THE WILLIE SUTTON EFFECT IN HEALTH CARE: INDEPENDENCE AT HOME QUALIFYING CRITERIA

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1 THE WILLIE SUTTON EFFECT IN HEALTH CARE: INDEPENDENCE AT HOME QUALIFYING CRITERIA 49% 25% $ Bruce Kinosian Peter Boling George Taler Dan Gilden for the Independence at Home Learning Collaborative

2 IAH Learning Collaborative No Relevant Financial Disclosures

3 The Independence at Home Demonstration is a 20-year, Overnight Promising Innovation CMS IAH Demonstration, a provider-managed care model, is a test of whether mobile, interdisciplinary teams caring for high risk, high cost elders can lead to better care and smarter spending. The Demonstration is in it s 4 th year, operating under a 10,000 beneficiary cap that it reached in Year 2 with 15/17 practices still participating CMS reported Year 1 savings of $25 M, or over $3,000 per beneficiary All practices met the quality threshold and 4 met all 6 quality measures LESSONS: Home-Based Primary Care is an effective approach for high-quality elder care. Simple eligibility criteria can identify a high-risk, high cost population, using readily available information.

4 The Promise of the Independence at Home Demonstration rests on 3 Pillars: HBPC, Aligned Incentives, and Targeting HBPC TARGETING Aligned Incentives Intervention: Home based primary care using mobile interdisciplinary teams, meeting patients where they are, fostering trust between patients and providers Payment Model: Aligns incentives, using Shared Savings with Discipline, covering all A&B spending tied to Quality Metrics and minimum performance (5% savings), with suspension for nonperformance Targeting Criteria: IAH-Qualifying criteria identify a subset of the FFS population with high cost and high mortality

5 Independence at Home Qualifying Criteria: Two or more chronic conditions Need for assistance with two or more functional dependencies Non-elective hospital admission within the last 12 months Received acute or sub-acute rehabilitation services in the last 12 months in SNF, IRT, or Home Health IAH-Q Criteria identify a high-cost group where hbpc can be effective at directing smarter spending IAH-Q criteria allow identification of IAH eligibles in claims data as the post acute care criterion requires an MDS, OASIS or FIM to assess function- so as to accurately calibrate risk adjustment to sustainably calculate savings

6 Questions: How many Medicare FFS beneficiaries meet IAH qualifying (IAH-Q) criteria? How well do IAH-Q criteria identify a high risk, high cost group? How do IAH-Q beneficiaries compare to other high risk, high cost groups?

7 Methods CY 2012 IAH Qualified Beneficiaries Source: Medicare 5% Sample CY 2012: A+B FFS at IAH-Qualification date (Index) Prevalent: January 2012 IAH-Q includes new in January and population qualified during 2011 Incident: First IAH-Q month is after January 2012 Mortality: Died in 2012 Long Term Institutional entry: LTI in last eligible month of 2012 HMO entry: HMO in January 2013 Recovery: Transition to low frailty by end of 2012, no death, no HMO and not LTI in December 2012 CY 2013 Prevalent: Survives to CY 2013 in Community and FFS A-B

8 Targeting: IAH Qualifications History of acute and post acute-care in last 12 months Inpatient acute, SNF, HH or Rehab claims. Presence of chronic diseases Presence of 2 or more major chronic conditions impacting functional risk from the 17 in the Chronic Condition Warehouse (IAH demo conditions) High level of impairment (frailty) in month of qualification Simulated using a monthly JFI score of 6+, denoting high risk for LTSS need JFI 6+ has a ROC area of.81 for 2+ ADL dependencies, with Likelihood Ratios of 7.4 (JFI= 6-7) and 20 (JFI= 8+)

9 Results Independence at Home Qualified are 2.2 million frail elders who are costly, with high rates of institutionalization and death Incident 1,038,080 Prevalent 1,223,780 1,679,840 Cost/month $3,835 $2, % 80% 83% 60% 40% 20% 15% 12% 28% 0% Mortality Long Term NH Hospitalization Readmission

10 Independence at Home Qualified have 4-7X per capita Costs and Service Use 43% are among the 5% most expensive in 2012 IAH-Q 6.4% Population Total A&B Spending 29% Readmissions- 46% IAH-Q 5% Duals 5% Duals LTI- 38% Mortality-23% Hospitalizations-24%

11 Comparing Prevalent cohorts: Independence at Home Qualifying Criteria identify as larger a share of Avoidable Cost and Events as top 5% or Dual status Duals, without those IAH-Q, are no more costly than their share of the population. % of Prevalent Population Events 30% 25% 20% 15% 10% 5% 0% IAH-Q Top 5% Duals Share of Events or Cost per Population Share IAH-Q Top 5% Duals Duals w/o IAH Source: Medicare Beneficiary 5% files

12 Finding Risk is Good, but Mitigating Risk is better.. Year 1 IAH Demonstration Results $25 M Total Savings 35% 30% 25% 20% 15% 10% 5% 0% -5% -10% -15% % Cost Reduction Matched Controls $11.7M awarded in Shared Savings CMS retained 54% of savings Top savings rate was 32%; Savings among the 9/17 who received shared savings averaged $9,116 per beneficiary per year (pbpy) Savings among the 12 programs that met benchmark averaged $7400 pbpy.

13 Conclusions Independence at Home qualifying criteria efficiently identify a high risk, high cost group of frail elders. Independence at Home appears to be a promising intervention to mitigate high risk and cost in this group. Other interventions that use Geriatric principles of teamdriven, patient-centered care should be tested in the IAHqualified population.

14 #IAHNOW This work does not involve any CMS-sponsored analyses of demonstration enrollees or comparison samples except what has been publically disclosed. The methods and results are the responsibility of the authors, and no scientific review, corroboration or verification by CMS should be inferred. CMS Demo Data