What’s Your Performance Improvement Strategy?

If you are a post-acute/long-term care provider still sitting on the sidelines waiting for a clearer understanding of how Healthcare Reform is going to impact your organization’s future, well then all I can say is, “Good luck with that – let me know how it works out for you.”

In an article published this past weekend (Medicare Seeks to Curb Spending On Post-Hospital Care), Kaiser Health News’s Jordan Rau reported on the wide variability in Medicare spending on post-hospital care across the county – and the attention that it is getting from CMS. Attention that is quickly turning to targeting: as in even more deeper cuts in reimbursement.
Several of the examples included:

Medicare recipients in Connecticut are more than two-times more likely to be admitted to a nursing home than residents in Arizona.

Medicare spends an average of $8,800 on a patient’s home healthcare in Louisiana – while spending $3,800 in New Jersey.

The rate at which beneficiaries receive post-acute services covered by Medicare in Chicago is three times the rate in Phoenix.

And the aggregate economic impact of variability in per capita spending is substantial. As the growth in post-65 age cohorts continues to accelerate both the inherent cost contribution (demand) as well as cost-push inflation (a result of seeking to satisfy that demand with scarce resources) is increasing. As reported in the Kaiser article, Medicare spending on PA/LTC, “has grown at 5 percent a year or faster in 34 of the nation’s 50 most populous hospital markets in recent years.”

The article goes on to describe the perceived reasons behind the variability that has captured CMS’s attention:

Misaligned incentives: Hospitals have not historically been economically impacted by the consequences of post-hospital care delivery, while PA/LTC providers have been incentivized to drive utilization based upon maximizing reimbursement rather than the appropriateness of the setting.

Information asymmetry: Very often PA/LTC referrals are a function of personal relationships and familiarity between those responsible for discharge planning and those responsible for marketing available beds.

Provider ambiguity: The evolution and confusion that today characterizes post-acute care services and settings (and the impact technology is having on care settings – e.g., telemedicine) often impairs market competition.

Lack of care coordination: While post-discharge readmissions have captured the popular media’s attention because of the ACA payment penalty, it’s the underlying lack of care coordination between acute and PA/LTC providers that results in cost inefficiencies extending well beyond avoidable readmissions.

These concerns, taken together with other indicators of potential waste and inefficiency (please refer to the article cited), will drive tremendous pressure in the years ahead to lower Medicare post-hospitalization expenditures (thus the chainsaw metaphor). How PA/LTC providers address these pressures will mean the difference between staying in business – or not.

When thinking about performance improvement as a vehicle to address this challenge remember this: more than any other singular criteria, successful PA/LTC organizations that survive the next decade will have learned to trade on value. Value in healthcare is quite simply the patient’s satisfaction with the care delivery experience divided by the cost to provide that experience (with the notable understanding that a patient’s satisfaction is typically augmented by their families’ satisfaction). With or without the Affordable Care Act, that is where the industry is headed.

But what does it mean to, “trade on value?” To help Pub visitors begin thinking about that I have provided a few fundamental questions that you might want to ponder – or discuss with colleagues:

  1. What’s most in demand?
    If Medicare, Medicaid and private insurers were to evaporate tomorrow, what core service offerings that you provide would be the most likely to still generate revenue? What distinguishes those services from others?
  2. Where do we fit in the care continuum?
    Forget the fancy charts and graphics of think tanks and consultants showing you where you fit. Think about the patients you care for every day from the perspective of their overall care experience: where does your organization provide the greatest value to that patient’s recovery along the care continuum?
  3. Who wants to work with us?
    How do potential partners in your market determine their value? Based on that understanding, can you enhance their value? What are the risks that you would lower it? Can you effectively address those risks?

  4. How do we protect and enhance our core value?
    In healthcare, more than any other industry, the innate ability to produce value is primarily attributable to direct caregivers. What should you be doing today to ensure you protect that most valuable resource? And what should you be doing tomorrow to help those caregivers increase the value you provide to patients?


Acute & Post-Acute/Long Term Care: How to Have That Difficult Conversation

We’ve all experienced times in our lives when we have to face a difficult conversation and the angst with which we anticipate its completion.  An example might be the nervousness and anxiety of approaching someone to whom we are romantically attracted.  Another example would be the dread and sorrow of approaching someone with news we know will devastate them.  More relevant to my purpose here are the myriad types of challenging but routine conversations that fall well within those two extremes.

In particular, I am referring to the conversations that are now beginning to take on a true sense of importance and urgency between leadership teams at acute care organizations and post-acute/long-term care (PA/LTC) organizations.  Whether driven by regulatory influence (e.g., the Hospital Readmission Reductions Program), new payment models (e.g., bundling pilots), cost containment initiatives or wanting to truly develop a full continuum of care, hospital administrators are getting earnestly engaged in wanting to understand how PA/LTC providers can help them reduce average length of stay and avoidable readmissions.

For healthcare organizations used to operating in silos, discussing subjects like strategic objectives, market positioning and perceived organizational strengths and weaknesses with other healthcare providers – let alone non like-kind providers – can be a most uncomfortable experience.  And that discomfort can cause such discussions to be entirely unproductive.  Time-wasting in today’s healthcare environment will not only put an organization at a competitive disadvantage – it is a short and narrow path to economic collapse.  So the obvious challenge is how to make sure such conversations – or meetings – are both meaningful and productive. 

From what I have observed and experienced over the past couple of years as a party to a number of these leadership conversations, there are some basic, yet very important, guidelines you can follow to help ensure the time you spend is productive and of value.  I have shared these below and hope that you find them useful.

Create a Statement of Purpose
How many times have you been to a meeting where a colleague says to you under her breath, “why are we here?” A Statement of Purpose should provide a clear articulation of why you are meeting and what must absolutely be accomplished for it to be a valuable use of everyone’s time. 
For example, a Statement of Purpose might read,

We will meet on <date> for the express purpose of creating a shared understanding of the joint-venture opportunity being considered, the attendant opportunities and risks, and whether both parties have sufficient interest in pursuing the joint-venture further.  Evidence of that interest will be satisfied if the parties enter into a Letter of Intent within 30 days following the meeting.

Drill Down on Your Value Proposition
Before meeting, have a very good understanding of why a potential venture or opportunity would be of value to your organization.  Define that value nominally (i.e., put it into real numbers).  For example, know that if successful, the project will add a net cash benefit of $X annually to your organization.  It is typically difficult to quantify economic success given the level of ambiguity at the early stages of discussion, but most executives I have worked with are usually surprised at the analytical specificity achievable when they are forced to work through assumptions and parameters.  And it is the very development of those assumptions and parameters that should serve as the meeting content (see next guideline).

Avoid Meeting Until There is Something to Discuss
I had a physician colleague tell me once that thousands of great ideas are presented and discussed at lunch tables across the country every day, yet very few ever make it back to the office – let alone to the type of initiative that merits having two organizations meet to discuss.  As Ashleigh Brilliant once wrote, “Good ideas are common – what’s uncommon are people who’ll work hard enough to bring them about.”

Generating interest and enthusiasm for a good idea (e.g., a joint venture) is usually a pretty enjoyable experience, so there is the natural inclination to want to meet and share that idea.  In my personal experience – and a lesson I had to learn the hard way – this is where most often ideas go to die.  They literally get talked into submission from exuberance over the imagined benefits before they can gain any traction and the support necessary to make it past lunch.

This is why taking the time and effort to develop the business case for a proposed venture before bringing the two parties together is so crucially important.  The level of detail should obviously be in sync with the desire to maintain a strong position of negotiation, but both parties must be able to understand the fundamental framework and objective reasoning that merit the time being committed by individuals attending that meeting.

Set Discussion Boundaries
Both parties should know in advance what they are willing and prepared to discuss.  As mentioned above, there ought to be a cognizant recognition that while bargaining in good faith should be a given, information is power in negotiation.  And while meeting to determine whether a potential venture merits further investment may not represent significant exposure, all too often information is exchanged without due consideration.  Of course, having a nondisclosure agreement in place is wise, and the terms and conditions will provide valuable guidance in establishing your conversational boundaries.

Have the Right People There – And Have Them Focused
With the advances made in information technology over the past decade, the ability to communicate with someone has never been easier – yet being heard has never been more challenging.  Competing for attention is one of the greatest singular obstacles to advancing organizational initiatives today.  It often requires a fair amount of dogged commitment, humility and political savvy to coordinate schedules in a way that gets the right people at the meeting in a frame of mind to concentrate on the meeting content.  But it is an effort that cannot be minimized without jeopardizing success.

Consider Using a Facilitator
Having a productive meeting often depends on the ability to stay focused on the deal points and ensuring you have the right levels of individual participation.  Personality types often dictate that level of participation, and without an objective means of balancing certain types, a few people can dominate the discussion – even if they aren’t the ones empowered to make decisions. 

Having a clearly defined agenda and a third-party facilitator that is familiar with your industry and business can add significant value.  That individual should have experience in effectively managing discussions and debate, ensuring that key concepts are introduced at just the right moments and have the ability artfully keep participants focused on the primary elements that comprise the Statement of Purpose.

Environmental trends and drivers are pushing acute and PA/LTC leadership teams to accelerate their interest in partnering on market initiatives that require collaborative efforts.  From the very beginning, the success of such initiatives depends on the ability to engage in meaningful and productive conversation.  By having the discipline and foresight to follow some basic guidelines those leadership teams can help avoid wasting valuable time.



Healthcare 2013: Get Ready for a Wild Ride!

cedar-point-4With the impending blizzard ready to ruin, or at least significantly delay, one of my favorite holiday traditions – taking down the outside lights and decorations – this seems like a good time to throw another log on the Pub’s corner stove and set upon contemplating what’s just around the bend.  With implementation of the Affordable Care Act now ready to swing into full motion in 2013, might as well use this downtime to start preparing for the wild ride ahead.  So here are a few items on the horizon.

Fiscal Cliff Resolution
As written about here before, how Congress and the Administration resolve – or don’t – the Fiscal Cliff will significantly impact implementation of the Affordable Care Act in 2013.  Neither political party wants to risk being blamed for going over the cliff; yet neither wants to be blamed for, “giving in” on principles.  The resolution? Why, kick the can over Father Time’s head, landing squarely in Baby New Year’s lap once again, of course.  That means having temporary legislation in place to avoid the most feared short-term economic impacts (e.g., avoidance of broad income tax increases, extension of unemployment benefits and forestalling the nearly 30% reduction in Medicare payments to physicians).

Unfortunately, what it is does not mean is any real sense of stability or reliable framework for budgeting and appropriating funds.  Though funding for many of the ACA provisions was appropriated as part of the Act, the interconnected nature of the federal budget means that discretionary funding will still have a great impact on HHS departmental planning and implementation.

Further, it is likely that any meaningful and sustainable fiscal policy compromise will involve some legislative modification to the ACA – i.e., particularly in lieu of the need to control entitlement spending.  So until a long-term bargain can be reached there will continue to be a lot of uncertainty on the actual means, methods and timing regarding key provisions of the ACA.  Notwithstanding such uncertainty, below are a few of the more significant items that are supposed to be implemented in 2013.

Health Insurance Exchanges
Health Insurance Exchanges (HIEs) must be certified and operational by January 1, 2014.  A
t the latest count,  upwards of 30 states have opted not to establish health insurance exchanges on their own, which by default means the federal government will have to set up HIEs in those states.  While portions of the underlying technological and operational infrastructure can be duplicated from state to state, there is still an enormous implementation effort beyond what was anticipated.  Implementation will likely be delayed even with a fiscal agreement in place.  Likely too, will be modification to the Minimum Essential Benefits definition in lieu of projected exchange plan pricing.

The HIEs will get a lot of media attention in 2013 because of the direct impact they will have on millions of individuals and the lightening rod they are likely to become as a portended bell weather of ACA failure once implementation challenges and frustrations emerge.  At the same time, private insurance exchanges – seizing the opportunity to gain comparative perceptual market advantage – will flourish.

Medicaid Expansion
To be – or not to be – morally supportive of providing access to life saving healthcare to your poorest citizens, that is, as some have framed the debate over Medicaid expansion.  Effective January 1, 2014, Medicaid coverage is to be expanded to include individuals between the ages of 19 up to 65 (parents, and adults without dependent children) with incomes up to 138%  of the Federal Poverty Level (based on modified adjusted gross income).

More than likely, most states will find it politically unpalatable to opt out of the federal expansion once the dollars begin flowing out of Washington.  But as written here before, Medicaid coverage is a particularly sharp problem within a thicket of thorny policy challenges.  It behooves any healthcare provider with exposure to Medicaid (i.e., particularly those PA/LTC providers) to be very aggressive in staying informed regarding state Medicaid program policy developments over the next two years.

Medicare Bundled Payment Program
Payment bundling is perhaps one of the most confusing concepts in a sea of confusion that is healthcare policy because the concept both actively precedes and  transcends the ACA.  Pilot programs and demonstration projects testing whether paying multiple providers a lump sum to coordinate treatment and care of a patient for a defined condition and/or disease have been met with mixed results.  Still, provider enthusiasm to participate in such programs seems to be growing.

The difference in 2013 is that the ACA mandates CMS to begin a Medicare bundled payment pilot program to begin in January and run for five years.  The impetus of this initiative is try and drive broader, sustainable alignment across providers.  This is a voluntary program requiring application and must include a hospital, physician group, skilled nursing facility, and home health agency.  Only one entity (the contracting organization) will be responsible for allocating the payment among all providers.

To be sure, there will continue to be significant discussion, disagreement and controversy on the long-term viability of payment bundling, from both an economic and patient quality/safety perspective.  But from a more pragmatic, short-term financial vantage, providers interested in staying in business would do well to at least begin to understand what payment bundling will mean to them in the near future.

Tax Provisions in 2013
There are also a number of ACA revenue (i.e., tax) provisions that will take effect in 2013.  These include:

  • Itemized individual deductions threshold on medical expenses will go from 7.5% to 10% of AGI
  • New limit on flexible spending account for medial expenses will be set to $2,500 per year
  • Increase in Medicare Part A tax rate on wages goes from 0.9% to 2.35% on earnings over $200,000 for individuals and $250,000 for married couple filing jointly (plus a  3.8% assessment on unearned income of higher-income individuals)
  • Elimination of tax-deduction for employers receiving Medicare Part D retiree subsidy
  • Excise tax of 2.3% on the sale of taxable medical devices

    There are more provisions in 2013 worth knowing and understanding, and Kaiser’s Health Reform Source provides a sharp, interactive means of tracking these here.  Those mentioned above are just a few that should get immediate and highest priority as healthcare providers.


Community Health Needs Assessment

TAKE NOTE: There is a new Form 990 reporting requirement for tax-exempt hospitals that nonprofit owners/operators of Inpatient Rehabilitation Facilities (IRFs) and Long-Term Acute Care Hospitals (LTACs) should be aware of – and begin preparing for very soon.

Legal Mandate
The Patient Protection and Affordable Care Act, Section 9007, Additional Requirements for Charitable Hospitals, created Section 501(r) of the Internal Revenue Code.  Section 501(r), in turn, imposes new requirements on 501(c)(3) (i.e., tax exempt) organizations that operate one or more hospital facilities.  Hospital facilities as defined by the IRS include IRFs and LTACs.

Nonprofit providers of aging services, senior housing and non-hospital post-acute/long-term care – while not impacted directly by this mandate – will still want to be educated on the reporting requirements, as it will very likely have a significant impact on future community partnership opportunities with those care provider types.

IRS Guidance
On June 26, 2012, the Internal Revenue Service published in the Federal Register proposed regulations and a detailed preamble regarding the Section 501(r) requirements. In general, the proposed regulations require each hospital to meet four requirements on a facility-by-facility basis:
     1.  establish written financial assistance and emergency
          medical care policies,

     2.  limit amounts charged for emergency or other
          medically necessary care to individuals eligible for
          assistance under the hospital’s financial assistance
make reasonable efforts to determine whether an
          individual is eligible for assistance under the
          hospital’s financial assistance policy before engaging
          in extraordinary collection actions against the
          individual, and
     4.  conduct a Community Health Needs Assessment
          (CHNA) at least once every three years (see Timing,

    In July 2011, the IRS issued Notice 2011-52, which provided conceptual guidance regarding the Section 501(r) CHNA requirement. The Treasury Department and the IRS are in the process of drafting proposed final regulations regarding the CHNA requirements. Hospitals preparing to meet the reporting requirements can look to Notice 2011-52 for CHNA guidance as if those proposed regulations were already in effect up until six months after the issuance of the final regulations.

Notice 2011-52 appears to permit the collaborative development of CHNA reports for individual facilities (i.e., to the extent plausible, utilize the same market knowledgebase).  Care must be taken, however, to distinguish the unique community needs of those facilities where appropriate: including uniquely defining each hospital’s targeted market (community). Separate implementation plans reflecting the individual operational characteristics of each hospital must be developed as well.

The IRS is also currently seeking comment on the portended advantages and efficiencies of allowing organizations with multiple hospital facilities to prepare a single CHNA for those properties. Each hospital will still be responsible for developing a unique community needs assessment. I believe the prudent approach at this juncture is to assume individual reports must be produced but to be cognizant of how those reports could be combined and integrated into a single report pending further guidance from the IRS.

The first assessment and adoption strategy (i.e., implementation plan) must have been completed within a three-year period that ends with the fiscal year commencing on or after March 23, 2012. For nonprofit organizations operating IRFs and/or LTACs this means having separate CHNAs and implementation plans completed and available to the public
not later than that organization’s fiscal year-end date in 2013.  Failure to complete a timely CHNA for each facility could result in an excise tax of $50,000 per hospital facility and the risk of losing 501(c)(3) status.

Compliance with this new reporting requirement should be taken very seriously.  The undertones driving the mandate reflect largely bipartisan support of the Treasury Department’s challenging the reasonableness and plausibility of organization’s maintaining their charitable status in lieu of being able to evidence community benefit.  This is a phenomenon which largely exists outside of Healthcare Reform if you will.

For many nonprofit organizations, the consequences of losing tax-exempt status would be financially devastating – so there is a strong incentive to develop a CHNA that aggressively seeks to address identified community needs.  But those organizations must also be aware of the reality that programs created to address identified community needs will be scrutinized by the IRS in subsequent years to determine compliance with representations made in the plans of implementation.

Given what’s at stake and the inherent nature of work effort involved in creating the knowledgebase necessary to complete the CHNA, I believe it makes tremendous sense to integrate the CHNA process into organizational strategic planning.  For many organizations – though likely an unwelcome requirement – it nonetheless offers the opportunity to complete a strategic planning effort where budgetary constraints had previously prevented such effort from being a priority.

In addition – and of critical importance – whatever service and care delivery programming is planned for as a result of the CHNA process should be incorporated into the organization’s long-range and strategic planning.  At a minimum, such planning should be viewed as risk mitigation in assessing whether programs created through the CHNA process are economically feasible and sustainable.  I have previously written a white paper outlining a strategic planning framework that can be integrated with the CHNA reporting mandate (White Paper).

As always, I welcome any comments and questions.

  ~ Sparky


Being Proactive in the Face of Uncertainty

While none of the Policy Pub’s guests have provided any comments yet (I’m hoping a few more “spirited” posts will begin to wear down the  contributory inhibitions), several patrons have emailed me privately and asked whether I had any practical advice on how to approach this period of policy limbo – between before knowing how SCOTUS will decide and the outcome of the fall general election.  So I thought this might be a good opportunity to offer some advice.

Accept the Brutal Reality
Often lost in the din of popular media reporting on the Healthcare Reform debate are the irrefutable realities that underlie how and why it has become a major public policy issue in the first place.  The Internet is replete with charts and tables illustrating the debated evidence of unsustainable healthcare spending.  I think a very poignant and candid assessment that ought to resonate with business-minded individuals can be found in the January 2012 Standard & Poor’s credit report, Mounting Medical Care Spending Could Be Harmful To The G-20’s Credit Health
.  It was noted there that, “steadily rising health care spending will pull heavily on public purse strings in the coming decades. If governments do not change their social protection systems, they will likely become unsustainable, in Standard & Poor’s Ratings Services’ view.”

The will to control healthcare spending is not a Republican or Democrat phenomenon.  So holding out hope that future policy outcomes directed at the behest of either current or future elected officials, irrespective of political party, will somehow relieve the pressure is a fantasyland belief that only serves to psychologically forestall the inevitable.  Healthcare organizations that are able to accept and internalize knowing that they will have to compete on value in the future will survive – those that do not, will not.  It is really as simple (and brutal) as that.

Use this Time to Answer Some Tough Questions
If the Affordable Care Act is either partially or fully struck down – and/or the general election delivers a major shift in party majority, there will be a brand new tsunami of political opportunism in its wake.  It will take a fair amount of time (I am betting six quarters, at least) for that special interest flooding to subside to the point where any type of meaningful legislation can be passed replacing the ACA.

What impact that actually has, however, on the timing of the policy-driven financial realties that senior housing and care providers are facing is unclear because much of the ACA’s impact is not scheduled to begin until 2014 in any event.  And while we wait for the Federal government, State budgetary pressures will continue to mount.  So I think a prudent approach is not to mark the passing of time by the political winds but assume that every month going forward should reflect a quantifiable movement toward a future state vision of your organization that is more lean, more efficient – and is able to deliver more value than your competition.

To accomplish this, however, you first need to decide what that future state vision looks like.  I just finished a new whitepaper on strategic planning and positioning that discusses the importance of visioning in context.  For the purposes of this post, I think the relevant questions that need to be answered by most organizations – and very soon – are:
     What business(es) are we in?
     Who really are our constituents and stakeholders –
        and how do we bring value to them?
     Are we ready to partner with other healthcare 
        providers – and under what circumstances?

     How do we ensure that our investments create
         future option value?
     Where are the opportunities to monetize our value
        chain into revenue?

Be Ready to Negotiate
If there was one skillset I would say – on average – represents the weakest link for high quality, high value senior housing and care organizations desiring to thrive in a future world of Healthcare Reform it would be the ability to negotiate business deals.  It is just not an inherent skill that seems to be well correlated with other leadership qualities that are of paramount importance – and have historically been sufficient to achieve leadership excellence.

That is changing, and quickly.  Effective negotiation will determine whether you are  “bought by” or “merged into” another organization.  It will determine whether the acquisition you make increases or decreases the overall value of the combined organizations.  It will determine whether you drive the terms and conditions necessary to financially survive under managed care, or accept what you’re given – and hope for the best.

When the time comes to partner with other market participants (whether those are community-based organizations, physician groups operating as a medical home or  hospitals) you don’t want to be sitting there with your hand up, saying, “oh pick me, pick me!” You want to know well in advance what you bring to the table, what it is worth and what you demand for that value.

Create an Opportunity Assessment Matrix
Finally, senior housing and care organizations will have to be able to react more quickly to opportunities than they have in the past.  As Healthcare Reform – in whatever final format that takes – begins to roll forward in earnest, market dynamics will accelerate.  New – and often unexpected – partnership opportunities will emerge.  Being able to react quickly – and before the competition – will be a huge strategic advantage and key to survival.

One idea that we have found helpful is the Opportunity Assessment Matrix.  This is a concept that we have used with several senior housing and care organizations, and it is a tool that is designed to streamline the process of identifying, assessing, analyzing and prioritizing market opportunities.  It is also helpful in mitigating risks and ensuring the requisite organizational support is in place before valuable resources are invested in pursuit of alternative opportunities.

The concept is basic: discuss, agree upon and document the various elements that any potential opportunity must possess to merit consideration.  Determine the relative weights of those elements in the context of the organization’s business strategy.  And then create a consistent methodology for who and how the individuals responsible for assessing the opportunity will be engaged.

Hope this is helpful . . .
  ~ Sparky