it’s not over yet!€¦ · turning 65 •2014 medicare transformation act: changes to quality...
TRANSCRIPT
Medicare PPS & Fee-For-Service: It’s Not Over Yet!
August 17 – 18, 2016Atlantic City, NJ
Changes, Changes, ChangesWhere to Begin?
INSPIRATION
2
INNOVATION
IMPLEMENTATION
Changes, Changes, ChangesWhere to Begin?
• PAMA
• IMPACT
• Nursing Home Action Plan
• Value Based Purchasing
• SNF Quality Reporting
• 2017 SNF PPS Final Rule
• OIG Work Plan
• Re-Hospitalizations
• And more and more and more…
4
Key Players Engaged in the Current Focus on Deficit Reduction
White House
Employer Interest Groups
Centers for Medicare and Medicaid Services
(CMS)
Pharmaceutical Interest Groups
Medicare Payment Advisory Commission
(MedPAC)
Insurance Interest Groups
Hill Leadership
Provider Interest Groups
Hill Committees of Jurisdiction
Decisions
5
Transformation From a Fragmented Post- Acute Care Delivery and Payment System to a Patient-Centered System
6
Long Term Care
Institutional and
Home and Community-
Based Services (HCBS)
Person-centered care: Prevention, Mitigation, Risk
Reduction, Continuity of Care & Care Coordination
Acute CarePost-Acute
CareHome Health
PCP
EMR
EHR EHR EHR EHR
Person
Information Follows the Person
“Volume to Value”Driving Forces for Changes
• 3M Americans rely on services provided by Nursing Homes at some point during the year with 1.4M residing in Nursing Homes every day– Escalating costs associated with Post Acute Care
– Goal of establishing payment rates according to the individual characteristics of the patient, not the care setting
• Benefits Improvement & Protection Act (BIPA) of 2000– Required the Secretary to report to Congress on
utilization of a standardized assessment items across PAC settings
7
“Volume to Value”Driving Forces for Changes
• Deficit Reduction Act (DRA) of 2005– Required the standardization of assessment items used
at discharge
– From an acute care setting and at admission to a PAC setting
– Established the Post-Acute Care Payment Reform Demonstration (PAC-PRD) to harmonize payments for similar settings in PAC settings
– Resulted in the Continuity Assessment Record and Evaluation (CARE) tool, a component to test the reliability of the standardized items when used in each Medicare setting
8
“Volume to Value”Driving Forces for Changes
• PAC Reform Demonstration requirement of 2006– Interoperability Standards
• Nursing Home Compare 2008– Developed Star Ratings To Identify Quality Homes
• Affordable Care Act 2010
Government Performance and Results Modernization– Required CMS To Develop Strategies Specific To
– Better Care, Lower Costs, Education/Prevention Expansion of Care Coverage, Enterprise Excellence
• Enhancement and Expansion of Nursing Home Compare adding MDS 3.0, Survey Findings and PEPPER 2012
9
“Volume to Value”Driving Forces for Changes
• 2011 First of the Nations Baby Boomers are turning 65
• 2014 Medicare Transformation Act: Changes to Quality Measures; Changes to CASPER, CMS finalizes Quality Policies
• 2015 Implementation of Increased Civil Monetary Penalties For “Inadequate Staffing Patterns, Training and Supervision of Staff, Resident Outcomes; Finalizes Five Star
• 2015 ICD 10 Implementation• 2016 Federal release of 2013 PUF Data
10
“Volume to Value”Driving Forces for Changes
• 2017 - 2020– Re-hospitalization penalties– Standardized PAC assessment– Episodic Payments– Bundled Payment– Risk sharing?– Census– Managed Care– Discharges– Community-based care incentives – Outcomes
11
PAC QRP SNF Estimated Timelines/Milestones toMeet the IMPACT Act of 2014 Timeline Requirements
2015 2016 2017 2018 2019 2020 2021
1/1/15-8/1/15Meas. Dev.
8/2/15-4/1/17Measure Development1
RulemakingFY 2016
RulemakingFY 2017
RulemakingFY 2018
Legend #1: IMPACT Act Measure DomainsA. Functional status, cognitive function, and changes in function and cognitive functionB. Skin integrity and changes in skin integrityC. Medication and reconciliationD. Incidence of major fallsE. Transfer of health information and care preferences when an individual transitionsF. Resource use measures, including total estimated Medicare spending per beneficiaryG. Discharge to communityH. All-condition risk-adjusted potentially preventable hospital readmission rates
Aug-Jan
Nov-FebAssessment InstrumentConsensus,
Expert & Stakeholder
Input
Aug-JanMAP
Aug-JanMAP
Aug-JanMAP
Aug-JanMAP
Legend #2: Standardized Assessment Domains• Functional status• Cognitive function and mental status• Special services, treatments , and interventions• Medical conditions and co-morbidities• Impairments
Item dev. for standardized assessment domains3 10/1/18Standardized assessment domains implemented
10/1/16Begin 2% reduction for
SNF failure to report quality and resource
use measure data
10/1/18SNF providers begin
reporting quality measures data
specified by the Secretary (C,E)2
10/1/19Confidential
feedback reports to SNF providers (A, B,
C, D, E, F, G, H)2
Jul 2020Preview Reports –
SNF provider opportunity to
review (A,B,C,D,E,F,G,H)2
10/1/20Public reporting of
provider-previewed individual
performance (A,B,C,D,E,F,G,H)2
Measure Applications Partnership (MAP)
Aug-JanMAP
Aug-JanMAP
4/15 7/15 10/15 1/16 4/16 7/16 10/16 1/17 4/17 7/17 10/17 1/18 4/18 7/18 10/18 1/19 4/19 7/19 10/191/20 4/20 7/20 10/20 1/21 4/21 7/21 10/21
IMPACT Act Milestones
10/1/16SNF providers begin
reporting quality and resource use measure data specified by the
Secretary (A,B,D,F,G,H)2
10/1/17Confidential feedback
reports to SNFproviders4
(A,B,D,F,G,H)2
Jul 2018Preview Reports
SNF provider opportunity to
review4
(A,B,D,F,G,H)2
10/1/18Public reporting of
provider-previewed individual
performance4
(A,B,D,F,G,H)2
10/1/18Assessment domains
standardized3
1. Quality measure development requires six months to two years and includes public input, stakeholder input, and the MAP process
2. IMPACT Act measure domains are defined in legend #1 above3. IMPACT Act assessment domains are defined in legend #2 above4. Provider feedback and preview reports and publicly reported data are refreshed at regular
intervals after starting
The Six Priorities Have Become theGoals for the CMS Quality Strategy
Making Care SaferStrengthen Person & Family Engagement
Promote Effective Communication & Coordination Care
Promote Effective Prevention &
Treatment
Work With Communities To
Promote Best Practices of Healthy Living
Make Care Affordable
13
SNF PPS Final Rule FY 2017
• Revisions to Five Star Quality Rating System– New measures – Survey & certification issues– CASPER
• Value-Based Purchasing – Re-hospitalizations– Incentives & penalties
• Electronic Submission of Payroll Based Journals – Nurse staffing
• Revisions to Medicare Intermediary Manuals– RAC and MAC review– SNF PUF data
• Revisions to Nursing Home Action Plan– CMS response to Congressional action and implementation
• Revisions to OIG Work Plan– Compliance
14
Post Acute Care Transformation Act SNF QRP
• As part of IMPACT 2014 and Final Rule 2016, beginning with payments in 2018, Secretary shall reduce annual market basket updates by 2% for any SNF that does not comply with quality submission requirements
– FY 2018 reporting year is based on data collected and submitted for admissions on/after October 1, 2016 and discharged from SNF by December 31, 2016
– 80% compliance with Medicare Part A MDS submissions required to calculate SNF QRP measures
– 90% of Medicare payments tied to quality/value in 201815
Final Rule Updates: aka Amendments to BBA 1997
• Increase of $920 M (2.4%) to Skilled Nursing Facilities for 2017
– Staying with the same RUG classifications and MDS assessments completed in compliance
with MDS Manual
• Specifies potentially preventable all-cause 30-day readmission measure for the
Skilled Nursing Facility Value Based Purchasing Program (SNF VBP)
– Implements requirements including performance standards, scoring methodology
– Includes review/correction policies and measures for the Skilled Nursing Quality
Performance Program (SNF QRP)
– Quarterly confidential feedback reports specific to CASPER
– Public reporting on NH Compare of SNFs receiving value-based incentive payments for high
quality; SNFs will be listed by ranking
• Adds new Quality and Resource Measures as part of requirements for IMPACT
– All cause all condition hospital readmission measure
– A resource use measure
– An all condition risk adjusted potentially preventable hospital readmission measure16
Final Rule Updates: aka Amendments to BBA 1997
• Requires SNFs to report standardized data (VBP & IMPACT) for measures in specified Quality and Resource use domains – Information collected in October 2016 will be utilized for facility
rates in October 2018
• SNF QRP Measures will also affect payment in 2018– Percent of Residents with Pressure Ulcers that are new or
worsened (SS)– Percent of Residents experiencing one or more Falls with major
injury– Percent of Patients with an Admission and Discharge Functional
Assessment and a Care Plan that addresses function
• Incorporates SNF VBP and Performance Improvement awards for 2019 payments – 1/1/17 – 12/31/17 will be the Collection Year for 2019– Will use a 0 to 100 point score with 25%, 50% and 75% thresholds
and benchmarks 17
Final Rule Updates
• SNF Level of Care – Administrative Presumption– Administrative Presumption utilizes the
beneficiary’s initial classification in one of the upper 52 SNF level RUGs on the Medicare 5 day initial assessment and meeting a SNF level of care
– Beneficiary in the lower 14 RUG levels is not automatically disqualified, however it is incumbent upon the SNF to ensure the level of care is appropriate, includes monitoring of condition and documented
18
• Consolidated Billing rules and exclusions continue with no changes
• Impact Act Medicare claim based Measure – Discharges to Community based on PAC-SNF-QRP
• IMPACT Act SNF QRP Quality Measure – Potential or Actual clinically significant medications
identified on admission
– Timely review to include medication accuracy and impact on function & safety
– SOM to include guidelines for management and review
19
Final Rule Updates
New QMs Added to Scoring on July 27
• Percentage of short-stay residents who were successfully discharged to the community (claims-based)
• Percentage of short-stay residents who have had an outpatient emergency department visit (claims-based)
• Percentage of short-stay residents who were re-hospitalized after a nursing center admission (claims-based)
• Percentage of short-stay residents who made improvements in function (MDS-based)
• Percentage of long-stay residents whose ability to move independently worsened (MDS-based)
• Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-based)
20
SNF MDS QRP Payment Oct. 2018 OMG!
NQF Measure ID Measure TitleData Collection
TimelineData Submission
Deadline
NQF #0674
Application of Percent of Residents Experiencing One or More Falls will Major Injury (Long Stay)
10/01/16-12/31/16 May 15, 2017
NQF #0678
Percent of Patients or Residents with Pressure Ulcers that are New or Worsened
10/01/16 – 12/31/16 May 15, 2017
NQF #2631
Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
10/01/16 – 12-31/16 May 15, 2017
21
Significant MDS Updates & Changes Impacting Care & Quality Measures
• CMS has added clarifications and definitions to better capture significant resident care areas: –Falls: – Types, injury, care planning
–Pressure Ulcers: – Definitions, treatments, care planning
–ADL definitions and Rule of 3–Bowel Continence–Diagnoses–Height / Weight–and more to come…
22
Standardization of Admission & Discharge Functional Assessment & Care Plan
• CMS adopted this QM to satisfy IMPACT requirements:
– PAC providers to report standardized data regarding functional, cognitive status and changes in same
– Reports the % of patients with admission & discharge assessments
– Will be expanded to look at admission status, discharge status, progress to goals, condition on discharge to lower care levels (SNF, home, ALF, return to hospital)
23
What is Standardization?Standardizing Function at the Item Level
Inpatient Rehabilitation
Facilities – Patient Assessment
Instrument (IRF-PAI)
Skilled Nursing Facilities – Minimum
Data Set (MDS)
Home Health Agencies – Outcome
& Assessment Information Set
(OASIS)
Long-Term Care Hospitals- Continuity Assessment Record &
Evaluation (CARE) Data Set (LCDS)
IRF-PAI MDS OASIS LCDS
Eating Eating Eating Eating
24
Section GG Admission & Discharge
25
MedPAC Data
• 17% to 20% of Medicare beneficiaries discharged from hospital are readmitted within 30 days
• 84% of 7 day readmissions were potentially preventable
• 75% of 15- and 30-day readmissions were potentially preventable
• Potential savings: $12B (30-day), $8B (15-day), and $5B (7-day)
30
Nursing Home Action Plan 2016/2017CMS Work Plan to Incorporate All Mandates
• Enhance Consumer Awareness: Nursing Home Compare– Five Star Quality Rating System
– Improve Staffing Data based on Case Mix adjustment
• Strengthen Survey Process, Standards and Timing– Increased surveyor staff to increase frequency of SNF survey visits
– Revised Interpretative Guidance to Surveyors incorporating standards of practice, investigative protocols and guidance for severity and scope of deficiencies; increased training for Central and Regional office staff
– Improvement in Nursing Home Survey Process utilizing Traditional Survey, Focused Survey and Quality Indicator Survey processes
– Increased training and testing of Long Term Care Surveyors including the Surveyor Minimum Qualifications Test
• Revised Fire and Life Safety Codes to reduce fires in SNF– Better Protection, Better Information and Reporting, Better Monitoring
and Better Enforcement
31
Nursing Home Action Plan 2016/2017CMS Work Plan to Incorporate All Mandates
• Improved Complaint Investigation Process– Increased training for Regional and State Office staff including
investigation skills and documentation
– Improvement in complaint intake and triage
– Improvement in consistency of investigations/substantiations/decision making/reporting
• Management of Healthcare Associated Infections (HAI) – 300,000 people die from infections in SNF environment annually
– Preventable but frequent due to understaffing, lack of staff training, prevention, overuse of antibiotics, increased clinical acuity of residents, lack of facility tracking/management/reporting
– Coordination with the CDC, Hospitals and other agencies
– Improved guidance to F-tag 441
32
Nursing Home Action Plan 2016/2017CMS Work Plan to Incorporate All Mandates of other Regulation and Directives
• Improvement in Enforcement Activities– Transparency, consistency, data management, tracking and
Reporting
– Increase in Civil Monetary Penalties
• Continuation of Special Focus Facilities– Increasing the amount of facilities from 2 per State to 30%
– Improving data and standards used to place facilities under Focus
– Enforcement of Timeframes for palns of correction and Improvement
– Post all SFF on Nursing Home Compare with Notices of Closings
• Promote of Quality Improvement 33
Compliance with Care & Payment
• Increased Auditing and of Claims by OIG, ZPIC, RAC, Justice Department and Whistle Blowers– Federal SWAT Teams utilizing software to review patterns of
care and claims $– Worthless Services– SNF PUF data for MAC & RAC audits – Additional oversight with patient admission requirements,
staff licensure
• Focused MDS Survey, QOL and Dementia protocols; Re-hospitalization Monitoring; Managed Care
• Prevention, detection, and punishment • ROI• Changes to the appeals system
34
