Two large Philadelphia-area health systems with a joint venture ACO developed a collaborative post-acute care (PAC) strategy that led to a series of quality improvements, including an 83 percent reduction in readmission penalties.
The Hospital and Healthsystem Association of Pennsylvania (HAP) recently gave its “Living the Vision Award” to Jefferson Healthcare and Main Line Health. The award recognizes a project that demonstrated accomplishments in all dimensions of the Triple Aim of improving community health and patient experience, while reducing healthcare costs.
A writeup from the ACO and shared by HAP about the project provides a wealth of details. It starts by stating the problem: Post-acute care (PAC) providers are highly variable in cost and quality and are the single most variable component of Medicare spending in our country. Historically there have been few controls or processes addressing appropriate utilization or distribution of use of post-acute services in fee-for-service Medicare. Fourteen Hospitals between Jefferson and Main Line Health are at risk for penalties due to readmissions.
All the hospitals in the two health systems are participating in Bundled Payment Care Initiatives – Advanced (BPCI-A). Both the health systems and the ACO have other value-based commercial contracts in addition to Medicare Shared Savings Program (MSSP) contracts. All these programs require trusted PAC partners to manage hospital and ACO patients in an optimal manner to achieve success. It was determined that creating one collaborative PAC strategy though the joint venture ACO that was applicable and adaptable to all these existing value-based programs and those that will be created in the future is a critical factor to the success of all three organizations.
PAC Steering Committee
The joint venture ACO chartered a PAC Steering Committee whose purpose is to address post-acute network requirements and establish a preferred network and evaluate its performance. The committee also promotes effective methods of sharing best practices among all members and post-acute service providers. A high priority is placed on transitions of care, appropriate utilization of post-acute services, and standardization of reporting for the purpose of evaluating post-acute providers.
The ACO used Web-based, real-time automation and evidence-based clinical guideline tools to facilitate the creation of an efficient, top of license, by exception approach to care coordination in the PAC space.
The ACO also did a Medicare claims analysis, which was then leveraged with publicly reported outcomes data to measure the variability in spend and outcomes by PAC providers in the Skilled Nursing Facility (SNF), Home Health (HH), Hospice, and Outpatient Rehabilitation Therapy (ORT) space.
The committee developed a Preferred Partnership Networks with SNF, HH, Hospice, and ORT organizations. The Preferred SNF Network has narrowed to 35 SNFs from 76, aligned by hospital campuses with a shift away from ACO-led meetings to hospital campus-led meetings.
A Preferred Home Health Network was first established in 2017 and started out with six partners. There were two tiers based on outcomes and cost. Because of robust publicly reported outcomes for home health, the decision was made not to include an application process. After two years, the tier two partners were unable to improve their cost outcomes to match that of tier one. The Post-Acute Steering Committee decided to eliminate the tiered approach and narrowed to four providers.
A Preferred Hospice Network was first established in 2019, modeled after the Preferred Home Health process and currently consists of four providers based on cost, quality and geographic coverage.
In January 2020, the ACO created a Preferred Outpatient Therapy Network in response to a more than 60 percent increase in spend in this area since 2014, and the recent payment reforms in SNF and home health reimbursement. The PAC Steering Committee decided on four providers that focus on the frail elderly population who receive care in their homes.
Using this approach, ACO MSSP claims data received throughout 2019 demonstrated a $13 million reduction in combined SNF, HH, and Hospice spend in calendar year 2018 with a quality score of 88/100. Health system 1 achieved a 17 percent decrease in spend for the first nine months participating in BPCI-A2 . Health system 2 achieved a 13 percent decrease in SNF cost per BPCI-A episode for their first nine months. By federal fiscal year 2019 health system 2 achieved an 83 percent decrease in readmission penalties.
The ACO noted that its reduction in spend for HH and Hospice has continued in 2019, but it has seen an increase in SNF spend due to increased utilization of SNF. It is working with hospital inpatient care management, physician, and rehabilitation partners to address this increase in utilization. They developed a patient mobility program using the evidence-based Activity Measure for Post Acute Care (AM-PAC) to provide objective decision support criteria for discharge disposition.
Summing it up, the ACO said that “as hospitals and health systems transition further into value-based care where their revenue will be increasingly dependent upon care that happens outside of the hospital walls, having a data-driven, comprehensive post-acute care strategy will be a critical factor of success.”