Chronic Care Management Critical Access Hospital Administrator's
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National Rural Health Resource Center 2019 Delta Regional Community Health Systems Development Summit LANCE W. KEILERS, MBA, CAPPM SEPTEMBER 24-25 2019 Why are We Here? Physicians and health care providers continue to improve quality of care, lower costs Affordable Care Act Accountable Care Organization initiatives put patients at the center of their care while generating more than $1.29 billion in total Medicare savings since 2012 The Centers for Medicare & Medicaid Services (CMS) today announced the 2015 performance year results for the Medicare Shared Savings Program and the Pioneer Accountable Care Organization Model that show physicians, hospitals, and health care providers participating in Accountable Care Organizations continue to make significant improvements in the quality of care for Medicare beneficiaries, while achieving cost savings. Collectively, Medicare Accountable Care Organizations have generated more than $1.29 billion in total Medicare savings since 2012. *https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-08-25.html My Hometown (Where I grew up!) Ozona, Texas Population 3,000 Volunteer Fire Department and EMS Local Fire Station Ozona, Texas Medicare Spend 2/3 of Medicare spending is for people with 5 or more chronic conditions* *Used with permission, Deborah Whitley, CPA • Three percent of Medicare expenditures involve individuals with one or less chronic conditions. • Ninety-seven percent of Medicare expenditures involve individuals with two or more chronic conditions. Medicare Benefits* Used with permission, Deborah Whitley, CPA Technology WILL drive everything! So What Should We Be Monitoring? Let’s Look at a Case Study Hospital Clinical and Financial Metrics Case Study Sample Hospital Overall Case Mix Index (CMI) - Medicare Only: 1.0254 Medical Case Mix Index (CMI) - Medicare Only: 1.0248 Surgical Case Mix Index (CMI) - Medicare Only: 1.2666 Overall CC/MCC Rate: 36.2 % Average Length of Stay: 3.5 days Bed Utilization Rate: 42.4 % Average Daily Census: 10.6 Total Acute Days: 3,867 Medicare Advantage Days: 73 Adjusted Patient Days: 10,929 # of Discharges: 433 Clinical and Financial Metrics (cont.) Case Study Sample Hospital # of Discharges: 433 # of Medicare Discharges: 327 # of Medicaid Discharges: 4 Est. # of Outpatient Visits: 6,407 # of Denied Inpatient Medicare Claims: 1 Denied Inpatient Medicare Charges: $36,946 Pct. Medicare Inpatient Claims Denied: 0.2 % Clinical and Financial Metrics (final) Case Study Sample Hospital # of Denied Outpatient Medicare Claims: 102 Denied Outpatient Medicare Charges: $83,732 Pct. Medicare Outpatient Claims Denied: 1.9 % Est # of ER Visits: 7,350 Pct. Medicare ER Visits Admitted: 0.3 % Est # of Inpatient Surgeries: 2 Est # of Outpatient Surgeries: 33 Est # of Total Surgeries: 35 Top Referring Physicians/Providers Case Study Sample Hospital RANK PHYSICIAN PRIMARY SPECIALTY 1. Thomas Darter Family Practice 2. Richard Caldwell Family Practice 3. Kimberly Nelson Family Practice 4. Dustin Pratt Family Practice 5. Weldon Green Family Practice Top Hospitals By Revenue Leakage (Medicare) Case Study Sample Hospital HOSPITAL NAME $ REVENUE LEAKED Northwest Texas Healthcare System $1,319,429 BSA Hospital $1,140,793 Covenant Medical Center $522,491 United Regional Health Care System $450,987 Vibra Hospital of Amarillo $427,517 Total Leakage: $3,861,217 Why Does Leakage Matter? You have to be able to identify “leakage” by DRG to analyze patients that are leaving your market AND Determine if you are losing patients you should be keeping REMEMBER THAT WAS ONLY MEDICARE DOLLARS……….. What if they could have “kept” 2%?? = $77,224.34 Patient Origination (Medicare) Case Study Sample Hospital ZIP CODE CITY % OF TOTAL CASES 79201 Childress, TX 7.6 % 79245 Memphis, TX 1.8 % 79248 Paducah, TX 1.8 % 79252 Quanah, TX 1.2 % 79095 Wellington, TX 0.5 % ❑ Why does this matter? You have to understand your patient origin to maintain and grow your market. Top Drug Classes Prescribed (All Payors) Case Study Sample Hospital RANK DRUG CLASS 1. Serotonin Uptake Inhibitors [MoA] 2. beta-Adrenergic Blocker [EPC] 3 Increased Diuresis [PE] 4. Angiotensin Converting Enzyme Inhibitors [MoA] 5. Angiotensin Converting Enzyme Inhibitor [EPC] ❑ Why does this matter? Prescribed Medication by your Providers Drive Healthcare Cost in your “Population”! Cost per Discharge - Medicare Only Case Study Sample Hospital Case-Mix Adjusted Cost Per Discharge: $4,053 State-Average Case-Mix Adjusted Cost Per Discharge: $7,018 Case-Mix and Wage Adjusted Cost Per Discharge: $4,941 State-Average Case-Mix and Wage Adjusted Cost Per Discharge: $8,173 Financial Strength Case Study Sample Hospital Metric Performance Percentile Net Patient Revenue $28,410,591 11 Net Patient Revenue Growth (1 year) 8.2 % 75 Net Operating Profit Margin -2.3 % 44 Days Sales Outstanding 46.2 56 Current Ratio 4.2 85 Clinical Quality Strength Case Study Sample Hospital Metric Performance Percentile Readmission Reduction Adjustment Penalty Score -0.08 % 75 Total Hospital-Acquired Condition (HAC) Score -0.127 58 Medicare Value-Based Purchasing Total Performance Score 52.0 88 All Cause Hospital-Wide Readmission Rate 14.6 % 86 Serious Complication Rate 0.97 50 HCAHPS Summary Star Rating Network Strength Case Study Sample Hospital Metric Performance Percentile Optimization Across Care Continuum Not Optimized Inpatient Market Share 18.9 % 11 Outpatient Market Share 41.7 % 48 Number of Hospitals in Network Information Not Available Common Therapy Areas Case Study Sample Hospital Metric Inpatient Revenue Percentile Congestive Heart Failure $358,131 8 Diabetes $484,896 12 Digestive Disorders Pneumonia and Respiratory $359,125 8 Sepsis $206,569 7 Urinary Tract Infections $61,007 1 Claims-Based Payor Analysis Case Study Sample Hospital PAYOR CLAIMS % OF TOTAL CLAIMS UnitedHealthcare (AKA UnitedHealth Group) 907 31.5 % Amerigroup 354 12.3 % VA Health Care 185 6.4 % Aetna 131 4.6 % Cigna 119 4.1 % Payor Mix (Medicare Cost Report) Case Study Sample Hospital PAYOR NET PATIENT REVENUE % OF TOTAL NET PATIENT REVENUE Medicare $3,912,692 14 % Medicaid $2,186,535 8 % Private/Self Pay/Other $22,311,364 79 % Total $28,410,591 100 % Gundersen Health's $50K knee replacement list price is 5 times what it costs Written by Morgan Haefner | August 22, 2018 | In 2016, a La Crosse, Wis.-based Gundersen Health System hospital's average list price for knee replacement surgery was more than $50,000. After an 18-month review, Gundersen found the procedure actually cost a fifth of the list price — $10,550 at most, according to The Wall Street Journal. Here are highlights from the article: ➢ Time spent wheeling VCR carts, a lack of available post-surgery beds and delays in starting physical therapy were among the inefficiencies discovered in the report. ➢ The hospital cut its cement costs by 57 percent by opting for a generic version, which research indicates leads to the same results in most cases, according to WSJ. ➢ Gundersen implemented changes to its knee replacement surgery process after the review. The surgery now costs the hospital $8,700 on average, reflecting a savings of 18 percent. The future of rural healthcare….. Where Do We Go From Here?? 1. We have to acknowledge healthcare is changing 2. We have to learn to use the data we have 3. We have to focus on high quality care 4. We have to focus on growth. Final Thoughts As rural providers we must: ➢ Focus on financial performance AND clinical quality ➢Know our data (financially and clinically) ➢Engage our providers ➢Engage our communities ➢Find ways to keep patients locally ➢Find new service lines ➢Provider better care than our neighboring hospitals ➢NEVER FORGET THAT ARE HERE FOR OUR PATIENTS HOW DO WE WIN? Simple: 1. Realize that healthcare is a business ◦ Be operationally efficient and grow revenues 2. Provide better care than anyone else ◦ Use data to identify clinical opportunities and enhance patient experience in our organizations LANCE W. KEILERS, MBA, CAPPM PRESIDENT CONNECTED HEALTHCARE SOLUTIONS, LLC [email protected] WWW.CONNECTEDHCSOLUTIONS.COM (816)272-5300 (OFFICE) (325)212-2143 (CELL) Contact Information.