How innovative care delivery models and technologies are breaking the cycle of unnecessary hospital admissions.

1. Post-Acute Care
& Beyond
How i n novat iv e c a r e del ivery model s an d
t ec hn o lo g ies a r e breakin g th e cycl e of
un n ec essa ry h o s p ita l adm iss ion s
Q4 / 2012
Industry Perpsective
UNCOMMON CLARITY
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2. Founded in 1997, TripleTree provides independent, research-driven advisory
services on mergers and acquisitions, recapitalizations, divestitures and raising
growth capital for innovative companies in healthcare.
We are continuously engaged with decision makers across the sector including
best-in-class companies balancing competitive realities with shareholder objectives,
global companies seeking growth platforms, and financial sponsors assessing
innovation investments or first mover opportunities.
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3. Q4
Table of Contents
INDUSTRY PERSPECTIVE
05 / MAJOR TRENDS AND MARKET FORCES
20 / SKILLED NURSING / REHABILITATION
6 / A PERFECT STORM IS LOOMING
22 / HOME HEALTH
13 / UNDERSTANDING READMISSIONS
24 / DME / HME / INFUSION
16 / A CALL TO ACTION
25 / HOSPICE
17 / PAYERS
29 / TREATMENT IN PLACE – The Most
17 / PROVIDERS
18 / CONSUMERS
Impactful Mode Of Care For Reducing
And Reduce Unnecessary Inpatient Utilization
Unnecessary Admissions
19 / POST-ACUTE CARE – Solutions To Organize
Care, Engage Consumers / Patients / Members,
31 / SUPPORTING TECHNOLOGY PROVIDERS
34 / INTEGRATED CARE & CARE COORDINATION
39 / LOOKING AHEAD

4. EXECUTIVE SUMMARY
•
One in every ten hospital admissions could have been
avoided with 6% coming from avoiding chronic condition-
Health reform is still taking shape as 30 million additional
related admissions and 4% from preventable acute
Americans enter the U.S. healthcare system. Beyond
conditions. 2
improving access, a paramount objective of the “Patient
Protection and Affordable Care Act” (PPACA) is to create
integrated care and payment models that demand higher
•
Nearly one-fifth of Medicare beneficiaries in traditional feefor-service (FFS) are re-admitted to a hospital within
20 days of their original discharge. 3
degrees of accountability and drive improved health outcomes.
It is increasingly clear that a tremendous opportunity exists
Today, care delivery in the U.S. is highly fragmented and
for innovative solutions that strengthen the seams between
plagued with little coordination and communication across
healthcare settings and promote a more holistic, integrated
the healthcare system. Physicians are encouraged to narrow
care system. Delivery models and supporting technologies that
their focus and are trained to become experts in very specific
can help patients navigate our rapidly transforming healthcare
medical disciplines, and many healthcare strategists argue
system and eliminate waste in a $63.5 4 billion post-acute
that delivery models with greater focus and more repetitions
care marketplace are not only integral to the sustainability of
(commonly referred to as “focused factories”) improve
the U.S. healthcare system, but will also garner significant
outcomes. While this “practice makes perfect” model has
interest from both the strategic acquirer and financial sponsor
shown signs of success within each silo, it undermines the
communities.
importance and value of care coordination between them.
Unnecessary hospital admissions account for more than $26
This report will analyze the market dynamics and trends that
are driving demand for improved post-acute care coordination.
billion 1 in excess cost, burdening the healthcare system today,
a number that is poised to escalate as more Americans access
developing post-acute care delivery strategies to break the
our disjointed care delivery system.
4
It will also explore forward-thinking companies that are
cycle of unnecessary patient admissions and re-admissions.
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5. Major Trends and Market Forces
There is no need to read the 2,200 pages of the healthcare reform
The post-acute care market, as shown in Figure 1 (next page),
legislation to conclude that one of the primary aims of PPACA is
represents a significant share of the care continuum and is an
to manage the chronically ill, high cost patients responsible for a
area of particular focus within the reform legislation. The care
vast majority of healthcare spending in the United States. Today’s
delivered following a patient’s discharge from the hospital, is highly
specialist-based, hospital-centric delivery system requires little
fragmented and uncoordinated and typically crosses multiple sites,
accountability for cost and quality and provides limited incentives
including skilled nursing, rehabilitation, home health and hospice.
for care coordination services. Without holistic, integrated care
Fragmentation and poor communication are causing over $26 billion
coordination models, patients repeatedly bounce between multiple
in unnecessary hospital admissions – a top priority for policy makers,
sites of care (hospital, emergency room, home, etc.) leaving them with
payers and providers.
hefty medical bills and suboptimal care plans designed to promote a
full recovery.
MAJOR TRENDS AND MARKET FORCES // INDUSTRY PERSPECTIVE Q4 / 2012
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6. Figure 1: Fragmented Post-Acute Care Delivery System (Representative Constituents)
Hospital
Skilled Nursing /
Rehabilitation
Home Health
Hospice
A Perfect Storm is Looming
Medicaid: Insurance coverage expansion is the centerpiece of the
Historically, post-acute care has been primarily viewed as an “add-
healthcare reform law. What is less commonly known is the fact
on” to our nation’s healthcare system. However, healthcare cost
that over 75 percent of the 30 million Americans expected to gain
and outcomes data have reversed this trend as a growing number
insurance in 2014 will be covered under state-administered Medicaid
of patients are requiring continued and coordinated care to achieve
programs. According to CMS, PPACA will result in 23 million new
a full recovery. This is especially true as an explosion of high-risk
Medicaid enrollees in 2014 as the new healthcare reform law expands
individuals with multiple chronic illnesses is poised to occur in our
coverage to all adults under age 65 with incomes below 133% of the
disjointed healthcare system in 2014. According to CMS, PPACA
Federal Poverty Level. This expansion is problematic in many ways.
will expand access to coverage to over 30 million Americans across
Compared to the low-income privately-insured population, Medicaid
the Medicaid and individual markets. While the volume of entrants is
beneficiaries are more likely to be in fair or poor health. As illustrated
certainly notable, the risk profile (i.e. utilization rate, lack of adherence,
in Figure 3, 33 percent of non-disabled, childless adults are in fair
health status, etc.) and the impact that these newly insured individuals
or poor health compared to 12 percent of those individuals covered
will have on our healthcare system cannot be overstated. A perfect
by private insurance. Similarly, roughly 44 percent of non-disabled
storm is looming, creating a pressing demand for new services that
Medicaid enrollees have two or more chronic conditions compared
promote coordinated, cost effective and high quality care.
to 28 percent of the privately insured. These comparisons highlight
many of the common behavior patterns we see across the Medicaid
population:
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7. Figure 2: A Perfect Storm is Looming
Hospital
•
•
Skilled Nursing /
Rehabilitation
Hospice
Limited to no engagement with a primary care physician
High utilization of certain services, such as pharmacy, inpatient
hospital and emergency room services. Medicaid enrollees
access care through the emergency room at twice the rate of the
uninsured and privately covered populations[5]
•
Home Health
. . . An explosion of highrisk individuals with
multiple chronic illnesses
is posed to occur in our
disjointed healthcare
system in 2014.
Poor adherence to treatment plans
MAJOR TRENDS AND MARKET FORCES // INDUSTRY PERSPECTIVE Q4 / 2012
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8. Figure 3: Health Status of the Privately Insured Versus the Medicaid Population
The Congressional Budget Office (CBO) estimates that PPACA’s
Medicaid expansion will cost the federal government $434 billion
that an additional 10 million individuals will receive coverage either
over the next decade, accounting for more than 40 percent of the
through insurance exchanges or directly from a private insurer.
healthcare law’s total expenditures. In addition to increasing the
Many of the provisions in the healthcare reform law, however, will
federal deficit, the expansion will have a significant impact of
drive increased adverse selection, thereby creating a risk pool
state budgets, healthcare provider budgets, and patients’ ability to
that cannot be overlooked. The following are a few of the most
access care.
8
Individual: As a result of the individual mandate, CMS estimates
impactful provisions:
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9. Community Rating. Prevents insurers from varying premiums
Medicare: In 2011, the first wave of baby boomers turned 65; by
on the basis of a policyholder’s age, gender, or health status.
2030, it is projected that there will be 72 million elderly Americans
This provision will increase the cost of health insurance for the
aging into Medicare – more than double the number from 2000. This
healthy individual and reduce the costs for sicker individual.
•
startling demographic change has tremendous implications for our
society, ranging from the availability and utilization of our healthcare
Guaranteed Issue. Forces insurers to cover everyone with
resources and economic costs to the fundamental principals that
pre-exiting conditions and therefore drives up premiums. If
shape our lives. As we develop new strategies for care in the post-
an individual can buy insurance after getting sick, that person
acute care market, it makes sense to focus first on the segment
has every incentive to drop out of the system until he or she is
of the population that accounts for the vast majority of overall
actually ill.
•
healthcare spending. It is well known that chronic conditions drive a
wildly disproportionate share of costs across all demographics, with
Mandatory Benefits. Forces plans to cover certain services (e.g.
more than 84 percent of our total healthcare dollars consumed by
maternity care and substance abuse treatment). In other words,
persons with one or more chronic diseases. This becomes even more
it is a a good deal for a pregnant female or a couple planning to
pronounced in the Medicare population, with more than 99 percent
have a child. Otherwise it’s another reason to drop coverage.
•
of all Medicare expenditures associated with members who have
one or more chronic conditions. As a result, any successful effort to
Tax Penalties. The magnitude of the penalty (roughly $100) for
moderate the cost of healthcare is highly dependent on effectively
not purchasing insurance will not compel healthy individuals to
managing chronic and/or multiple conditions in this segment of the
purchase insurance.
•
population.
Clearly, the incentives to purchase insurance are in favor of the highrisk individuals.
MAJOR TRENDS AND MARKET FORCES // INDUSTRY PERSPECTIVE Q4 / 2012
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10. Dual Eligibles
While the explosion in Medicaid and Medicare eligibles will have
Duals are among the sickest and poorest individuals covered under
a meaningful effect on the healthcare system, no segment of the
Medicaid or Medicare and therefore account for a disproportionate
population captures this phenomenon better than the dual eligible
percentage of healthcare costs. As illustrated in Figure 4, average
population. It is so important that our team at TripleTree is in the
per capita Medicare spending for dual-eligible beneficiaries is more
midst of concluding a research report on dual eligibles.
than twice that of non-dual-eligible beneficiaries, which is reflective
of this population’s greater health needs and utilization of services
Approximately nine million individuals are currently covered by
compared to other Medicare and Medicaid beneficiaries.
both the Medicaid and Medicare programs. These individuals are
commonly referred to in the health policy arena as dual eligibles
or “duals”. While this population represents just 15% of the total
fee-for-service (FFS) coverage setting, where many individuals
Medicaid population, duals account for over 39% of total Medicaid
receive excellent care, but where there is no means of (or
spending. Similarly, they represent 21% of Medicare enrollees, but
accountability for) ensuring that duals’ considerable health needs are
36% for total Medicare expenditures. With state budgets under
being addressed in a high quality and cost-effective manner. Today,
increasing pressure from the economic downturn and continued
coordinated care programs currently serve a modest proportion of the
sputtering of the U.S. economy, politicians and policy makers are
nation’s dual eligibles with just one million duals receiving Medicaid
intensifying their focus on developing solutions to address the
benefits through a managed care program in 2009. However, both
growing spend burden of this demographic. Specifically, states are
states and managed care organizations are clearly signaling that dual
looking to control costs by moving their dual eligible populations to
eligibles are top priority, and therefore we should expect to see these
managed care contracts, shifting the responsibility to health plans
constituents make aggressive moves to serve this population. Thirty-
and exploring managed care approaches via care coordination
seven states and the District of Columbia have submitted letters of
models. As a result, Medicaid and multi-line insurance carriers are
interest to CMS to coordinate care for dual eligibles, and the Center for
jockeying for a position to win contracts that in aggregate represents
Medicare and Medicaid has chosen 15 states to design new approaches
more than a $300 billion market opportunity.
10
These expenditures have predominantly occurred in the traditional
to coordinate care for this population.
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11. Managed care organizations are also making bold strides to position
organizations are looking to leverage their footprint in the Medicare
themselves as constituents in the dual eligible market. UnitedHealth’s
market to capture more shares of the Managed Medicaid / Dual
acquisition of XLHealth is an example of how managed care
Eligible market.
Figure 4: The Cost of the Dual Eligible Population
Differences in spending and service use rate between dual-eligible beneficiaries and non-dual eligibles
Differences in spending and service use rate between dual-eligible beneficiaries and non-dual eligibles
Average Medicare Payments
AVERAGE MEDICARE PAYMENTSfor all Beneficiaries
FOR ALL BENEFICIARIES ($ In Actuals)
Service
Average Medicare Payments for all Beneficiaries
Benificiaries
Inpatient Hospital
Physician
Inpatient Hospital
Outpatient Hospital
Physician
Home Health
Outpatient Hospital
Skilled Nursing Facility
Home Health
Hospice
Skilled Nursing Facility
Prescirbed Medication
Hospice
Prescirbed Medication
Total Medicare Payments
Total Dual Hospitalizations
Variance
Dual-Eligible
Non-Dual-Eligible
Benificiaries
Service
Dual-Eligible
$
5,369
$
$
Non-Dual-Eligible
$
2,751
2,884
5,369
$
1,647
2,884
752
1,647
1,160
752
403
1,160
4,262
403
4,262
16,477
Variance
$
$
16,477
$
Total Medicare Payments
Source: MedPAC, CMS
Source: MedPAC, CMS - need to confirm 60% / 40% split
Total Dual Hospitalizations
2,618
2,294
2,751
886
2,294
379
886
484
379
153
484
852
153
$
Total Dual Hospitalizations
590
$ 2,618
761
590
373
761
676
373
250
676
3410
250
852
7,799
Poten&ally
Avoidable
Admissions
Poten&ally
40%
Avoidable
3410
$ 8,678
7,799
Non-­‐
Avoidable
Admissions
Non-­‐
60%
Avoidable
Admissions
60%
Admissions
40%
$ 8,678
Source: MedPAC, CMS - need to confirm 60% / 40% split
MAJOR TRENDS AND MARKET FORCES // INDUSTRY PERSPECTIVE Q4 / 2012
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12. United’s Purchase of XL Health
In February 2012, UnitedHealth Group purchased XL Health, a Baltimore-based Medicare Advantage plan that focuses primarily on Special
Needs Plans (SNPs), including members with chronic illnesses and dual-eligibles. XL Health serves over 113,000 Medicare Advantage
members and is one of a few Medicare Advantage plans that successfully serves the chronic disease population. The XL Health
acquisition solidifies United Healthcare’s (UHC) lead in managing the dual-eligible population, the largest reserve of untapped revenue for
the managed care industry, and an end-market where managed care can prove a superior ability to improve lives, lower medical expenses
and earn a profit by coordinating the care and payment of care for frail elderly, disabled and other duals.
Figure 5: Intensified Focus on the Dual Eligible Opportunity
Buyer
Target
UnitedHealth Group
XL Health
Inspiris
Humana Senior Brige
MetCare
Cigna HealthSpring
WellPoint CareMore
TA Associates
Senior Whole Health
Oak Investment Partners
Independent Living Systems
Univita All-Med Services
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13. Understanding Readmissions
Primary Causes of Readmissions
Each year, nearly nine million people – 24,000 per day – are discharged from shortterm acute care hospitals and require some form of post-acute care. The most
• Communication. An inadequate relay
of information by hospital discharge
planners to patients, caregivers, and postacute care providers, to ensure the patient
understands to the treatment plan
• Compliance. Poor patient compliance
with care instructions, medication
therapy, etc. primarily as a result of the
patient receiving little or no information
on how to achieve a successful recovery
• Follow-up. Inadequate follow-up care
from post-acute and long-term care
providers or failure by the patient to
schedule a follow-up appointment with
their physician
• Support. Family members or caregivers
common settings include but are not limited to sub-acute and post-acute nursing
facilities, the patient’s home, primary and specialty care offices, rehabilitation
facilities, home health, hospice, long-term care facilities and other institutional,
ambulatory and ancillary care providers. Patients receiving post-acute care
typically see multiple physicians in as many settings, often creating a confusing
and a hard-to-follow regimen of medications and treatments. For the patient,
their caregivers and family members, it is not surprising that communication
problems and other errors proliferate as patients transition between settings.
Adverse events often occur during care transitions and are concentrated
among individuals with complex and chronic conditions. Accordingly, a failure
to communicate critical information related to a patient’s medical care, support
services, safety, medications, and other matters can compound the situation.
These adverse events result in a substantial number of unnecessary hospital
admissions. According to Medpac, among Medicare patients:
•
rehospitalized in 90 days.
are often uninformed or unable to provide
the necessary care and support for
transitioning the patient from the hospital
to the home
20 percent are rehospitalized within 30 days, and more than one-third are
•
More than 76 percent of these rehospitalizations are said to be avoidable
and cost our healthcare system more than $26 billion per year.
MAJOR TRENDS AND MARKET FORCES // INDUSTRY PERSPECTIVE Q4 / 2012
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14. Figure 6: Care Trends Post Discharge
The causes of unnecessary hospital admissions are complex, multifaceted and interrelated. The most common variables include severity
poorly understood. What is clearer, however, is that despite the fact
of illness, communication with patients and families, medication
that the problems of high readmissions rates and poor coordination
errors and compliance, and coordination with community clinicians,
have been known for many years, little to no improvement has been
caregivers and family members. Each of these factors can play a
14
role, but the relative importance is difficult to measure and therefore
made in our healthcare system in our very recent history.
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15. Figure 7: Change in 30-Day Readmission Rates Following Discharge
Condition
% Readmissions
% Change
Company Profile
2004 2009
Medical 15.9% 16.1% 1.2%
CHF 20.9% 21.2% 1.4%
AMI 19.4% 18.5% -4.6%
Created by Select Medical and
Pneumonia 15.1% 15.3% 1.7%
Universal American and backed
Hip Fracture 14.3% 14.5% 1.4%
by Welsh Carson, NaviHealth
Surgical 12.7% 12.7% 0.0%
Source: The Dartmouth Institute for Health Policy & Clinical Practice
partners with health plans, health
systems and post-acute providers
to manage the entire continuum
of post-acute care. In February
As illustrated in the Figure 7, the rate of readmissions increased from 2004 to 2009
2012, NaviHealth purchased
for five of the six causes of hospitalizations studied. Only readmission rates for acute
SeniorMetrix, which utilizes a
myocardial infractions (heart attack) improved only slightly, decreasing from 19.4% to
decision-support technology to
18.5% - a positive development, but not enough for a healthcare system that needs to
project therapy regimens, most
do more. So what does this tell us?
appropriate care settings and
timing of expected outcomes.
In a new world of ACOs, bundled payments, value based purchasing, STAR ratings
and consumerism, the opportunities for new service models and technology providers
to improve the cost and quality of care in the post-acute care market through more
holistic and integrated care delivery models is tremendous.
MAJOR TRENDS AND MARKET FORCES // INDUSTRY PERSPECTIVE Q4 / 2012
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16. A CALL TO ACTION
The post-acute care market is estimated to be a $63.5 billion market[6]. Aside from its sheer size, there are a number of factors that are
contributing to the increased attention the post-acute care market is receiving. Figure 8 provides a brief overview of the key factors driving a
focus on the post-acute care market for payers, providers and consumers.
Figure 8: A Call to Action for Payers, Hospitals / Health Systems, and Consumers
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17. Payers
Company Profile
Several of the factors listed in Figure 8 are impacting the ways in which health
plans view post-acute care. HEDIS measures, Star Ratings and ACOs have payers
Recapitalized by Summit Partners in
increasingly accountable for their performance across several important dimensions
September 2011, Carecentrix, Inc.
of care and service. With more plan members (many of whom are among the
is a provider of home health benefits
sickest) accessing the post-acute care market for the range of reasons mentioned
management services that recently
heretofore, improving the post-discharge coordination of care, patient experience
launched a Care Transitions program
and outcomes is a priority. Payers, both public and private, are aggressively seeking
designed to reduce avoidable hospital
lower cost alternatives to hospital admissions / readmissions and improved care
admissions and other adverse medical
coordination across the continuum of care to eliminate waste.
events. Carecentrix’s HomeSTAR
(“Successful Transition and Recovery”)
Providers
program was designed to help
In a post reform world of value-based purchasing and bundled payments, providers
health plans and providers decrease
are held more accountable, primarily through financial penalties, for the care
avoidable hospital readmissions and
they provide. In October 2012, Medicare started penalizing hospitals with high
other adverse medical events while
readmissions rates – defined as patients being readmitted within one month of
improving patient satisfaction in
discharge – by reducing reimbursement by as much as one percent. The maximum
their care. Through this program,
penalty increases to two percent the following year and three percent in 2014.
Carecentrix identifies members at risk
These penalties are one of the Affordable Care Act’s efforts to reward hospitals for
for an adverse event, stratifies the
the quality of care they deliver instead of the quantity of services. With hospitals
risk, and mitigates the risk by enrolling
facing penalties, theoretically they will take ownership of following-up with
them into structured care plans
discharged patients. According to the Kaiser Family Foundation, Medicare evaluated
delivered face-to-face in the home.
readmissions rates at 3,367 of the nation’s hospitals and imposed penalties on 2,200
in October 2012 with 278 hospitals receiving the maximum penalty of one percent.[7]
A CALL TO ACTION // INDUSTRY PERSPECTIVE Q4 / 2012
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18. While the reimbursement risk associated with this program may seem insignificant,
many providers operate under single digit margins, making even a 1% reduction in
Company Profile
Medicare reimbursement meaningful. For example, if a hospital’s total inpatient
operating payments for FY 2012 were $25 million, that hospital will have $250,000
at risk for reimbursement reduction in this program. With the maximum penalty
increasing 1% per year until FY 2015, the penalty and dollars at risk will undoubtedly
heighten providers’ focus on their readmission rates.
Consumers
Established consumer engagement
platforms are increasingly
exploring additional capabilities
to address market demand for
payer / provider / consumer
collaboration as healthcare
With consumers increasingly on the hook for the cost of care, individuals are no
reform drives convergence.
longer standing on the sidelines and are instead demanding more transparency,
MEDSEEK is a provider of
information and a greater role in managing their own health. With that comes an
online strategic engagement
ever-increasing financial and administrative challenge, and as our healthcare system
and analytics solutions. The
is inundated with an aging population and new Medicaid members, demands from
company’s software platform helps
the post-acute care market will include tools to help them navigate their journey
healthcare organizations attract
post discharge.
and retain patients and improves
patient experience and care
Hospitals, health systems, managed care organizations, and post-acute providers
through enhanced patient-doctor
are all keenly aware of and engaged in discovering innovative delivery and payment
communication and information
models, technologies and services to transform the post-acute care market. Success
accessibility.
however, will require trust, collaboration, cooperation and aligned incentives
between providers, payers, consumers and policy makers.
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19. POST-ACUTE CARE
Solutions To Organize Care, Engage Consumers / Patients / Members,
And Reduce Unnecessary Inpatient Utilization
A number of solutions are solely
Figure 9: The Post-Acute Care Market Landscape
focused on care coordination services
and technologies, but a comprehensive
review of the market place should
include various providers across the
post-acute care continuum. While skilled
nursing, rehabilitation and home health
providers may not have dedicated
programs to improve care coordination
per se, they do play a very important
role in the post discharge care
experience for patients. The integrated
care delivery / care coordination
providers and supporting technology
providers identified in Figure 9
support the post-acute care providers
and patient as they transition from
setting to setting.
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
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20. Skilled Nursing / Rehabilitation
The $200 billion skilled nursing and rehabilitation market is in
CMS’ initiative in addition to the Hospital Readmissions Reduction
the midst of a transformation, and in a new world of ACOs and
Program is forcing skilled nursing care facilities to reevaluate their
readmission penalties, these providers will play a significant role in
current delivery models. As hospitals face Medicare reimbursement
helping hospitals reduce readmissions and providing patients with
reductions for unnecessary readmissions, they will seek to partner
coordinated and professional care in a sub-acute environment.
with facilities that actively play a role in reducing those readmissions.
There are many programs currently being developed to focus on
In March 2012, the Medicare-Medicaid Coordination Office and the
this issue, but one that seems to have gained acceptance in the
Center for Medicare and Medicaid Innovation announced the Initiative
marketplace is the INTERACT II (Interventions to Reduce Acute
to Reduce Avoidable Hospitalization among Nursing Facility Residents.
Care Transfers Version II) program, designed to improve the early
Through this initiative, CMS is partnering with seven organizations
identification, assessment, documentation, and communication about
to implement strategies to reduce avoidable hospitalization for dual
changes in the status of residents in skilled nursing facilities. This
eligibles who are typically long-stay residents at nursing facilities.
program includes specific tools around communication, advanced
Each participant in the initiative is required to partner with a
care planning, quality improvement, and care paths that were refined
minimum of 15 dual eligible certified nursing facilities in the same
and tested in a six-month collaborative improvement project with 25
state where the intervention will be implemented. The goal of the
nursing homes in three states.
initiative is to:
In addition to implementing INTERACT II, Life Care Centers of America
(LCCA), one of the nation’s largest skilled nursing providers, is
• Reduce the number of and frequency of avoidable hospital
making some waves in the industry through its success in reducing
admissions and readmissions;
rehospitalizations. Beginning in 2010, LLCA began placing a full-time
• Improve beneficiary health outcomes;
• Provide better transition of care for beneficiaries between
an earth shattering idea, the impact was certainly noteworthy - in just
inpatient hospital and nursing facilities; and
• Promote better care at lower costs while preserving access to
beneficiary care and providers
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doctor in some of its facilities. While this move does not seem to be
one year, LCCA reduced re-hospitalization at its facilities with a fulltime physician to 15% from 40%. In addition to a dramatically reduced

21. readmissions rate among those participating facilities, LLCA also
•
outstanding experience;
experienced reduce staff turnover and improved clinical outcomes.
•
Genesis Healthcare is another example of a skilled nursing provider
Enhanced Guest Services team and training to ensure an
Expanded dining services in multiple locations, including cafes,
dining rooms and room service.
leading the initiative to reduce hospital readmissions. Genesis, a
leading provider of short-term post-acute, rehabilitation and skilled
Although reducing rehospitalizations may negatively impact skilled
nursing care services, launched a new discharge product called
nursing facilities revenue in the short-term (e.g. fewer Part A SNF
PowerBack Rehabilitation aimed to reduce post-discharge setbacks
days), long-term care providers are increasingly pursuing this
and transition patients back to their homes as quickly as medically
goal anyway, believing that higher quality care will enhance
possible, rather than a nursing home that lumps all patients together,
referrals in the long-run. LLCA is certainly experiencing
regardless of specific needs or acuity level.
increased referrals as a result of its recent successes and we
anticipate other innovators like Genesis and Extendicare to see
Genesis’s Brightwood campus is the first of its kind to offer the
referral gains in the near future as well.
innovated model of care (PowerBack) which features:
•
Expanded clinical capabilities to include cardiac,
orthopedic and pulmonary specialized care;
•
Two full-time physicians and three full-time nurse
practitioners on campus;
•
State-of-the art therapy technologies;
•
Therapy pool;
•
A 4,000 square foot therapy gym open 12 hours a day;
•
Added care planning and daily schedules to be directed
by the patient;
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
21

22. Home Health
As illustrated by the cost and length of stay statistics publish by
In recent years, the home health industry has been battered by a
MedPac in Figure 10, home health represents a very compelling care
challenging reimbursement environment and increased regulatory
delivery option for payers, providers and most importantly, patients
scrutiny into the Medicare reimbursement practices at many of
post discharge. The key question is how home health providers in
the industry’s largest players. In the longer-term however, we
the older world of fee-for-service payment models and generally
view the home health industry as an attractive market for growth
limited collaboration with hospitals are now redefining their value
and consolidation as ACO tailwinds intensify and the appropriate
proposition and developing new models of care to meet cost and
incentives are implemented to reduce overall healthcare costs.
quality requirements under healthcare reform.
Figure 10: Home Health Versus Other Post-Acute Care Options
Hospital
LTAC
IRF
SNF
Hospice
Home Health
Avg. Cost of Stay
$10,043
$38,582
$17,582
$10,833
$11,217
$5,706
Avg. Length of Stay
5 days
27 days
13 days
27 days
86 days
120 days
Avg. per Diem Cost
$1,853
$1,450
$1,304
$400
$130
$48
Source: US Census Bureau and MedPac March 2012 Report
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23. Amedisys, one of the largest publicly-traded home health and hospice
Amedisys’s Comprehensive Continuous Chronic Care Management in
providers, is one company taking a leading position in demonstrating
the Home or C4M, combines existing home care infrastructure with
the value proposition that home healthcare providers can provide in
technology and clinical capabilities to provide intensive continuous
a new world of accountability. Designed to deliver care to the most
home-based health care.
complex, chronic and costly patients in the comfort of their homes,
Figure 11: Amedisys C4M
READMISSION RATES
External Benchmarks
Amedisys Benchmarks
< 30 days: 4.7% - 6.2%
< 30 days: 1.48% - 1.60%
31-60 days: 8.1% - 10.7%
31-60 days: 1.17% - 1.76%
61-90 days: 6.5% - 12.8%
61-90 days: 0.62% - 1.32%
91+ days: 8.2% - 14.1%
91+ days: 0.70% - 0.90%
1. Department of Health and Human
Services-Offices of Inspector General
2000, 2002, 2004, 2005
2. 2002 NHS Trust Plan and Report
3. 2004 Institute for Healthcare
Improvement
4. Healthcare Cost Containment Council
2005
1. Post episodic DM call center results
2. 14,313 patients tracked over a 6 month
period
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
23

24. As the value that home health can provide to our healthcare system
DME / HME / Infusion
is demonstrated by innovators like Amedisys, TripleTree anticipates
The $27 billion durable medical equipment (DME) industry is at an
significant private equity investment and consolidation in the years
important inflection point. While margins are being squeezed as a
to come. Growth, via acquisition, is very common in the home health
result of CMS’s Competitive Bidding Program, DME companies are
industry as the market remains highly fragmented with over 11,500
also being confronted with new opportunities to play a greater role
home health agencies in the U.S. The four largest, publicly-traded
in the post-acute care continuum. DME companies already have
players (Amedisys, LHC Group, Almost Family, and Gentiva) account
an established position in the home, which ideally positions them
for 15% of the market. After several years of robust M&A volume,
to expand their services and create a more holistic home health
2011 experienced a meaningful dip as a result of reimbursement cuts,
approach. Some industry players have attempted this in the past
increased audits and investigations and talks of sequestration.
with little avail, as the incentives for hospitals and other providers
to leverage these expanded services were limited. Today, penalties
In addition to the traditional strategic buyers in the space (i.e. the
for readmissions and other incentives are changing the game for the
large publicly-traded home health and hospice organizations),
DME industry. This influence of penalties and incentives has DME
the compelling fundamentals of the home health industry are
vendors relying on partner organizations for automated solutions.
also attracting some out-of-the box buyers as exhibited by The
Once such firm is Brightree, who offers a cloud based billing and
Washington Post Company (NYSE: WPO), a diversified education and
business management platform for a range of provider settings.
media company, purchasing a majority stake in Celtic Healthcare,
a provider of skilled home health-care and hospice services the
Univita Health provides a clear example of how a once traditional
northeastern and mid-Atlantic regions.
DME provider is transforming itself to become a comprehensive care
delivery and coordination provider in the home. Over the last three
years, Univita Health has purchased segments of the home health
care industry and combined them to deliver holistic services in a
new, coordinated way to become a one-stop shop for managed care
and employers to manage their chronically ill and elderly patients.
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25. •
March 2012: Acquired All-Med Services of Florida, a DME/HME
Hospice
home and hospital delivery company.
•
The hospice market has seen consistently strong growth over the
January 2010: Acquired Atenda Healthcare Solutions and its
affiliated companies, including Florida Home Medical Equipment.
•
December 2009: Acquired Enurgi, a web-based service for
caregiving and family support.
last several years. Since 2004, the hospice market has grown 12%
per annum as a result of favorable demographic trends, strong political
support, favorable reimbursement trends and increased realization of
the value proposition hospice services provide. Despite an acceleration
of M&A volume over the last four years, the hospice market remains
By integrating these disparate services into its existing operations
incredibly fragmented with the top players (Chemed (Vitas), Gentiva,
and creating a broader suite of services, Univita Health is creating
Amedisys, and LHC Group) owning just 15% of the market[8]. The
significant value for its managed care and employer customers.
remainder of the market is dominated by both non-profit and private
Univita Health has inked deals with large managed care companies
non-profit single state and regional players. M&A has been a common
to manage their chronically ill members in the home on a capitated
growth avenue for the industry’s largest players and TripleTree expects
basis. By offering an integrated, single source solution for home
this activity to continue as hospice continues to play a greater role
care, Univita is transforming how care is delivered in the home while
in integrated care delivery and coordination. Both home health and
driving accountability and outcomes and reducing readmissions
hospice have been targeted areas for aggressive expansion for Kindred
healthcare costs.
Healthcare, which purchased IntegraCare Holdings, Inc., a provider
of home health, hospice and community services, from private equity
firm, Flexpoint Ford, for $75 million in total consideration. In order
to support a continuum of care within an ACO or bundled payment
environment, Kindred is seeking opportunities to provide integrated
and coordinated care throughout a post-acute episode. As illustrated
by Kindred’s acquisition of IntegraCare, home health and hospice are
a key component of the company’s strategy to provide high quality,
patient-centered integrated care.
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25

26. Post-Acute Providers (e.g. Hospice): A Foundational Element of Accountable Care
It is no secret that the ACO movement will have a profound impact on
The most likely ACO / post-acute provider strategies that will emerge
provider approaches towards care coordination, provider-to-provider
in the evolving ACO environment will resemble the following:
collaboration, and patient engagement. An important component
in the formation and success of ACOs will be the introduction of
• ACO / Provider Partnership to Provide Services to Entire
value-based reimbursement where providers will be placed at “risk”,
Population – similar to an exclusive or preferred partnership in
making them responsible for overspending and rewarding them
which an ACO contracts with a provider (or multiple providers) to
across certain quality measures. In this new payment environment,
provide post-acute services to the entire member base.
it will be imperative for ACOs to create an integrated system of care
• ACO / Provider Partnership to Address Specific Concerns or
coordination among providers and partners that includes initiatives to
Cost Drivers – An ACO contracts with provider to provide specific
aggressively monitor member patient health and drive care outside of
post-acute services to address key concerns and / or cost drivers
inpatient settings. In doing so, the primary focus will be:
(i.e., readmissions, drug adherence, and emergency department
utilization).
• Avoiding high-cost care episodes resulting from poor risk
identification and member health monitoring.
• Delivering routine care and preventive services in low-cost,
efficient settings.
• ACO / Provider Partnership to Treat Specific Members – An ACO
contracts with a provider to provide targeted post-acute services to
a specific subset of members. For example, an ACO many contract
with a home health provider to provide standard care / monitoring
services to members with diabetes.
While post-acute providers are unlikely to serve as an organizing
partner of an ACO, they provide a tremendous value-add to ACOs
The playbook for ACOs is relatively the same regardless of the partnership
by enabling chronic care management, extending care coordination
arrangement; all scenarios involve a heavy emphasis on providing the
efforts, and facilitating the provision of care in lower-cost settings
necessary preventive and follow-up care in lower cost settings in order to
(through home health or hospice services).
control costs as well as to minimize the impact high-cost care episodes.
26
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27. A recent example of how these emerging ACO / post-acute provider
services account for 10 percent of the nation’s $2.6 trillion healthcare
relationships might unfold is through CMS’ Pioneer ACO Program,
budget. Furthermore, for those aged 65 and older, the last 12 months
an initiative designed to test the impact of different payment
of life account for 27 percent of total costs. Given the potential
arrangements on organizations operating as ACOs or similar
spending burden that these types of conditions create and the
arrangements in controlling Medicare spending. Michigan Pioneer
resultant pressures that would be placed on an ACO, it is no secret
ACO (Michigan ACO) is a partnership between the Detroit Medical
that the post-acute space will be a critical focus area for ACOs and
Center (DMC) and its physicians and was selected to introduce
similar risk-bearing entities.
a specialized case manager pilot program identifying terminally
ill patients that require customized care at home. To operate the
As the ACO movement continues to take shape and build momentum
program, the Michigan ACO signed a three-year contract with
over the next few years, it is likely that subsequent ACO / post-acute
Hospice of Michigan, where through its HOMe subsidiary, terminally
provider partnerships will emerge as these providers address a
ill patients are provided with comprehensive home medical services.
critical (and costly) part of the care continuum.
The goal of this pilot program is to reduce unnecessary costs
associated with end-stage illness (HOMe also has contracts with
several other leading Michigan payers, including Blue Care Network,
Priority Health and United Healthcare, to provide similar services).
The Michigan ACO example highlights the growing payer / ACO
acceptance of the vital role that post-acute providers play in
controlling healthcare costs (as well as their willingness to form
partnerships in order to distribute these services effectively). In
the case of the Michigan ACO, where efforts were directed towards
controlling end-of-life spending through hospice care, the program is
especially significant given that studies have shown that end-of life-
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
27

28. Figure 12: Case Study Snapshot – Michigan Pioneer ACO
Michigan Pioneer ACO
Detroit Medical Center
Hospice of Michigan
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29. Treatment in Place – The Most Impactful Model of Care
for Reducing Unnecessary Admissions
and adhere to a plan of care for each individual patient, (ii) monthly
Both Evercare, a business unit within UnitedHealth Group’s Optum
escalation to the NP upon identification of a change in condition
platform, and Bluestone Physicians Services are examples of
with the patient, and (iv) implementation of a care plan that avoids
innovative care delivery models that are having a significant impact
the unnecessary hospital admission by treating the patient in their
on reducing cost and significantly improving the quality of care for
home. The value proposition that this model (and Bluestone Physician
our systems most frail and expensive patients. The construct of these
Services’) delivers to each constituent is tremendous:
NP visits with daily monitoring by the NP and SNF staff, (iii)
models are similar and therefore accomplish a common goal – deliver
holistic and integrated care to the patient in their home to improve
•
Members. Better health outcomes and reduced hospital admissions;
clinical quality and reduce unnecessary utilization, resulting in fewer
more benefits and services than FFS Medicare, including
ER visits, acute admits and re-admits.
coordinated care focused on individual needs of the enrollee;
•
Facilities. Increased revenue through more skilled nursing days
Evercare
in the facility, rather than admitting the member to the hospital;
Evercare deploys a patient-centered approach to providing primary
members receive better care; improved clinical and health
care to the systems sickest and most costly members. Through
outcomes; increased member and family satisfaction;
partnerships among individual patients, their healthcare providers,
•
Providers. Comparable reimbursement as Medicare; improved
clinical outcomes and additional support for patient through the NP;
and the patient’s family, Evercare cares for seniors, individuals with
long-term or advanced illness, and members with complex needs.
•
CMS / States. Lower costs of care.
Evercare’s roots can be traced to the nursing facility environment
where the nurse practitioner (NP) is the central component of this
For more than 20 years, Evercare has achieved strong results,
model and provides routine and more intensive primary care while
including improved medication adherence and utilization
working in collaboration with nursing home staff and primary care
management, decreased hospital admissions by 50%, and industry
physicians. The primary objectives of the model are (i) to establish
leading member and family satisfaction ratings.
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
29

30. Bluestone Physician Services
Through an interdisciplinary team of physicians, nurse practitioners
Bluestone’s care model has transformed how care is delivered to
and physicians assistants, Bluestone Physician Services (Bluestone)
the assisted living and group home populations in the Twin Cities
provides on-site primary care services to complex, frail and special
area of Minnesota. The company has contracted with several local
needs patients in assisted living, memory care and group home
health plans to serve over 3,000 patients in more than 130 assisted
communities. The company’s delivery model is supported by a
living communities. Today, Bluestone is sharing its model with
robust communications portal and EHR that allows the nursing staff,
other geriatric care providers and developing even more enhanced
homecare and hospice nurses, and family members to reach the care
care coordination strategies to further drive change across our
team (as opposed to dialing 911) when a change in condition occurs
healthcare system.
and deliver high quality, coordinated care. Bluestone’s care plans are
customized with the family for each patient to assure appropriate
end-of-life care, further reducing costs and improving care quality.
Each patient visit includes the review of current medical concerns
and medications, as well as preventative care, foot care, skin care,
chronic disease management and arrangement of specialty care
when needed. This type of ongoing preventative care has proven to
not only reduce the need for emergency care and trips to the hospital,
but also significantly improve overall health.
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These two models
exemplify what healthcare
reform is all about
– improved quality,
improved outcomes and
greater affordability.

31. Supporting Technology Providers
Company Profile
Supporting technology providers can play a pivotal role in care coordination post
discharge. When a patient leaves a hospital they and their caregivers require all, but
Homecare Homebase is a healthcare
software company serving the
technology needs of the home health
and hospice industries. The company
offers a comprehensive integrated webbased software solution to improve
the clinical, operational and financial
success of home health and hospice
agencies. Homecare Homebase’s
software connects nurses and workers
in the field to central offices, capturing
billing, patient and care information,
eliminating paper-based administrative
tasks and ensuring compliance with
Medicare standards. It can be used
on a variety of different platforms,
including smartphones. The web-based
software can be updated immediately
in response to new regulations without
users having to upgrade to a different
version.
not limited to the following: (i) information about their treatment plan, (ii) education
about their medications and other equipment, (iii) reminders about medications
and follow-up appointments, and (iv) proper transition of patient information and
medical records between hospital physicians and ambulatory-care physicians. The
common thread amongst all of these requirements is communication and patient /
caregiver engagement.
From both a research and advisory perspective, TripleTree is well versed in the
dynamics surrounding the explosion of interest in healthcare consumerism. Shifting
retail-based models and engaging the consumer are some of the motivations behind
market consolidation and ‘net new’ approaches between and amongst providers,
payers and consumers.
While ACOs, value-based purchasing, and other incentives / penalties for increased
accountability are taking hold, so too have the strategies of consumer engagement
platforms to address the growing market demands for payer / provider collaboration
and improved care coordination.
Figure 13 highlights some of the most notable investments, product launches
and acquisitions in the consumer engagement space that illustrate the need and
opportunity for consumer engagement solutions to drive improve outcomes at a
lower cost.
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
31

32. Figure 13: Consumer Engagement Activity Continues to Accelerate
January 2012
April 2012
• RedBrick Health launches mobile platform for
consumer health and wellness engagement
• Liazon Corporation raises $18 million from various
investors, including Bessemer Ventures, Bain Capital, and
Beacon Bioventures
• change:healthcare announces $10 million equity
raise
June 2012
February 2012
• Altegra Health acquires patient communications company Warm Health
• Getinsured.com partners with Accenture for the implementation of a
statewide California Health Exchange
• Aon Hewitt invests $40 million on internal development of exchange
platform
• Through Q2 2012, HCSC has
invested $100 million in replatforming MEDecision with
enhanced patient engagement
solutions
Q1 2012
Q3 2012
Q2 2012
2011
• Eliza recapitalized by
Parthenon
• Xerox partners with Medco
Health Solutions on new
communications system
• Varolii raises $8 million from
various investors
• Aetna acquires PayFlex
• Optum Health acquires
Connextions
March 2012
• Precision Health Media
raises venture funding and
expands leadership team
May 2012
Today
August 2012
• Castlight announces $100 million raise
• SolutionReach announces growth equity
investment from Summit Partners
• MEDSEEK announces buyout with Silver
Lake Sumeru and Essex Woodlands
• Healthline launches Consumer
Engagement Platform
• Change Healthcare
announces new leadership after
partnership and capital raise
from BCBS
• Connecture raises $20 million
in a recapitalization lead by
Great Point Partners
• Towers Watson acquires Extend Health
for nearly 7x revenue
CO N F I D E N T I A L Property of TripleTree, LLC. Not For Distribution.
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8

33. Multi-model consumer engagement has become a top priority across payer, provider
Company Profile
and PBM with the realization that the healthcare industry is amidst a transition from
a business-to-business (B2B) to a business-to-consumer (B2C) model. Technologies
Founded in 1999, Curaspan Health
Group, Inc. is connecting providers
hospitals, post-acute care providers,
payers and transportation companies
via secure electronic patient-transition
networks to improve outcomes as
patients transition between sites and
levels of care. With a customer base of
over 400 hospitals and 4,000 postacute care providers, the company’s
SaaS-based Synchronized Patient
Management Solution is catching the
eye of our nation’s largest providers
and payers by enabling these parties
to communicate and securely share
real-time, clinical information, access
patient data in any setting and use that
and services to communicate at the right time, with the right message, through the
desired mode, have proven to drive increased actions individuals must take to obtain
the greatest benefit from the healthcare services available to them.
Amongst a myriad of evolving technology solutions, Phytel is taking a leading role in
providing innovative solutions that automate care coordination and health management
programs to improve outcomes and reduce cost in the post-acute market. Phytel has
a deep product suite of automated patient engagement, population reporting, care
coordination, discharge follow-up and patient self-management tools. In particular,
Phytel Transition provides a comprehensive toolkit that closes provider communication
loops and empowers patients and their providers to improve outcomes by: (i) identifying
high-risk patients, (ii) communicating post-discharge instructions and educating the
consumer, and (iii) gauging the patient experience.
A wide range of technologies have the potential to support post-acute care transitions.
The following table provides an overview of these technologies, their applications and
their potential outcomes.
data to drive better clinical outcomes.
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33

34. Figure 14: The Potential Impact of Supporting Technologies
TECHNOLOGY APPLICATIONS
• Patient Education
• Medication adherence & reconciliation
• Remote patient monitoring
• Personal health information
• Social support
• Remote training an supervision
EXAMPLE TECHNOLOGIES
• Automated patient communication
• Medication reminders and dispenser
• Medication list software
• In-home diagnostic devices
• Problem detection algorithms
• Videoconferencing
• Social networks
POTENTIAL OUTCOMES
• Reduced hospitalizations
• Increased patient satisfaction
• Reduced costs
• Improved health
• Increased quality of life
Integrated Care & Care Coordination Providers –
Emerging Care Delivery Models
profiled below are a few of the industry players that have developed
Despite the fact that the need for care coordination services has
models that are poised to have a significant impact on care
been apparent for some time, the industry is still in its infancy
coordination and costs within our healthcare system.
or currently provide solutions to support emerging care delivery
with regards to design and implementing programs that show
measureable results. One only needs to consider Medicare
spending and its unsustainable path, which will only worsen as the
quality became ever more apparent when Humana announced
baby boomers continue to age. Drastic changes are underway for
on November 5th its agreement to purchase Metropolitan Health
the Medicare program to ensure its long-term sustainability and
Networks (MHN), a provider of coordinated and accountable to care
while Medicare Advantage is a part of the solution, government
to over 87,500 MA, Medicaid and other customers. Over 80% of
policy will impact the profitability of commercial insurers. How
MHN’s revenues were generated through contracts with Humana
these insurers manage care across a variety of post-discharge
to manage the care of its members in Florida on a capitated-
settings is a massive lever for cost management. The companies
34
The trend of vertical integration and aligning physician pay to
basis, whereby MHN assumes the risk for all of its patients’ cost.
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35. Figure 15: MHN’s Utilization Results
Medicare Population
Metropolitan Health Networks
Results
Admission / 1,000
335
317
Down 5%
Hospital Days / 1,000
1,968
1,412
Down 28%
Average Length of Stay
6.2
4.23
Down 32%
Acute Readmissions
21%
9%
Down 12 ppt
Generic Dispensing Rate
60%
84%
Down 24 ppt
Utilization Metric
Source: Metropolitan Health Network Q2 2012 Investor Presentation
Through the company’s newly formed subsidiary, Symphony Health
practices, has achieved proven results (Figure 15) of high quality
Partners, Inc., MHN has struck a graduating risk arrangement with
care, lower costs and improve patient satisfaction and providers
Humana to manage the provision of healthcare services to nearly
across the U.S.
one million Humana Medicare Advantage members in Cincinnati,
Northern Kentucky, and Indianapolis service areas. After the first
The purchase of MHN is Humana’s latest foray into providing medical
two years of the contract, during which Symphony will receive a
services, as the insurer seeks more levers to control rising costs
base administrative fee, the arrangement shifts to a limited risk basis
in Medicare. We expect further vertical integration as medical cost
beginning in 2014, followed by full-risk in 2015. MHN’s provider-
management has become a critical focus for this country, given
centric model is becoming increasingly popular, as it helps lower
skyrocketing healthcare costs and ballooning deficits. Regardless,
costs and increase quality by giving physicians additional financial
MHN’s patient-centric approach to care coordination has driven results
incentives to keep patients out of the hospital. The company’s model
that should be the envy of payers and providers across the U.S.
of care, which includes a physician network of 33 owned primary
care practices and 450 contracted independent primary care
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
35

36. Independent Living Systems (ILS)
provides an integrated suite of care management solutions focused on long term managed care, nutritional support services, complex care
management, care transition services, and a range of other member management related services. As shown in Figure 16, these synergistic
services create a patient-centered, holistic approach to long-term care that enables strong partnerships among individual patients, caregivers,
payers and the care delivery system. Today, ILS serves over 2.5 million lives on behalf of its health plan clients and is gaining significant traction
as its value proposition to the major healthcare constituents continues to proliferate.
Figure 16: ILS’ Integrated Suite of Care Management Solutions
Managed Long-Term Care
Nutritional Support
Services
Complex Care Management
Care Transition Services
Holistic care and support
services provided in the
home of Medicare, Medicaid
and Duel Eligibles
Provides means and nutrition
services to members to help
them regain and maintain
their health
Patient-centric
communication that facilitates
access to community based
services and expert care
coordination for the elderly,
those with special needs, and
dual-eligible populations and
their families
A holistic approach to transition
services to provide critical
support, care coordination
and guidance to patients
post discharge to facilitate a
successful recovery at home for
elderly and at-risk populations
“High-touch”, “low-cost”
services that address daily
living and innovate systems
that monitor, measure and
report care
Post discharge meals: meals
are delivered to the patients
home immediately upon
discharge
Following a telephonic
assessment, A group of highly
trained nurses, social workers,
and care coordinators work
as a team to manage the care
and services identified on a
member’s individualized care
plan
Individualized counseling.
Coach meet with patients in
hospital prior to discharge,
follow-up with a home visit in
72 hours and maintain contact
telephonically during transition
(up to 60 days)
Reduces financial burden
for consumers, payers and
providers
Chronic Care & Disease
Management Meals.
Nutritional plans for those
with chronic diseases,
To optimize the utility of the
service, ILS has developed
a proprietary cloud-based
care management tool that
integrates member data with
metrics relevant to health
plans’ needs
Comprehensive home visit.
Assessment of the patient’s
needs and lifestyle through a
home visit
Meals for sustained health
living. Ensure members
have access to health meals,
particularly when they are
unable to shop for or prepare
themselves
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Specialized technology. Identifies
institutionalized members
and manages cases through a
web-based portal, which can be
integrated into a health plan’s
existing medical management
and operational processes

37. The Power of Surveillance in Population
of medications, chronic conditions and other indicators and assigns a
Health Management
personal health concierge to these members to lower medical expenses
Managing the care of a health plan’s installed membership base
requires superior surveillance capabilities to identify the individuals
by facilitating effective care, increased patient satisfaction and improved
quality scores (HEDIS and STAR ratings).
that need the most support from the healthcare system. Establishing
a plan of action and closing each patient’s unique gaps in care,
improves outcomes, quality and patient satisfaction. On the backs of
traditional HEDIS and Medicare Advantage risk adjustment audits
and more recently the Affordable Care Act, a new category of clinical
auditing solutions are emerging that cut across cost, care and quality
management. One company that is at the forefront in changing how
individuals are cared for in the healthcare system is Outcomes Health
While the health plan marketplace must continue to invest to automate
its legacy medical management competencies, the industry is most
focused on innovation and collaboration. However, legacy care
management / population health management platforms are woefully
inadequate to address today’s and tomorrow’s market needs:
•
from retrospective care management towards real-time /
Information Solutions (Outcomes). Outcomes is a leading provider
of end-to-end solutions for healthcare data acquisition, auditing
and analytics for use in payment integrity, compliance and quality
prospective population management
•
Advantage plans to measure and influence results by closing gaps in
the day-to-day actions of providers
•
actionable intelligence. The company extracts meaning from volumes of
diverse data to pinpoint patient care needs and address discrepancies,
facilitating the right care at the right time for each specific patient.
Additionally, the company’s senior care services identifies high-risk
Need for Payers to “Cross the Chasm” and Become More
Provider Relevant – Payer-based technology vendors must help
care and quality. The company’s unique surveillance technology allows
it to organize disparate data to efficiently listen to data and create
Need to Empower Clinicians With Actionable Data at the Point of
Care – Alert-driven workflow and analytics must be woven into
reporting in the healthcare industry. More specifically, the company
provides a “preemptive” suite of services that allows Medicare
Need to Look Forward, Not Backward – Systematic shift away
obtain connectivity inside the four walls of the provider office
•
Need to Help Enable Providers to Take on Payer-based Activities
– Providers will be taking on more payer-driven activities and will
be as focused on quality measure as well as HCC-risk scoring for
their MA members
patients and gaps in care via risk scores, prior admissions, number
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37

38. ZeOmega
ZeOmega, a provider of web-enabled and rules-driven workflow
software for integrated care management, is taking a leading role in
fulfilling these industry needs. The company’s solutions enable the
integration of workflows across the care management continuum,
automate workflows intelligently based on client business rules and
facilitate collaboration between payers, providers and members,
thereby transforming traditional episodic-based care management
into a proactive and collaborative population management paradigm.
With an installed base across health plans, TPAs, care and disease
management organizations who collectively manage over 23 million
members, ZeOmega is placing actionable intelligence in the hands of
payers and providers to drive better outcomes, improved efficiencies
and increased collaboration among all the major constituents in the
healthcare ecosystem.
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39. LOOKING AHEAD
As we await the influx of new enrollees in the healthcare system in
Hospice, Infusion Therapy, Managed Care, and On-site Healthcare
2014, a perfect storm is looming for which the healthcare system
Delivery / Urgent Care) and looks forward to helping business
could be grossly unprepared. While it is unlikely that one player in
owners, investors and others interested in this important arena
the post-acute care market can solve the problem of unnecessary
within healthcare to understand and capitalize on the opportunities
hospital admissions, we do believe that increased collaboration
that undoubtedly exist.
between the providers, payers and consumers can make significant
strides in eliminating this waste in the system. The incentives for
these constituents to work together are beginning take hold and
innovators across the care continuum are making investments and
developing new strategies to prepare for the explosion of high-risk
individuals into our currently disjointed healthcare system in 2014.
For a growing number of market participants, the post-acute care
market represents an outstanding opportunity for growth and value
enhancement. Entering 2013, we believe there is an increased
demand for products, services and solutions in this category,
resulting in continued strong growth, robust M&A activity and an
increased focus from the professional investment community.
TripleTree is dedicated to the Healthcare Services (Acute Care,
Alternative Site Delivery, Care Coordination and Collaboration,
Community-Based Care Delivery, DME Distribution, Home Care,
POST-ACUTE CARE // INDUSTRY PERSPECTIVE Q4 / 2012
39

40. end notes
1
Agency for Healthcare and Quality, National Healthcare Quality Report, 2011.
2
Agency for Healthcare Research and Quality, Potentially Preventable Hospitalizations for Acute Chronic Conditions, November 2010.
3
AHIP, Innovations in Reducing Preventable Hospital Admissions, Readmissions, and Emergency Room Use, June 2010.
4
MedPac, Health Care Spending and the Medicare Program, June 2012.
5
American Action Forum, Healthcare Reform and Medicaid: Patient Access, Emergency Department Use, and Financial Implications for
States and Hospitals, September 2010.
6
7
http://www.foxnews.com/politics/2012/08/23/more-than-2200-hospitals-face-penalties-for-high-readmissions/
8
40
Represents Medicare spending
June 2012 Amedisys Investor Presentation
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