SNF VBP and SNF QRP review Tips for success Operational considerations - Payment Reform, the New Playbook: Success through Quality & Value-Based ...
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5/14/2019
Payment Reform, the New Playbook: Success through Quality &
Value-Based Programs
SNF VBP and SNF QRP review
Tips for success
Operational considerations
Payment Reform, the New
Playbook
1
5/14/2019
What is the SNF VBP program?
Program designed for quality
• “Protecting Access to Medicare Act
improvement and offers incentive of 2014” (PAMA)
payments to SNFs based on their • Performance standards
performance on specified measure • Automatic 2% withhold
of readmissions • Confidential feedback reports
• SNF 30-Day All Cause Readmission • Performance Reports
Measure (SNFRM)
• Different measure than Nursing Home • Public reporting
Compare and SNF QRP
Payment Reform, the New Playbook
SNF 30-Day All Cause Readmission Measure
Estimates risk-standardized rate of all-cause, unplanned hospital readmissions of
Medicare SNF beneficiaries within 30 days of discharge from their prior acute
hospitalization
Claims Based
Counted regardless of whether
patient was readmitted from SNF or
from home after SNF discharge
Excludes planned readmissions, AMA,
cancer dx, d/c’s to other SNF, 1 day
lapse in admission from hospital
Risk adjustments include patient
demographics, diagnosis,
comorbidities and other factors that
affect probability of readmission
Payment Reform, the New Playbook
2
5/14/2019
Incentive Payments
HOW? WHEN?
➢ Performance Period vs. Baseline Period
➢ Utilizes 2 performance scores ➢ On annual basis at start of new fiscal year
➢ Achievement score = facility’s performance ➢ First incentive payment began 10/1/18
against national averages
➢ Improvement score = facility’s performance
from baseline to performance period HOW MUCH?
➢ Incentive payment based on the higher of the 2
performance score ➢ Automatic 2% withhold
➢ Performance will dictate if facility incentive
Fiscal Year Achievement Benchmark
payment is “net negative” or “net positive”
FY 2020 19.79% 16.28% ➢ Total incentive payment payouts = 60% of
FY 2021 20.53% 16.79% total withhold amount
FY 2022 20.52% 16.79% ➢ Over $500m to be withheld with only
$300+m going back to SNF’s (FY 2019)
Baseline and Performance Periods
Impact on
Performance Period Baseline Period
Reimbursement
CY 2017
FY 2019 CY 2015
FY 2020 FY 2018
FY 2016
FY 2017
FY 2021 FY 2019
FY 2022
FY 2020 FY 2018
Payment Reform, the New Playbook
3
5/14/2019
SNF VBP Reports
Quality Improvement Quarterly Confidential
Evaluations System Feedback Reports
(QIES) and CASPER
Annual Performance Provider Reports –
Score Report Ranking File
The Future Outlook of
Key Regulatory Programs and Proposals
What is the SNF QRP program?
Program designed to meet requirements
• QRP will allow for
of the IMPACT Act of 2014 requiring CMS • Means of comparison
• Outcome measurement
to develop and implement quality • Standardized data
measures across 5 quality domains. Also • Improve Care Coordination
requires reporting of measures on • Required for all PAC settings
resource use, hospitalization and
• Submission and
discharge to community Review/Correct Deadlines
• 2% payment penalty for non-
compliance effective 10/1/18
Payment Reform, the New Playbook
4
5/14/2019
Current SNF QRP Quality Measures
Assessment Based Claims-Based
➢ Changes in Skin Integrity Post-Acute Care: ➢ Total Estimated Medicare Spending Per
Pressure Ulcer/Injury Beneficiary (MSPB)
➢ Percent of Residents Experiencing One or More ➢ Discharge to Community
Falls with Major Injury
➢ Potentially Preventable 30-day Post Discharge
➢ Percent of Patients with Admission and Discharge Readmission Measure for SNF
Functional Assessment and a Care Plan That
Addresses Function
➢ Drug Regimen Review Conducted with Follow-Up
for Identified Issues
Payment Reform, the New Playbook
SNF QRP for FY 2020
• Additional QM’s added for FY 2020 SNF QRP
• Data collection for the following measures began 10/1/18
Coincidence:
data
Change in Self-Care Score Discharge Self-Care Score collection
for Medical for Medical begins 1 year
Rehabilitation Patients Rehabilitation Patients before
(NQF #2633) (NQF #2635) PDPM?
Functional
Outcome
Change in Mobility Score Measures Discharge Mobility Score How could
for Medical for Medical CMS use
Rehabilitation Patients Rehabilitation Patients these new
(NQF #2634) (NQF #2636) QM’s for
Applications of IRF FOM’s payment??
Payment Reform, the New Playbook
5
5/14/2019
QM: Falls with Major Injury
Definition/Purpose Calculation
➢ Reports percentage of residents with one or
more falls with major injury # of Part A stays that
indicate one or more falls
➢ Major Injury = bone fracture, joint dislocation, with major injury
closed-head injury with altered consciousness, or
subdural hematoma
QM %
➢ Exclusions: unusable response (“-”), resident died
during SNF stay # of Part A stays eligible
stays, minus exlcusion
Payment Reform, the New Playbook
QM: Admission/Discharge Fxl Assmt & Care Plan
Definition/Purpose Calculation
➢ Reports percentage of residents with an
admission and discharge functional assessment Complete stays
and a care plan that addresses function +
Incomplete stays
➢ Compliance measure
➢ Higher percentages are better QM %
➢ Complete stay = admission assessment, d/c goal # of Part A stays during
and discharge assessment measurement target
period
➢ Incomplete Stay: admission assessment & d/c
goal
➢ Unplanned d/c, discharge to hospital, LOS <
3 days, resident death
Payment Reform, the New Playbook
6
5/14/2019
QM: Change in Self-Care
Definition/Purpose
➢ Estimates the risk-adjusted mean change in self-
care between admission and discharge
➢ Not a simple calculation
➢ Higher score = greater independence
➢ Target population = Part A stays, minus exclusions
➢ 6-point rating scale and activity not attempted
➢ Exclusions: incomplete stay, Independent at time
codes (Section GG)
of admission, certain medical conditions, younger
➢ Activity not attempted codes = 01
than 21, hospice, did not receive PT or OT on 5d
➢ If item skipped, dashed or missing = 01
assessment
➢ Scoring range of 7 to 42
Payment Reform, the New Playbook
QM: Change in Mobility
Definition/Purpose
➢ Estimates the risk-adjusted mean change in
mobility between admission and discharge
➢ Not a simple calculation
➢ Higher score = greater independence
➢ Target population = Part A stays, minus exclusions
➢ Exclusions: incomplete stay, Independent at time ➢ 6-point rating scale and activity not attempted
of admission, certain medical conditions, younger codes (Section GG)
than 21, hospice, did not receive PT or OT on 5d ➢ Activity not attempted codes = 01
assessment ➢ If item skipped, dashed or missing = 01
➢ Scoring range of 15 to 90
Payment Reform, the New Playbook
7
5/14/2019
QM: Discharge Self-Care Score
Definition/Purpose Calculation
➢ Estimates the % of part A residents that meet or
exceed an expected discharge self-care score # of resident stays with
➢ Risk-adjusted D/C score that is equal to
or higher than expected
➢ Functional outcome measure D/C score
➢ Higher scores = higher percent of residents QM %
met/exceeded expected discharge score
➢ Exclusions: incomplete stay, certain medical # of Part A resident stays,
conditions, under 21, hospice, did not receive PT except exclusions
or OT services on 5d assessment
Payment Reform, the New Playbook
QM: Discharge Mobility Score
Definition/Purpose Calculation
➢ Estimates the % of part A residents that meet or
exceed an expected discharge mobility score # of resident stays with
➢ Risk-adjusted D/C score that is equal to
or higher than expected
➢ Functional outcome measure D/C score
➢ Higher scores = higher percent of residents QM %
met/exceeded expected discharge score
➢ Exclusions: incomplete stay, certain medical # of Part A resident stays,
conditions, under 21, hospice, did not receive PT except exclusions
or OT services on 5d assessment
Payment Reform, the New Playbook
8
5/14/2019
QM: Pressure Ulcer/Injury Transition
CMS is transitioning from one pressure ulcer QM to a new pressure ulcer QM
Pressure Ulcer Measure Data Collection Provider Preview Reports Nursing Home Compare
Percent of Residents with
Final Report = May 2019 Final Display = July 2019
Pressure Ulcers that are Last Quarter = Q3 2018
(data from 10/1/17 – (data from 10/1/17 –
New or Worsened (Short (7/1/18-9/30/18)
9/30/18) 9/30/18)
Stay)
Changes in Skin Integrity Initial Report = Summer
Initial Display = Fall 2020
Post-Acute Care: Pressure Initial Quarter = Q4 2018 2020
(data from 1/1/19 –
Ulcer Injury (10/1/18-12/31/18 (data from 1/1/19 –
12/31/19)
12/31/19)
Payment Reform, the New Playbook
QM: Changes in Skin Integrity
Definition/Purpose Calculation
➢ Reports percentage of residents with a stage 2-4
pressure ulcers, or unstageable pressure ulcers
due to slough/eschar, nonremovable # of Part A stays that
dressing/device, or deep tissue injury, that are indicate new or
new or worsened since admission worsened pressure ulcers
➢ New or worsened unstageable pressure ulcers
now count
QM %
➢ Lower percentages are better
# of Part A stays ending
➢ Exclusions: missing data (“-”) on discharge, during selected time
resident death window, minus exclusions
➢ Risk Adjusted: dependent/max assist for sit to
lying, bowel incontinence, DM, PVD, PAD, low BMI
Payment Reform, the New Playbook
95/14/2019
QM: Drug Regimen Review (DRR)
Definition/Purpose Calculation
➢ Reports percentage of residents in with a DRR was
conducted at the time of admission and timely
follow-up with a physician occurred each time # of Part A stays that DRR
potential clinically significant medication issues completed on admission
were identified throughout the stay & appropriate follow-up
throughout the stay
➢ Adopted to meet IMPACT Act requirements
➢ Higher percentages are better
QM %
➢ Data collection began 10/1/18 # of Part A stays during
the reporting period
Payment Reform, the New Playbook
QM: Discharge to Community
Definition/Purpose Exclusions
➢ Reports risk standardized rate of Part A residents
who are discharged to community after a SNF stay ➢ Age under 18
and do not have an unplanned ACH/LTCH ➢ No short-term acute care stay within 30 days
readmission or death in the 31 days following preceding and IRF, SNF or LTCH admission
discharge ➢ D/C to psychiatric hospital
➢ AMA discharges
➢ Community = home or self-care, with or without ➢ D/C to Hospice
HH ➢ Patients not continuously enrolled in Medicare
Part A for the 12 month prior to PAC admission
➢ Based on how discharge to community is coded date and 31 days post PAC discharge date
on claim ➢ Planned discharges to ACH or LTCH
➢ Patients whose short term acute care stay was for
➢ Higher rates are better non-surgical treatment of cancer
➢ PAC stays that end in transfer to same level of care
➢ Exclusions: (i.e. SNF to SNF)
Payment Reform, the New Playbook
105/14/2019
QM: PPR and MSPB
Potentially Preventable 30-Day Post Discharge
Medicare Spending Per Beneficiary - SNF
Readmissions
➢ Evaluates SNF’s efficiency relative to the efficiency
➢ Estimates risk-standardized rate of unplanned,
of national median SNF providers
potentially preventable readmissions
➢ Assesses cost to Medicare for services
➢ Not a simple calculation
➢ Price standardized, risk-adjusted
➢ 30-day window from PAC Discharge
➢ Score calculation /provider’s value:
➢ Measure is currently suppressed – not on NHC
➢ > 1 = spending higher than national median
➢ < 1 = spending less than national median
Payment Reform, the New Playbook
SNF QRP – Public Reporting
Payment Reform, the New Playbook
115/14/2019
SNF QRP – Data Submission Requirements
➢ All data must be submitted/corrected by the final submission deadline
➢ Failure to meet submission requirements = 2% penalty
Payment Reform, the New Playbook
SNF QRP Reports
Quality Improvement Review and Correct
Evaluations System Reports
(QIES) and CASPER
Provider Preview NHC Website Posting
Reports
Payment Reform, the New Playbook
125/14/2019
SNF QRP – Reporting Timeline for New QM’s
Payment Reform, the New Playbook
SNF VBP and SNF QRP: Readmissions and D/C to Community
Education
• Are staff aware of the various readmission/ discharge measures and their impact
across programs & reimbursement?
• Are they aware of and reviewing feedback reports available via CASPER?
• Do they know the submission and correction deadlines?
• Clinical education to improve quality, identify patients at risk
• Are staff knowledgeable in regards to diagnosis that are “potentially preventable”
for readmissions?
• Are staff aware of the most common reasons for readmission?
Processes
• Are you tracking readmissions during SNF stay? After SNF stay?
• QAPI to identify and correct care issues
• Readmission reviews
Transition planning
• Comprehensive preparation and planning for discharge
• Care coordination with home health
Payment Reform, the New Playbook
135/14/2019
Section GG Tips and Operational Considerations
Education
• Have all staff received the appropriate training?
• Has a QAPI been competed to ensure accuracy of coding?
• Do staff utilize the reports available via CASPER?
• Do they know the submission and correction deadlines?
• Are staff aware that Section GG is a process measure AND outcome measure AND
reimbursement driver under PDPM?
The GG Team
• Designate a Section GG “Quarterback”
• Identify team members: nursing, rehab and others
• Define roles and expectations
Compliance & Documentation
• Do you have process in place for GG supportive documentation? Who is responsible to
audit?
• Is GG scoring truly interdisciplinary?
• Are you capturing usual performance? Baseline performance? Using all 3 days of the
window?
• Who is responsible to care plan?
Payment Reform, the New Playbook
QUESTIONS
Matthew Nash
QUESTIONS
VP of Strategic Development, PTS
mnash@preftherapy.com
Matthew Nash
QUESTIONS
VP of Strategic Development, PTS
mnash@preftherapy.com
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