POST-ACUTE CARE
The Next Frontier
A FOREWORD FROM BRUCE GREENSTEIN, EVP and Chief Strategy and Innovation Officer at LHC Group, and moderator of the Post-Acute Care: The Next Frontier focus group at Modern Healthcare’s 2018 Leadership Symposium on October 11, 2018:
My goal at LHC Group, having started recently, is to accelerate the shift in the way that we do business from fee-forservice to value-based mechanisms, offering new products and services that we haven’t envisioned before. When you’re in a business like healthcare, which is low-margin and often less nimble, doing something even a little bit different can be disruptive, but it can also be innovative.
Before joining LHC, I was Chief Technology Officer for the U.S. Department of Health and Human Services. While there, we created the Kidney Innovation Accelerator — called KidneyX, opened up thousands of data sets for entrepreneurs, researchers and innovators, and worked on efforts to create a less burdensome environment for providers and give patients more access to information so that they can become consumers, not just patients. That work continues at LHC. I hope you enjoy the following conversation between esteemed leaders who are shaping the future of our industry.
BRUCE GREENSTEIN: CONSIDERING YOUR HOSPITAL’S PRESENT AND FUTURE STRATEGIES, DO YOU SEE POST-ACUTE CARE AS A POTENTIAL AREA FOR COST SAVINGS, OR A COST DRIVER THAT'S BEEN HARD TO CHANGE?
Suja Mathew: My concern as a provider is to make sure that I can secure the highest quality services that are really going to prevent readmission into my inpatient space. And communication around that care continues to be a major challenge. That challenge continues decades after we’ve started an industry conversation about it, especially in an organization with multiple inpatient and outpatient touchpoints. Between primary, specialty and other areas, not everyone intersects during that inpatient hospitalization. So, there are real opportunities to improve that communication. When you add in post-acute services and home-care services, it’s yet another challenge to make sure post-acute providers are sharing in the responsibilities of caring for that patient, and that there are the appropriate communication lines set up. We have to ask ourselves whether those should be facilitated by social workers at the hospital, whether it should be case managers in our managed care organization, or whether it should be primary- or specialty-care physicians.
Eric Lloyd: As a payer, I think a lot of what Suja mentioned really resonates, because communication is key, especially when it comes to coordination with discharge planners. When you're talking about postacute care for high-cost hospitalization, we're always looking for the optimal setting for that member as well, in the most cost-effective space. So, we rely heavily on our post-acute relationships, whether that be a Skilled Nursing Facility (SNF), Long-Term Acute Care Hospital (LTCH) or rehabilitation center. When you talk about the Medicaid space especially, it’s especially about who will contract for a rate that's desirable for them to want to take on this business as well. That confluence
“Small markets are incubators of innovation, and that allows us then to come up with things that might be state-specific or even transferable to another market. ”
Eric Lloyd President, Nevada and Colorado, Anthem Blue Cross Blue Shield
of appropriateness of care, right time and right place is important. We don’t want to create an environment that's going to create recidivism back into the ER.
BG: DETERMINING THE APPROPRIATE CARE SETTING IS OBVIOUSLY IMPORTANT. BUT ON THE POST-ACUTE FRONT, THERE'S VERY LITTLE CARE MANAGEMENT — YOU CAN GO WHEREVER YOU WANT TO GO. IN MANY CASES, IT’S THE SAME COST — FREE — TO PATIENTS REGARDLESS OF SETTING, SO THEY OFTENTIMES CHOOSE THE MOST EXPENSIVE BENEFIT AVAILABLE WITHOUT COST-SHARING. BUT IF YOU'RE LEAVING HUGE COSTS ON THE TABLE BECAUSE YOU'RE CONTRACTING THE WAY THAT WE DID IN THE '90s, IS IT TIME TO COME UP WITH NEW MODELS, SUCH AS BUNDLES OR A RISK-BASED INHOME PROVIDER? IS THERE SOME WAY TO FIGURE OUT HOW TO PROVIDE MORE BENEFITS AND SAFER CARE THAN IN A SNF?
Kristen Cusack: Sometimes it's easy when you look at the numbers to say, these patients have the same set of needs, and they could go here or there, so they should go to the less-expensive setting. But, I don't know — it's never as easy as that. For example, though it can bring more risk, sometimes a SNF can be more accessible, more stable and provide better care for their needs. I think we ultimately have to look at timing and consider how needs should be addressed based on that, because we also know that at home, there can be low compliance. We also have to figure out how to centralize the information about the patient somewhere. It’s ridiculous how many black boxes we have of where their information lies, and we can't see it. If we don't figure out how to get that information out so that every provider can quickly access what has already been done, we’ll continue to unnecessarily repeat tests and we’ll miss information that has already been discovered.
EL: A lot of it is driven by a benefits structure based upon the state-provided benefit, certainly from a Medicaid standpoint. I think this really introduces an opportunity for entrepreneurialism — this is where true innovation can thrive. We are partnering with some very innovative companies that are going at risk on 30-day readmissions, and providing services related to social determinants to create a positive environment for the member to prevent recidivism.
BG: LET’S TALK ABOUT METHODOLOGY. HOW DO YOU INVITE ENTREPRENEURS AND COLLABORATE WITH THEM? HOW DO YOU CONTRACT? HOW DO YOU SHIFT FROM THE SLOW PACE OF THE HEALTHCARE SALES CYCLE TO SOMETHING THAT MAKES YOU AN AGILE LEADER, INSTEAD OF BECOMING A FOLLOWER?
EL: Individual markets require you to do things that are new and different. For us it has been a pivot to survive. I think part of the effort is finding the right partners that work with you, understand your vision, understand your needs and then create the tools that allow for quick contracting — whether it's at-risk or per member per month (PMPM). We're agnostic to whether it is at risk or not, but we must define what the metrics are so that we can define success.
KC: Is there an avenue to get to the payer and say, “I have an idea”? If I created a new device or service and want to try it out with a provider, right now it’s hard to do so and it may take over a year to come into use. At that point, it’s not actually a “new” innovation. Do you think there’s an avenue to expedite that?
EL: Instead of working at the corporate level and trying to shove it down to regional markets, I think we can make it work at the market level, where I’m at and where the innovation engine can start quicker. Small markets are incubators of innovation, and that allows us then to come up with things that might be state-specific or even transferable to another market. That entrepreneurial spirit is alive when you work through it at the market level, as opposed to the corporate level.
BG: INNOVATION SOMETIMES WEARS PEOPLE DOWN. AS A LEADER OF PHYSICIANS, I OFTEN HEAR ABOUT INNOVATION FATIGUE. AS RECIPIENTS OF INNOVATION, CAN YOU TALK ABOUT WHAT GETS YOU EXCITED AND LOOKS PROMISING, AS WELL AS THINGS THAT AREN’T EFFECTIVE?
SM: At CCHHS, I would say we are not on the receiving side. We’re both the provider and the payer, so innovation often originates with us. We identify what our need is and then seek out partners. It sounds like in this discussion, new technology is pitched to the payer, but that really has not been our experience. Rather it's been us as a provider saying, "We need help and who can we find to help us?" For example, we’ve found partners to address social determinants like food insecurity and access to reliable transportation.
EL: Outpatient services are huge for us right now and that's why we’re bringing in new innovations. I think the idea of managed care has traditionally been holistic care, but what does that mean? Well, now it's many of the things that we've been discussing here. We believe we
“What we need to do is create more effective communication channels, so that all of us who are engaged in patient care — people's care and community care — know one another and what we're doing and keep our eye on the patient in the center of that.”
Suja Mathews, MD Chair of Medicine, Cook County Health and Hospitals System
must look at a member from a social aspect before we can look at their physical health, behavioral health and other needs. By offering transportation, food options, housing support and vocational help, we’ve started to get into the business now that's even beyond healthcare and it's become more like social care. That’s where I think healthcare must shift.
KC: On the provider side, I think the reason you're seeing that is because you often have to think, "Okay, what can I get paid to do?" You have to run the business. I think that's why you're seeing so much vertical integration because when you’re both the payer and provider, it’s easier to do things like addressing social determinants. You don’t have to deal with a multitude of payers and Medicare, which is never going to catch up fast enough.
BG: IT’S THE REVENUE CYCLE — THE FINGER ON THE OTHER SIDE OF THE SCALE. THERE IS A MYRIAD OF NEW APPROACHES THAT WE MIGHT USE THAT WOULD SAVE MONEY, BUT IF THERE'S NOT A WAY TO PAY FOR IT, THEN WE NEVER GET ACCESS TO IT.
LET’S TALK ABOUT 2019. WHAT'S THE BIGGEST CHALLENGE YOU’RE TRYING TO ADDRESS? WHAT’S THE NEXT BIG THING?
KC: I really want to be looking at how the patient goes through the system. They often come to the hospital through the ER, and I don't think that's necessarily the right way, and that's why I do think that some sort of centralization makes sense — someone needs to find a way to pull the information together. That's happening out there in some organizations — there is a way to do it. I think that’s going to be key because it may be that the ER is the best place for someone to start in certain cases, and it may be that staying at home is possible if we have the right information about the patient before they come to us.
SM: What we need to do is create more effective communication channels, so that all of us who are engaged in patient care — peoples’ care and community care — know one another and what we're doing and keep our eye on the patient in the center of that. And I think we need to be increasingly open and inclusive about what we consider important aspects of an individual or community's health.
EL: I think for me it's understanding the community that you live in. The firms that are going to be successful are the ones that can disrupt the models that in the past have typically been the only ones that we know of. Successful disruptors will be able to effectively look at data and pivot quickly on it to create an environment that is conducive to communities that are in need of that service. That's how I see the future of health care — it’s not going to be driven so much by episodic care or large systems coming down on a certain population. It's going to be community-driven, steered by the data needs for that group of individuals.