provided by a nurse practitioner are a health benefit under Medicare and most commercial insurance programs, Mountain Vista bills for the services provided by their nurse practitioner.

 

EMS MIH Opportunity: Hospitals are looking for clinically safe, cost-efficient systems to navigate patients to the most appropriate care. This is a perfect fit for an integrated healthcare delivery model that navigates patients to the most appropriate setting for their care or, even better, prevents the need for acute care services.

 

Summary

 

There are numerous reasons why hospitals across the U.S. are funding MIH services. The key to success is in an effective relationship built upon collaboration to meet a defined need for the community and the patient, while simultaneously enhancing the economic model for the hospital as a payer.

 

Become part of the solution!

 

REFERENCES

 

1. Rau J. (Nov. 14, 2013) Methodology: how value based purchasing payments are calculated. Kaiser Health News. Retrieved on April 2, 2014, from www.kaiserhealthnews.org/stories/2013/november/14/value-based-purchasingmedicare-methodology.aspx.

 

2. Hooten D, Zavadsky M. Patient experience revolution. JEMS. 2014;39(2):54—59.

 

3. Rau J. (August 2, 2013) Armed with bigger fines, Medicare to punish 2,225 hospitals for excess readmissions. Kaiser Health News. Retrieved on April 2, 2014, from www.kaiserhealthnews.org/Stories/2013/August/02/readmission-penalties-medicare-hospitalsyear-two.aspx.

 

4. Greene J. (Dec. 10, 2012) Hospitals face reimbursement penalties over readmission rates. Modern Healthcare. Retrieved on April 2, 2014, from www.modern-healthcare.com/article/20121210/INFO/312109979.

 

5. QualityNet (n.d.) Medicare spending per beneficiary measure overview. Retrieved on April 2, 2014, from www.qualitynet.org/dcs/ContentServer?c= Page&pagename=QnetPublic%2FPag e%2FQnetTier3&cid=1228772053996.

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