Shifting from PPS to Quality & Value Maureen McCarthy, RN, BS, RAC-MT, QCP-MT President/CEO Celtic Consulting www.celticconsulting.org Presented by Maureen McCarthy, RN, BS, RAC-MT, QCP-MT
Maureen is the President of Celtic Consulting, LLC and the CEO and founder of Care Transitions, LLP; a care coordination service provider, both women owned companies. McCarthy is also the creator of the MCCARTHY METHOD, a documentation improvement system for ADL coding. She has been a registered nurse for 30 years with experience as an MDS Coordinator, director of nursing, rehab director and a Medicare biller. She is a recognized leader and expert in clinical reimbursement in the skilled nursing facility environment; She is currently the president for the Association of Long Term Care Financial Managers, is the Medicare & MDS 3.0 Advisor for Connecticut Association of Health Care Facilities (CAHCF), and is an advisor to the J13 Medicare contractor National Government Services Provider Advisory Group. She is also an Editorial Advisor for HCPro, a national publication for post-acute care providers, as well as an advisor to the New York State Health Facilities Association on the
Nursing Leadership Committee, as well as, the Payment for Services Group. Maureen is dually certified in the resident assessment process by nationally recognized organizations and holds Master Teacher status with AANAC. She holds a degree in Business Management as well as a Nursing degree and served as an expert witness. In September of 2011, she released her first co-authored publication, THE LONG TERM CARE COMPLIANCE TOOLKIT, and is currently under contract for a second publication, ICD-10 Compliance Process Improvement and Maintenance for LTC, which was released June 2015, a third publication on Medicare Audits: A Survival Guide for SNF released October 2016 with a 4th publication on Using the 5-Star Quality Rating System Technical Users Guide to improve outcomes released 3/15/17. Maureen and her associates at Celtic Consulting regularly provide education and training on reimbursement, regulatory
compliance, quality improvement, preferred provider networks and ICD-10 coding for SNFs, state affiliates and provider organizations. Objectives Review CMS initiatives for healthcare reform Explain the SNF Value Based Program Explain the SNF Quality Reporting Program Discuss how new MDS sections and quality measures affect these initiatives
Suggest recommendations for preparation, monitoring, and improvement Medicare Trust Solvency Medicare beneficiaries will increase from 54 million to 81 million by 2030. Of those, 64 million expected to be FFS CMS Triple Aim: Better Care
Healthier Population Lower Costs Future Payment Reform CMS expects 30% of FFS payments to be tied to an quality or value by 2016 (ACO/MSSP) Goal has already been met for 2016 Then increase to 90% of all FFS payments by 2019
Quality & Value is the new currency Federal Oversight Reporting structure
Quality measures CASPER reporting 5-star rating system PEPPER reports Medical record reviews (ADR) Current CMS Measurement Reporting
NH Quality Measure Report 5-star Rating System SNF Value Based Purchasing SNF Quality Reporting Program And more to follow Survey weights 3 most recent annual inspections Includes substantiated complaint surveys
Each deficiency is weighted by scope & severity More recent surveys weigh more heavily Most recent= of survey score total 1st prior survey= 1/3 of survey score 2nd prior survey= 1/6 of survey score Complaint surveys
Substantiated findings from last 36 months Within the last calendar year= weight 13-24 months ago= 1/3 weight 25-36 months ago=1/6 weight How resurvey weighs in Revisit # 1st
2nd 3rd 4th Takes into account multiple revisits to achieve compliance Noncompliance points 0
50% of survey score 70% of survey score 85% of survey score Cut point tables Survey score thresholds for NY 1 star 52 or^ Feb 2017
2 star thru 26 3 star thru
13.3 4 star 5 star thru 3.33 below
3.33 Staffing Stars Expected staffing levels calculated based on resident acuity levels using RUGs (MDS data) 2 separate staffing measures with equal weight, score based on combination RN staffing hours PPD Total nurse staffing hours PPD
RNs, LPNs, Aides Where does CMS get staffing data Staffing numbers come from the CMS-671 form completed during survey Full time employees Part time employees Contracted staff
Census from the 672 (total residents) Resident census & conditions report Staffing Stars Compares 3 areas of staffing Actual staffing hours per patient day (PPD) Expected staffing hours PPD-based on CMI/RUGs Adjusted staffing hours PPD
Expected Staffing weights Staffing is a case-mix adjusted based on RUG categories RUGs for each resident are calculated on the last business day of each quarter using the most recent assessment for each resident at the facility during the quarter Facilities with higher acuity are expected to have higher staffing levels Expected Staffing Stars Based on percentile ranking compared to other facilities
nationwide Staffing thresholds for RUGs from time studies (STRIVE) 19951997 Uses the quarter closest to the date of the most recent standard (annual) survey Case mix adjustment-RUGs Case-mix adjustment PPD Hours reported on 671 divided by hours expected times National average hours
Hrs reported/hrs expected x national hrs= adjusted hrs Reported hours-671 form at survey Expected hours-reported hours with case-mix adjustment National average- average across the country Payroll-based staffing reporting Quarterly electronic reporting of payroll Reported staffing levels auditable back to payroll
Allows CMS to calculate QMs for staff turnover/retention and changes throughout yr Report types and levels of staffing for each facility CMS expects providers to use the data to improve staffing and quality of care Now reported on 5-star reports Minimum staffing levels??
5 Star Ratings/Quality Metrics Star Ratings fluctuate MDS Data can go back as far as 369 days Monitor your QM reports regularly CASPER vs. Nursing Home Compare Survey sets the basis for your stars, then QMs and staffing add to the star basis
Long Term QMs Pain pre-scripted, watch timing, interviews only High risk PU is striated, watch covariates Restraints-very low threshold Falls with injury-longest look-back UTI-watch for s/s, positive test results, and treatment Catheter-neurogenic bladder/obstructive uropathy Psych meds-any use Late loss locomotion
Late loss ADL decline Quality Measures 2016 New long stay measures (101 days or more in the SNF) Mobility decline since prior MDS Decline in locomotion on the unit Either walking or wheelchair mode Risk adjusted based on prior assessment coding of eating, toileting,
transfer, walk in corridor 1 point level decline will trigger Short Term 5-star QMs Moderate to severe pain (interview) New or worsened pressure ulcer New psych meds Improvement in Function-mid-loss (transfer, walking, locomotion) Each measure has its own cut point tables
Additional QMs are reported, but not used in 5-star QM calculations. Weight loss, behaviors affecting others, Bowel & bladder loss low risk, signs of depression, antianxiety/hypnotics, vaccinations Quality Measures 2016 Claims based measures are all short stay (100 days or less in SNF) 1 additional SS measure is MDS based
Improved mid-loss ADLs Transfer, walking in corridor, locomotion on unit Compares 5-day MDS to DRNA MDS for improvement MDS coding of 7 or 8, translates to 4-total
Risk adjusted based on certain indicators Improvement in function upon DC Measuring those who gain independence in transfer, locomotion and walking during their episodes of care. Excludes hospice, 6 months or less life expectancy Comatose, or unplanned discharge Excludes those coded independent on 5-day Mid-loss ADLs sum of 3 codes:
Transf, loco-unit, walk-corridor Any decrease triggers here Claims Based Measures for 2016 All cause/all condition rehospitalizations within 30 days of hospital discharge Emergency Department use within 30 days of hospital discharge Successful Discharge to the Community readmissions or death within 30 days of SNF discharge
Emergency Room Measure If a nursing home often sends many of its residents to the ED, it may indicate that the nursing home is not properly assessing or taking care if its residents Measures residents going to ED within 30-days of a SNF admission Excludes hospice and comatose Excluded if admitted
Discharge to the Community Measures successful discharges back to community within 100 days of SNF admission Successful=no readmissions, or death for 30 subsequent days Measures at the end of the episode not the stay Discharge return not anticipated SNF Quality Reporting
Program Implementation 10/1/2016 Shifting from FFS to Quality
Phased in over 5 years Standardize reporting over the care continuum All PAC providers to report data similarly New section to MDS- GG begins 10-1-2016 Measures functional limitations on admission and at discharge Can compare Med A vs. all payers Other sections to change to match coding across PAC settings
Improving Medicare PAC Transformation Act of 2014 This Act is more detailed than Triple Aim and calls for:
Data element uniformity (standardized assessment and data) Quality care and improved outcomes Comparison of data across continuum Improved discharge planning Exchangeability of data Coordinated care
Phased in over 5 years through 2020 CMS is required to report data within 2 years of inception of the measures QMs for SNFQRP under IMPACT MDS-Based Measures:
Functional status and cognition changes from admit to d/c (10-1-16) Skin integrity and changes: new or worsening pressure ulcers (10-1-16) Falls with major injury (10-1-16) Care Plan- communication of health info (10-1-18) Medication reconciliation (10-1-18)
FY17 Claims-Based Measures Under Consideration MSPB-Medicare Spending per Beneficiary Discharge to community, All-cause re-hospitalization, MDS data affect on FY17 Medicare Rates CMS currently looking for compliance with submitting SNFQRP data
At least 80% is expected Data collected will be compared and analyzed Will likely be used for future payment methodology PPS Final Rule refers to FY17and future years Hospital rates affected by measures, SNFs likely to be next Skin Integrity Measures new or worsening pressure ulcer data collected 10-1-1612-31-16 Short term measure under 5-star, will be used for all residents under
QRP, regardless of length of stay Used for FY 2018 payments, your current data will be used against you beginning 10-1-17 Falls with Major Injury Resulting in fractures, subdural hematoma, closed head injury with altered consciousness, dislocation, even if not detected until after discharge Data collected 10-1-16 through 12-31-16 will be used for 2018 rates.
MDS section J1900C = 1, 2; Any fall with major injury, counts as a change in function Change in Functional Independence Percentage of patients with admission and discharge functional assessment and a care plan that addresses function Introduces Section GG into MDS for Medicare FFS residents CMS unsure how the care plan component will be addressed delayed until 10/1/18
IMPACTing Section GG Satisfies the functional assessment requirement of IMPACT on admission and discharge Compares usual status observed days 1-3 from admission, to discharge status of usual performance on last 3 days of the stay, Requires facility to set goals at the time of the 5-day MDS, for improvement in the functional areas assessed in the new section Required to be completed for all traditional Medicare Part A PPS
admissions 10-1-16 and after If ARD is 10-1-16 or after, will be required to be completed, but data will not be used in SNFQRP calculations Admission and Discharge Functional Assessment and Care Plan Measures functional and cognitive changes from admission to discharge at the end of the episode of care
It is also expected that the resident has at least 1 goal addressing function Uses Admission MDS & Discharge return not anticipated, does not include MDSs in between, or Discharge return not anticipated Also includes End of PPS stay, which also ends the episode of care Measures focus on residents care needs and mobility in 3 ways: 1. Admission Performance 2. Discharge Goals
3. Discharge Performance Admission and Discharge Functional Assessment and Care Plan Functional care areas include: Eating- using utensils Oral hygiene- using utensils
Toileting hygiene- includes clothing and cleaning after using the toileting receptacle Mobility and turning while mobile Transferring position during various situations Tip: When coding discharge goal section, be sure to include in care plan. CMS is expecting licensed clinicians to collaborate on this section (RN, LPN, PT, OT, SLP) GG0130
Self Care Measures for 2017 & 2018 Full year data collection, updated April & October annually MSPB Medicare Spending per Beneficiary Successful discharge to community 30-day all cause re-hospitalizations
Proposed measure for FY 2019, beginning 10-1-18 Medication reconciliation 2017 Anticipated Section N October 1, 2017 MDS changes Did the resident receive antipsychotic meds since admission, reentry or last OBRA assessment?
Was a gradual dose reduction (GDR) attempted? Date of last GDR Is GDR contraindicated by physician? Date of determination by physician Not related to SNFQRP data, but will likely be measured in another
program. FY18 SNFQRP Medication Reconciliation Medication review conducted Follow up of identified issues Reporting period 10-1-18 to 12-31-18 for FY 2020 2018 changes to Section N of MDS
Reporting Data Collected through MDS submissions Claims data is not covered under this requirement At least 80% of all MDSs submitted must report this data (no dashes) 2% penalty for not reporting per requirements Penalty is enforced for the entire fiscal year, annual payment update Highest risk is with payer source identification upon admission, or
with changes in payers Reporting Data (continued) Additional MDS type required to collect data for the PPS stay SNF Part A PPS discharge Both discharges and those ending a PPS stay, Level of care drop-resident not leaving building but cut from Part A benefits, or benefits exhaust Tip: Verify submission status of MDSs via validation report and follow up on
warnings Deadline to submit data is 5/15/17 All MDSs with assessment reference dates (ARD) of 12/31/16 and before are expected to be finalized and submitted by 5/15/17 Data Collection Purpose CMS is researching future payment methods based on patient characteristics
Likely to be based on episodes of care Likely to be paid based on bundled methodology or a step down approach Data will be publicly reported Fall 2018 CMS training slides state providers will have an opportunity to correct the data claims-based data only, before it becomes public, not the quality data. Recent calls with CMS suggest that there may be an opportunity for MDS data to be corrected as well during Phase 1.
Managed Care MDSs Managed Care MDSs (regardless of whether they are Medicare replacement plans or commercial) should not be transmitted to the CMS repository, unless required for OBRA. DO NOT submit managed care MDSs unless needed for survey, i.e. significant change, annual, admission, quarterly So if your facility tracks these MDSs, they should not be submitted
Keep in mind, not all payers require PPS MDSs 3-yr Limit- must have ARD within 3 yrs for submission (any type of payer or MDS) 62 HIPPS & RUGs for HMOs If a resident is not in the facility long enough for an admission assessment (14 days), a RUG score and HIPPS modifiers of AAA00 may be used.
No assessment is required Unless you are contracted to be paid by the RUG CMS memo 12/4/2014 SNF Value-Based Purchasing The Next CMS Initiative Hospital Readmissions
Value-Based Purchasing Readmission Policy Readmission rates will be risk-adjusted CMS is looking at phasing in readmission penalties for SNFs Financial impact to hit in 2019 Adding additional measures to be monitored Purchasing Value Value Based Purchasing (VBP) is part of CMSs long
standing effort to link Medicares payment system to value-based system to improve healthcare quality. Hospital payments are adjusted based on their performance in 4 weighted domains Clinical care process 10%, patient experience 25%, outcomes 40%, and efficiency 25% SNF Value Based Purchasing Part of Protecting Access to Medicare Act of 2014 (PAMA)
Program begins FY 2019 (10/1/18) Concept calls for providers to show their value by reducing costs, so CMS is buying good value with their Medicare dollars. Currently, measures are based on re-hospitalizations. SNF VBP Result of PAMA of 2014 enacted 4-1-14 under Social Security Act Focus of the program:
Performance standards including achievement and improvement ratings Rank SNFs for from low to high based on performance 2% of PPS/Medicare payment withheld to fund program Incentive payments to providers must total 50-70% of amount withheld
Incentive payments=buying your money back, up to 2% Both measures are based on hospital readmissions SNF PPR- potentially preventable, risk adjusted (begins 10/1/18) SNF RM- all-cause/condition, original measure (begins 1-1-17) Payments affected 10/1/18 SNF RM Risk- standardized, all cause, all condition, unplanned hospital
readmissions within 30 days of hospital discharge Identified through Medicare claims Regardless of whether SNF discharged resident, or if it happened after discharge from the SNF Risk adjustment standardized based on demographics, diagnoses, prior hospitalization Excludes planned readmissions This measure will be used for 1st year of program This is how the data for new re-hospitalization QM was delivered
SNF PPR Potentially Preventable Re-hospitalizations Also a 30 day window of risk Applies a risk adjustment covariate prior to SNF discharge Some apply during the SNF stay (within PAC stay) Some apply after SNF discharge (past discharge list) More risk adjustment opportunities than SNF RM
Will replace SNF RM measure in future systems SNF VBP Re-hospitalization measure RM _____________________________ 2017 your SNF Improvement Rating up to 90 points _____________________________ 2015 your SNF Better of the two, Improvement Rating
Achievement Rating SNF VBP Re-hospitalization measure RM Benchmark- average top performing SNFs in 2015 (16.40) (83.60% treated in house) _____________________________ 2017 your SNF Achievement Rating 25% threshold (20.41) or (79.59) _____________________________ 2015 ALL SNFs
If your SNF meets the benchmark, then your rating is 100. If your SNF doesnt meet at least the 25th percentile, then your rating is 0. Remainder will be disbursed, 0-99. SNF VBP Measure Results in achievement rating score based on percentage of residents that were not readmitted during the window Compares value rating scores between providers How did you do in 2017 compared to all SNFs nationwide in 2015?
If you did better than benchmarks (100 points) If you did worse than achievement threshold (0 points) All facilities in between points assigned based on Achievement Score Second score Improvement Score based on how well your facility did in 2017 compared to your 2015 data Above benchmark (90 points) If worse than 2015 (0 points)
Performance Scores The lower the readmission rate, the better. Since a lower readmission rate is better, CMS has inverted every SNFs readmission rate using (1 readmission rate) for the purposes of the performance standards (i.e., benchmark and achievement threshold) and performance scoring. Standard 2015 25th Percentile 20.41% Achievement Threshold 79.59%
Mean of the Best Decile 16.40% Benchmark 83.60% 2015 Performance data Risk Adjustment Example risk adjustment variables include the following (List is not all inclusive): patient demographics (e.g., age and sex)
principal diagnosis in the prior hospitalization comorbid conditions disability as the original reason for Medicare coverage health service factors (e.g., length of stay and any time spent in intensive care unit during the patients prior proximal hospitalization) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ValueBased-Programs/Other-VBPs/SNF-VBP.html. SNF VBP CMS considering how to translate those scores into Medicare
payment methodology Quarterly reports to SNF before public reporting Excluded Rehospitalizations SNF stays where: There was an intervening post-acute care admission within the 30-day measure window There was more than 1 day between the prior proximal hospital discharge and the SNF admission The patient was discharged from the SNF against medical advice
The principal diagnosis from the prior proximal hospitalization was for pregnancy The principal diagnosis from the prior proximal hospitalization was for medical treatment of cancer SNF VBP Preview Reports CMS has begun to provide them via the Quality Improvement Evaluation System (QIES) and the CASPER reporting application currently used by SNFs to report quality performance.
Blank example reports were distributed to all SNFs in October 2016 and reports populated with CY 2013 data were disseminated in December 2016.CY 2014 data was provided to SNFs in late February CY 2015 data planned to be provided in June SNFVBP Preview Reports Potential Additions to the Provider Reports
Patient-level data elements currently being considered for inclusion include: Patient identifiers (Health Insurance Claim Number [HICN], Sex, Date of Birth) Index SNF information (admission/discharge dates, discharge status code) Prior proximal hospital informationCMS Certification Number [CCN], admission/discharge dates, discharges status code, principal diagnosis) Readmission hospital information (CCN, admission/discharge dates, principal diagnosis) SNFRM risk-adjustment factors
Retrieving SNFVBP Reports Modifying Data It is the responsibility of each SNF to provide corrections to information prior to the time of public reporting. CMS has finalized a process where the quarterly reports will provide SNFs with: A count of readmissions The number of eligible stays at the SNF
The SNFs risk-standardized readmissions rate The national SNF measure performance rate Modifying Data For the first phase, SNFs must submit correction requests for their quality measure data to [email protected] and provide the following: CMS Certification Number Facility name
Correction requested and basis for the correction Appropriate documentation or other evidence supporting the request Modifying Data Phase One corrections are limited to review and correction of SNFs quality measure information. Phase Two corrections are limited to SNFs performance scores and ranking. CMS will propose more specific requirements for Phase Two corrections in
the future, and welcomes feedback. Correction requests to the contents of any quarterly report will be accepted until March 31 following the reports delivery. If corrections are provided after information is publicly reported but before the March 31st deadline, corrections will be made retroactively. CMS will review the requests and notify the requesting SNF of the final decision. Provider Reports
New Programs to Encourage Value Payments to nursing homes will be tied to Value CJR Bundling Shared savings & ACO partnerships SNF_PUF files Estimated Medicare spending per beneficiary Monitor spending
Rehospitalizations is a huge impact on spending Become familiar with these concepts and data CMS directed CCJR Pilot Comprehensive Care for Joint Replacements 67 MSAs nationally, and began 4/1/2016 2 counties in New York NY/Newark/Jersey City-NY/NJ/PA Bergen, Bronx, Dutchess, Essex, Hudson, Hunterdon, Kings
Middlesex, Monmouth, Morris, Nassau, Ocean, Orange, Passaic, Pike, Queens, Richmond, Rockland, Somerset, Suffolk, Sussex, Union, Westchester, Buffalo/Cheektowaga/Niagara Falls Erie/Niagara Counties CJR Lower limb joint replacements (hip, knee, ankle) Hip & Femur fractures to be included 10/1/17
Introduces episodic payments to providers Starts at hospital admit through 90 days after discharge One payment for the episode, payments to providers disbursed by episode owner, hospital All care is bundled for all providers Mandatory participation for providers in MSA CMS Bundles
Cardiac Bundle begins 10/1/17 delayed from 7/1/17 AMI-Heart Attack CABG- Bypass List of participating counties or hospitals not announced yet
Sharing Risk Future Payments for SNFs RUG rate minus 1% The 1% goes into the shared savings pool Quality measures must also be met before any shared savings are disbursed, not just cost savings Hospital must provide CMS with structure of how shared savings, if any, will be disbursed.
Episode of Care Hospital owns the episode of care Responsible for spending by all providers Responsible for outcomes Tracking data and outcomes Performance measured quarterly Risk adjusted for MCC
Sweet Spot for SNFs The carrot for SNF providers is the safe harbor in CJR program 3 stars or higher to waive the 3-night qualifier 2 stars or lower can not cover on Medicare A unless 3-night qualifier is met Episodic payment structure Payments from CMS based on amount
reimbursed for that diagnosis/condition for the episode of care No RUG influence , diagnosis based No incentive to push up rehab provision Must receive enough to avoid rehospitalization or poor outcome, SNF may be responsible for 30-day period post-discharge. Documenting Quality Care
Physicians orders Treatments and services given Resident response Any changes from baseline, new symptoms, or changes in
frequency or intensity of prior conditions Communications with other health professionals or caregivers regarding the resident Outside the Box
continue to monitor Assess the resident. What, why, how are you monitoring? What are you doing with the results of this monitoring? Was the treatment plan altered? Enhanced Care & Coordination Program
Current pilot in 7 states (NY, PA, MD, NE, NV, IN, AL) 80% of rehospitalizations related to 6 conditions
COPD PNA Dehydration CHF UTI Skin ulcers/cellulitis Proactive Solutions
Clinical programming Improve nursing skills #1 physical assessment skills Improves physician communication and confidence Enhances SBAR success Successful programs include increased nursing presence
APRNs focus on clinical changes Proactive Solutions Use services onsite to decrease costs and avoid disruptive transfers IV starts, IV push meds, or clysis Respiratory treatments and diagnostics NG tube placement and care Medication reconciliation at admission and discharge
Both medical and financial benefits Will be required by 10/1/18 Questions? Maureen McCarthy, RN, RAC-MT, QCP- MT President/CEO Phone: 860-321-7413
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