Transcript Project Status

Larry Putnam, Project Director
Frontier Community Health Integration Project (F-CHIP)
Montana Health Research & Education Foundation (MHREF)
Terminology
 The term “frontier CAH” is used to describe the existing
Critical Access Hospital health care service delivery and
reimbursement model.
 The term “Frontier Health System” is used to describe a
proposed new model of integrated health care service
delivery and reimbursement. The model would integrate
an existing frontier CAH and other essential services under
a new provider type and reimbursement methodology.
 The term “Montana F-CHIP facilities/or facility” refers to
the nine (or one of the nine) CAHs in Montana
participating in the Frontier Community Health
Integration Project (F-CHIP) under a cooperative
agreement with HRSA/ORHP.
You’re A Frontier CAH if.........
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Your ambulance has a gun rack
Your physical therapy whirlpool is powered by a trolling motor
Your anesthesiologist is named Jack Daniels
Your budget for duct tape exceeds $20,000 per year
Your first Code Blue step is to cancel the dietary tray
Your local 9-1-1 system is a party line
Your surgical scrubs are made by OshKosh
Your medical staff gets CME’s for watching the farm report
Thanks to the Illinois Hospital Association Rural Hospital Constituency for this list.
Frontier Healthcare Service Delivery—A Brief History
 Medical Assistance Facility (MAF) –1987-1998
--Montana-only model, only 12 MAFs in 1998
--MAF demonstration=foundation for the CAH model
--15 bed limit
 CAH model-1998 to 2011
--national scope (46 states), not just Montana’s MAF or mid-west EACH/PCH
--cost-based reimbursement
--allowed non-physician (PA/NP) medical staff
--bed limit increased to 25 beds (total number of CAHs in 2011=1,327)
--no longer a frontier model (what is a frontier CAH?—see next slide)
 MHA Task Force (2007-2008)
--CAH model not working for Montana’s frontier communities
 Frontier Community Health Integration Project (F-CHIP)-2008 to 2011
2008 Medicare Improvements to Patients and Providers Act
(MIPPA)
 MIPPA authorized HHS Secretary “to establish a demonstration project to
develop and test new models for the delivery of health care services to
Medicare beneficiaries in certain frontier counties.”
 Purpose of any new frontier health care service delivery model shall be “to
improve access and better integrate the delivery of frontier…health care
services for Medicare beneficiaries.”
 Primary focus areas for a frontier demonstration shall be (1) to increase
access to and improve adequacy of payments for health care services
provided under the Medicare and Medicaid programs in frontier areas and
(2) to evaluate regulatory challenges facing frontier providers and
communities.
“Eligible Entities”—Who Can Participate In The Demonstration?
 Must be a CAH located in one of 4 frontier-eligible states: Alaska, Montana,
Wyoming or North Dakota
 CAH must be located in a county (or borough) with a population of 6 or fewer
people per square mile
 CAH must have an acute care average daily census of 5 patients or less
 LTC services (either a nursing home or CAH swing bed services) must be
provided in the county or borough (LTC doesn’t have to be owned by the CAH)
 CAH must provide one of the following services:
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Home Health
Hospice
Physician Services
Number of Frontier-Eligible CAHs
Montana
North
Dakota
Wyoming
Alaska
Totals
(4 states)
All hospitals
65
45
27
27
164
CAHs
48
36
16
13
113
Frontiereligible CAHs
35
19
10
7
71
Note: Data from IMPAQ International, MHREF and North Dakota, Wyoming and Alaska FLEX Directors
Frontier Community Health Integration Project (F-CHIP)
Overview
 Congress provided funding to HRSA/ORHP in 2010 to develop a frontier
healthcare demonstration project
 9/1/2010, an 18-month, $750,000 cooperative agreement awarded to
MHREF by HRSA/ORHP “to assist in the development of a Frontier
Community Health Integration Project.”
 Purpose of the F-CHIP project is to work with ORHP and CMS “to inform
the development of a new frontier health care service delivery model.”
Actual design and implementation of a follow up demonstration project
are the responsibility of CMS.
VISION
The overall vision of the Frontier Community Health Integration Project (F-CHIP) is to establish a new health care
entity—a Frontier Health System—that aligns all frontier health care service delivery by means of a single set of frontier
health care service delivery regulations and an integrated (not fragmented) payment and reimbursement system.
For the Medicare beneficiary, the new Frontier Health System would serve as a single point of contact and patientcentered medical home for the coordination and delivery of preventive and primary care, extended care (including
Visiting Nurse Services (VNS) with therapies), long term care and specialty care. Beneficiaries would benefit from the
new model through reduced unnecessary admissions and readmissions to inpatient, ER and long term care settings.
Homebound frontier Medicare beneficiaries who are unable to travel to obtain medical service would receive access to
expanded VNS home care, including monitoring and treatment of chronic conditions.
In essence, the local Frontier Health System would aggregate all health care service volume within its service area under
one integrated organizational, regulatory and cost-based payment umbrella, spreading fixed cost and producing lowercost care. In addition, budget-neutral, pay-for-quality incentives would be implemented by the local Frontier Health
System to demonstrate high quality care provided to frontier patients at lower cost, with savings shared with the
Medicare Program.
A new Frontier Health System provider type and Conditions of Participation (COP) would be created. Health care
services aggregated into the new Frontier Health System include: hospital ER, inpatient and outpatient; ambulance;
swing bed; and an expanded rural health clinic which includes a VNS component that may provide physical,
occupational or speech therapy in the frontier patient’s home as well as preventive and hospice services.
Each frontier-eligible state—Montana (MT), North Dakota (ND), Wyoming (WY) and Alaska (AK)—would propose
forming one or more networks of up to 10 Frontier Health Systems to provide statewide care coordination for frontier
patients, assistance in the implementation and measurement of Pay for Outcomes (P4O) incentives as well as
distribution of shared savings from CMS to network members.
F-CHIP Products and Timelines
 Framework For A New Frontier Health System Model: A Proposal To
Establish a New “Frontier Health System” Provider Type and Conditions of
Participation (completed)
 7 White Papers
--Frontier Referral and Admission/Readmission Patterns
--Frontier Care Transition Capacity and Planning
--Frontier Long Term Care Issues/Swing Bed Use
--Frontier Telehealth
--Frontier Healthcare Workforce
--Frontier Quality Measures
--Frontier Cost Report Issues
• ORHP F-CHIP Funding ends 2/29/2012. Possible CMS Center for Innovation
demonstration of new Frontier Health System model follows.
Project Organization
 3 F-CHIP partners
MHREF
 Montana Office of Rural Health (MORH)
 A formal network of 9 Montana frontier-eligible CAHs
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The network of 9 frontier CAH CEOs drives the project
 Consultants:
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Payment and Reimbursement
Regulatory
Quality
Facilitator
Technical assistance from DPHHS
F-CHIP Workgroup meets monthly or more often
--9 CAH CEOs, consultants, HRSA/ORHP, CMS contractor and MHREF
--via televideo (all 9 CAHs have televideo conferencing)
Frontier Community Health Integration Project Communities
October 2010
 KALISPELL
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CHESTER:
Liberty
Medical
Center
HAVRE
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CULBERTSON
Roosevelt
Medical Center
 CIRCLE:
 GREAT FALLS
McCone County
Health Center
 MISSOULA
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PHILIPSBURG:
Granite County
Medical Center
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TERRY:
Prairie
Community
Hospital
 HELENA
 BUTTE
 FORSYTH:
81 Miles
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BOZEMAN
 SHERIDAN:
Ruby Valley
Hospital
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BIG
TIMBER:
Pioneer
Medical
Center
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BILLINGS
Counties shaded in tan have a CAH Hospital.
Rosebud Health
Care Center 260 Miles
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EKALAKA
Dahl
Memorial
Healthcare
“The Tiniest of the Tiny”
Montana’s 9 F-CHIP Communities
 Isolated=Located an average 172 miles from a tertiary center (range of 63 to 308 miles)
 Isolated=Located in a town with an average population of 932 (range of 410 to 1,944)—7 of
the 9 towns have populations less than 1,000
 Isolated=Located in a county with an average population density of 1.7 persons per square
mile—3 of the F-CHIP counties have population densities of less than 1 person per square
mile
--Montana’s population density is 6.7 persons per square mile. If Washington DC
had the same population density as Montana, there would be 405 people living
there.
 Isolated=54% of Montanans travel more than 5 miles to see medical provider and 7%
more than 50 miles. No public transportation. Problem for 65+ Medicare beneficiaries
 Small medical staffs (primarily physician assistants & nurse practitioners, some
physicians)
--average size=2 (range of 1 to 4)
--in 2 CAH’s/communities, the medical staff consists of one PA
 Isolation magnifies workforce shortage issues (especially medical staff, RN’s, therapists)
Frontier Health Care—Very Low Volumes
Data for the 9 F-CHIP CAHs
 Average daily acute census is .78 patients per day
 7 of the 9 use their 25-bed CAH license primarily for LTC swing bed residents.
--some frontier CAH’s not able to admit local LTC residents
 8 of 9 operate a Rural Health Clinic.
--CAH provider-based RHC’s (not FQHC’s) provide the bulk of clinic
services in Montana’s frontier communities
 Only 1 of 9 does outpatient surgery, no surgery at the other 8
 2 of 9 provide assisted living services; some frontier CAH’s would like to be able to
provide assisted living to their communities
 One provides hospice services
 None of the 9 CAH’s provide home health services (a major gap)
 All 9 facilities have telehealth (interactive audio video) capability
9 F-CHIP CAHs—Struggling Financially
 Average patient revenue last fiscal year=$3.6M (range $1.4M to $6M)
 8 of 9 lost money last fiscal year (range=$608K loss to $63K net income)
--average loss was $175K
 3 years ago, 3 of the 9 facilities made money and average loss was $108K
--average annual losses getting worse
--concern that frontier CAHs may start to close, eliminating access
to frontier healthcare services (especially Medicare beneficiaries)
 All 9 F-CHIP CAH’s received county or health district subsidies last fiscal
year averaging $271K. Subsidies range from $95K to $450K
Frontier CAH’s—Healthcare Service Delivery Centers For Their
Communities
 Frontier CAH’s already provide a broad range of
healthcare services. They’re already fairly well
integrated.
 Generally, if a healthcare service is provided in a
frontier community in Montana, it’s provided or
coordinated by the CAH.
 Core frontier services: EMS, ER, acute, outpatient
diagnostic and therapy, clinic, long-term care (swing
bed or nursing home), preventive
 Optional frontier services: Home Health (replace
with RHC VNS), hospice, assisted living
Frontier Health System-A New Model
 Fully integrated frontier health care service delivery organization
 Limited to the 71 frontier CAHs in the 4 frontier-eligible states only
 Create new Frontier Health System provider type
 Each frontier-eligible state (MT, AK, WY, ND) would create one or more care
coordination networks of Frontier Health System organizations (like the
9-CAH F-CHIP network)
--better management of chronic patients (diabetes, COPD, CHF, fragile elderly)
--fewer ER, LTC, inpatient admits/readmits
 Pay For Outcomes reimbursement in addition to cost-based reimbursement
--cost savings shared with CMS (no downside risk)
Frontier Health System Model—
Key Access and Financial Recommendations
 Change bed limit from 25 to 35
--number of acute beds limited to 5
--could use additional beds for LTC swings
--no one turned away for LTC services in frontier communities
--one F-CHIP CAH generated an additional $623,000 per year by dropping its nursing
home license and converting to 25 swing beds and serving LTC residents in swing beds
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Eliminate (or allow waivers to) 35-mile ambulance rule
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Allow reimbursement for therapies (PT, OT, speech) and home health aide services to
VNS Medicare beneficiaries
--provides access to preventive and therapy services to homebound age 65+ patients,
often with multiple chronic conditions, who can’t leave home to see a medical provider
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Modify alternative coverage waiver to allow 25 (or, if changed, up to 35) beds for LTC
swing beds
Other Activities
 EHRs/Health Information Exchange: HealthShare Montana/F-CHIP
Supplemental Funding
--important in identifying frontier patients with multiple chronic
conditions
 Frontier Care Coordination Network pilot grant
--MT/$525K, 3-years: To support a network (the 9 Montana
F-CHIP CAHs) that focuses on care coordination for Medicare
beneficiaries with multiple chronic conditions that reduces
unnecessary ER, inpatient and LTC admissions and readmissions
 Frontier Community Health Integration Network Planning Grants
--ND, AK, WY/$85K, one year: To evaluate regulatory challenges
facing frontier CAHs and prepare frontier CAHs for a CMS frontier
healthcare demonstration project
 Technical Assistance to the other 3 frontier-eligible states (North Dakota,
Wyoming, Alaska)
Contact Information
Larry Putnam, Project Director
Frontier Community Health Integration Project (F-CHIP)
1720 Ninth Avenue
Helena, Montana 59601
Phone: (406) 390-0666—cell
Email: [email protected]