The Afforable Care Act gets a checkup

Wayne Smith is President and CEO of the Delaware Health Association, a statewide trade and membership services organization that represents hospitals and health systems in providing cost-effective, quality care. // Photo by Brian Harvath
Wayne Smith is President and CEO of the Delaware Health Association, a statewide trade and membership services organization that represents hospitals and health systems in providing cost-effective, quality care. // Photo by Brian Harvath

by Christi Milligan

When Delaware hospital officials looked at the sweeping changes in delivery and pay models demanded by the Affordable Care Act, they wanted a seat at the table.

“We did not want it to unfold from edicts from the bowels of bureaucracy,” said Wayne Smith, president of the Delaware Healthcare Association, who joined with health-care reps from across the spectrum to weigh in on the State Innovation Model that sought to put the ACA mandates into practice.

“If we were going to put our money at risk we wanted to make sure we had the chance to deal some of the cards.”

Nearly six years into the Affordable Care Act, officials say patients are benefitting from a streamlined coordination of care and a host of follow-up initiatives to thwart dreaded readmissions.

They’re also well on top of the mammoth task of building an infrastructure for care management, and shifting the fee for service to a pay-for-value system advanced by Accountable Care Organizations and bundled payments.

In Delaware, the number of uninsured dropped from 10.5 percent in 2013 to 9.9 percent in 2015, according the most recent Gallup poll. Delaware also expanded Medicaid under the ACA, with 12,451 gaining Medicaid or CHIP coverage since the beginning of the Health Insurance marketplace first open enrollment period.

“The fact is that access has been improved for people who did not always enjoy easy access,” said Smith.

It also produced a 7 percent jump in emergency room visits since 2010, an unintended consequence for supporters of the ACA, according to Smith, who touted a decrease in indigent care as a major underpinning of the health-care overhaul.

But while increased ER visits may have been a paradoxical result of the ACA, officials say the focus on coordinated, streamlined care has been very intentional and is generating results both within the ACA mandate and in the community they serve  — just as they had hoped.

Overseeing delivery

“This is a sea change for all health-care providers, but many hospitals, including those in Delaware have anticipated it,” said Julane Miller-Armbrister, executive director of the Delaware Center for Health Innovation (DCHI).

The nonprofit is basecamp for implementation of the state’s Healthcare Innovation Plan operating with a $130 million budget and a $35 million grant from the Center for Medicare & Medicaid Innovation (CMMI).

Its charge is to manage the plan designed to achieve the federal “Triple Aim” of improving population health, improving health care, and reducing costs through a system of delivery models.

“There is a rapid change in the landscape and DCHI is facilitating a plan that brings stakeholders around to table to drive consensus on what change should look like,” said Miller-Armbrister. “It’s driving everybody toward the same goal at the same time but in a new way.”

Managing their population

It’s a familiar scenario: a patient with a chronic illness gets discharged only to find himself with a handful of prescriptions he can’t afford or discharge instructions he doesn’t understand.

Years ago, he also stood a good chance of being readmitted.

In January, Christiana Care Health System launched Care Link as the technical platform for Christiana Care Quality Partner — an Accountable Care Organization —that connects a network of medical specialists who focus on Medicare’s populations with clinical and financial risks.

As part of the Medicare Shared Savings program, ACOs are rewarded if they lower their growth in health-care costs while meeting performance standards.

Longitudinally following patients with chronic diseases is the key to decreasing readmissions, according to Sharon Anderson, senior vice president for quality, patient safety and population health management at Christiana Care.

Focusing their efforts on “bundle populations” like pulmonary or joint replacement patients, specialists track them from discharge to their transition home, assisting with everything from prescriptions to living conditions.

It’s a multi-disciplinary team that includes nurse care coordinators, social workers, respiratory therapists and physicians who work in a virtual hub with electronic feeds from the Delaware Health and Information Network to manage the program, according to Anderson.

“It gives us real time clinical information about where the patient is — are they in the hospital or emergency department? — if they’ve had lab work, radiology reports,” said Anderson.  “We’re addressing a full gamut of issues that impact health, it’s a totally different model for us coming from an acute care hospital.”

In its first eight months, the Care Link team served more than 1,040 Medicare joint replacement and cervical spine patients. Patients discharged to the community (home or home health services) increased by 9 percent for the three populations combined and discharges to skilled nursing facilities decreased by 7.5 percent.

In addition to increasing patient satisfaction, these results reduced Medicare expenditures in the 90-day post-discharge period. Thirty-day and 90-day readmission rates decreased by about 26 percent overall, said officials.

Internal financial analyses show savings of $850,000 for joint replacement and cervical spine procedures in the first six months, officials said.
The successful methodology was expanded to four more bundle populations in 2015: lumbar spine and coronary artery bypass surgery in July, and heart failure and stroke in September.

Incentives

“Because there are financial penalties for missing readmission targets, there is a greater incentive,” said Smith of the ACA’s readmissions reduction program. “Providers are investing in things like personnel investing with people at discharge, checking in with them via phone; working closely to make sure they follow discharge instructions.”

An outlier when it comes to the ACA mandates applicable to other hospitals, Nemours/Alfred I duPont Hospital for Children is nonetheless seeing similar trends thanks the ACA, like an uptick in ER admissions, according to president Paul Kempinski.

As the only children’s hospital for the state of Delaware and a regional referral for tertiary and quaternary referrals, Kempinski said the philosophy has always been to keep care local.

That means that while hospital had seen an increase in acuity and complexity of the cases they see, satellite sites are handling a significant number of general care cases, thanks in part to a delivery system that relies on the primary care physician as the organizer and navigator of Nemours services.

Volume to value

But Kempinski said that hospital organizations and health-care systems as a whole are experiencing the beginning of a momentous change, as they move from fee for service to value-based reimbursements.

“For example, as reimbursement changes we will be involved in more risk-based reimbursement relationship with payers in Delaware and outside the state,” said Kempinski. “The criteria we’re paid for will be based on quality outcomes, our safety record.  And in turn, we’ll need to reduce the overarching cost of care.”

That’s the plan, according to ACA parameters. By lowering payment rate increases in Medicare, hospitals and healthcare providers, by design, must become more efficient.

“Hospitals will get paid less for the care they provide but the expectations for quality care will always be there and will grow,” said Kempinski. “We have to look at ways of managing the cost of care in ways that will not jeopardize care of the child.”

According to Miller-Armbrister, “We’re working with the payers as well.  One of our goals is to drive outcome based models across the state so at least 80 percent of the state’s population is taken care of with value-based payments and service delivery models.”

“We know there’s going to be a decline in Medicare reimbursements,” said Arek  Tatevossian, senior vice president of strategic planning at St. Francis Healthcare, also a participant in an ACO as part of a Medicare Share Savings Program. “We know the outlook is going to be reimbursement from all sources. But it’s a learning process, a new way of operating.”

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