POST-ACUTE CARE

The Next Fron­tier

Modern Healthcare - - Mergers and Acquisitions -

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.

Eric Lloyd Pres­i­dent, Ne­vada and Colorado, An­them Blue Cross Blue Shield

Kris­ten Cu­sack Se­nior Vice Pres­i­dent of Strat­egy and In­no­va­tion, Adep­tus Health

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