snf pps fy2020 - ohca...fy2017 snf pps final rule outlined a phase one requested correction deadline...
TRANSCRIPT
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Thursday, October 10, 2019
Here, There, Everywhere a Measure: Making Sense of Quality Measures
OHCA Fall Conference 2019
Contents
❖ Quality Measures- General Thoughts
❖ CMS Quality Measures
❖ Nursing Home Compare/5 Star
❖ SNF Value Based Purchasing Program (VBP)
❖ Ohio Medicaid Quality Incentive Program
❖ SNF Quality Reporting Program (QRP)
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Quality Measures:General Thoughts
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Advancing Health Information Exchange
❖ The Department of Health and Human Services (HHS) has a number of
initiatives designed to encourage and support the adoption of interoperable
health information technology and to promote nationwide health information
exchange to improve health care.
❖ The Office of the National Coordinator for Health Information Technology
(ONC) and CMS work collaboratively to advance interoperability across
settings of care, including post-acute care.
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Advancing Health Information Exchange
❖ CMS developed a Data Element Library (DEL) to serve as a publicly
available centralized, authoritative resource for standardized data elements
and their associated mappings to health IT standards.
❖ The 21st Century Cures Act (the Cures Act) (Pub. L. 114-255, enacted
December 13, 2016) requires HHS to take new steps to enable the
electronic sharing of health information ensuring interoperability for
providers and settings across the care continuum.
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Advancing Health Information Exchange
❖ These interoperable data elements can reduce provider burden by:
❖ allowing the use and exchange of healthcare data,
❖ support provider exchange of electronic health information for care coordination,
❖ person-centered care, and
❖ support real-time, data driven, clinical decision making.
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Statutory Basis and Scope
❖ Section 215(a) of the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113- 93, enacted April 1, 2014) added section 1888(g) to the Act requiring the Secretary to:
❖ specify an all-cause all-condition hospital readmission measure and
❖ an all-condition risk-adjusted potentially preventable hospital readmission measure for the SNF setting.
❖ Additionally, section 215(b) of PAMA added section 1888(h) to the Act requiring the Secretary to implement a VBP program for SNFs.
❖ Finally, section 2(c)(4) of the IMPACT Act amended section 1888(e)(6) of the Act, which requires the Secretary to implement a QRP for SNFs under which SNFs report data on measures and resident assessment data.
❖ Ohio State Budget Bill
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National Quality Forum (NQF)
❖ The National Quality Forum (NQF) is a not-
for-profit, nonpartisan, membership-based
organization that works to catalyze
improvements in healthcare.
❖ NQF measures and standards serve as a
critically important foundation for initiatives
to enhance healthcare value, make patient
care safer, and achieve better outcomes.
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CMS National Quality Initiative:Quality Measures
Purpose of QM’s
❖ Nursing home quality measures have four intended purposes:
❖ To give you information about the quality of care at nursing homes in order to help you choose a nursing home for yourself or others;
❖ To give you information about the care at nursing homes where you or family members already live;
❖ To give you information to facilitate your discussions with the nursing home staff regarding the quality of care; and
❖ To give data to the nursing home to help them in their quality improvement efforts.
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Short vs Long Stay Definitions
❖ The short stay resident quality measures show the average quality of resident
care in a nursing home for those who stayed in a nursing home for 100 days or less
or are covered under the Medicare Part A Skilled Nursing Facility (SNF) benefit.
Short-stay residents often are those recovering from surgery or being discharged
from a hospital stay. Many short-stay residents get care in a nursing home until
they’re able to go back home or to the community.
❖ The long stay resident quality measures show the average quality of care for
certain care areas in a nursing home for those who stayed in a nursing home for
101 days or more. Residents in a nursing home for a long-stay are usually not
healthy enough to leave a nursing home and can’t live at home or in a community
setting. These residents may be older and have more serious health issues.
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Nursing Home Compare
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5 Star
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5 Star- QM Domain
❖ QM ratings are based on performance on a subset of 12 MDS-based QMs
and five measures that are created using Medicare claims. These
measures were selected for use in the rating system based on their:
❖ validity and reliability,
❖ the extent to which nursing home practice may affect the measures,
❖ statistical performance, and
❖ the importance of the measures.
5 Star QM’s- Long Stay from MDS
❖ Percent of residents whose need for help with activities of daily living has increased
❖ Percent of residents whose ability to move independently worsened
❖ Percent of high-risk residents with pressure ulcers
❖ Percent of residents who have/had a catheter inserted and left in their bladder
❖ Percent of residents with a urinary tract infection
❖ Percent of residents who self-report moderate to severe pain
❖ Percent of residents experiencing one or more falls with major injury
❖ Percent of residents who received an antipsychotic medication
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5 Star QM’s- Short Stay from MDS
❖ Percent of residents who made improvement in function
❖ Percent of SNF residents with pressure ulcers that are new or worsened
❖ Percent of residents who self-report moderate to severe pain
❖ Percent of residents who newly received an antipsychotic medication
5 Star- Claims Data Measures
❖ Measures for Long-Stay residents that are derived from claims data:
❖ Number of hospitalizations per 1,000 long-stay resident days
❖ Number of outpatient emergency department (ED) visits per 1,000 long-stay resident days
❖ Measures for Short-Stay residents that are derived from claims data:
❖ Percent of short-stay residents who were re-hospitalized after a nursing home admission
❖ Percent of short-stay residents who have had an outpatient emergency department (ED) visit
❖ Rate of successful return to home and community from a SNF
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5 Star QM Risk Adjustment
5 Star QM Point System- Decile
❖ For long-stay ADL worsening, long-stay antipsychotic medication, long-stay
mobility decline, the two claims-based long-stay measures, short-stay
functional improvement, and three claims- based short-stay measures:
nursing homes are grouped into deciles based on the national distribution of
the QM.
❖ Nursing homes in the lowest performing decile receive 15 points for the
measure. Points are increased in 15 point intervals for each decile so that
nursing homes in the highest performing decile receive 150 points.
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5 Star QM Point System- Quintile
❖ For long-stay pain, long-stay pressure ulcer, long-stay catheter, long-stay
urinary tract infections, long-stay falls, short-stay pain, short-stay pressure
ulcer, and short-stay antipsychotic medication: nursing homes are grouped
into quintiles based on the national distribution of the QM.
❖ The quintiles are assigned 20 points for the lowest performing quintile, 100
points for the highest performing quintile, and 40, 60 or 80 points for the
second, third and fourth quintiles respectively.
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Ohio Medicaid Quality Incentive Program
Medicaid Quality Incentives- Existing
❖ Short Stay
❖ Short Stay new or worsened pressure ulcers.
❖ Short stay newly received anti-psychotic medications.
❖ Long Stay
❖ Long stay residents at high risk for pressure ulcers had pressure ulcers.
❖ Long stay received anti-psychotic medications
❖ Long stay un-planned weight loss.
❖ Target score is set at the 40th percentile
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Medicaid Quality Incentives- Existing
❖ Facility employee retention rate
❖ ODA Satisfaction Surveys:
❖ Resident Satisfaction Survey (Even years)
❖ Family Satisfaction Survey (Odd years)
❖ Target Score for these is set by the Department of Medicaid
Medicaid Quality Incentives- New
❖ 4 Long Stay Metrics are used from CMS 5 Star Rating
❖ (a) The percentage of the nursing facility's long-stay residents at high risk for pressure ulcers who had pressure ulcers during the measurement period;
❖ (b) The percentage of the nursing facility's long-stay residents who had a urinary tract infection during the measurement period;
❖ (c) The percentage of the nursing facility's long-stay residents whose ability to move independently worsened during the measurement period;
❖ (d) The percentage of the nursing facility's long-stay residents who had a catheter inserted and left in their bladder during the measurement period.
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SNF Value Based Purchasing
SNF VBP Program’s Hospital Readmission Measure
❖ The SNF VBP Program awards incentive payments to SNFs based on their performance on the SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510).
❖ The SNFRM measures the rate of all-cause, unplanned hospital readmissions for SNF residents within 30 days of discharge from a prior hospital stay.
❖ The SNFRM is risk adjusted for stay-level factors including clinical and demographic characteristics.
❖ Each SNF receives a SNFRM score for a baseline period and a performance period.
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SNFPPR Update- Change of Name
❖ Confusion between QRP and VBP Measures:
❖ Skilled Nursing Facility 30-Day Potentially
Preventable Readmission Measure (SNFPPR) for
VBP
❖ SNF QRP Potentially Preventable Readmission
Measure
❖ To minimize the confusion surrounding these two
different measures, we are changing the name of the
SNFPPR to Skilled Nursing Facility Potentially
Preventable Readmissions after Hospital Discharge.
Baseline and Performance Periods By Program Year
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FY 2020 Performance Standards
❖ FY2020 Achievement Threshold is 19.8%
❖ FY202 Benchmark is 16.3%
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FY 2021 Performance Standards
❖ FY2021 Achievement Threshold is 20.5%
❖ FY2021 Benchmark is 16.8%
FY 2022 Performance Standards
❖ FY2022 Achievement Threshold is 20.9%
❖ FY2022 Benchmark is 17.1%
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IS VBP a Success?
Year Achievement
Threshold
Benchmark
FY2020 SNFRM 19.8% 16.3%
FY2021 SNFRM 20.5% 16.8%
FY2022 SNFRM 20.9% 17.1%
Readmission Rates
❖ From 2013 to 2015 the Readmission Rate was essentially the same at 19.6%
❖ Payment for Care
❖ $1,986 Hospital Daily Rate in the US in 2015
❖ $515 SNF Average Medicare A Rate
❖ How many people are caught in the middle of these rates?
❖ 19.6%…
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VBP Phase One Review Correction
❖ FY2017 SNF PPS Final Rule outlined a Phase One requested correction
deadline of March 31 for the prior calendar year.
❖ FY2020 SNF PPS Final Ruling:
❖ “The 30 day review and correction period would commence on the day
that we issue the June report, and a SNF would not be able to request
that we correct any underlying claims or its measure rate after the
conclusion of that 30 day period.”
Managed Care/ACO/Preferred Providers
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Metric Categories- QM’s
❖ Quality Measures
❖ Short Stay Antipsychotic
❖ Short Stay Pressure Ulcers
❖ Short Stay Reporting of Pain
❖ Re-Admission Rates
❖ Total QM Average
2018 Re-Admission Rate by Insurance Company Region
Metric Categories- Operations
❖ 5 Star Rating
❖ Overall 5 Star Survey Deficiency Score-
❖ This isolates of the Deficiency Score total and eliminates the Star
calculation
❖ Discharge to Community
❖ Length of Stay (LOS)
❖ Medicare Spend Per Beneficiary
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Metric Categories- Efficiency
❖ RN Hours per Day
❖ Number of Complaints in last Survey cycle
❖ PT Hours per day
❖ Falls with Injury
SNF Quality Reporting Program (QRP)
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