plante moran pllc 5/13/2014
TRANSCRIPT
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 1
plantemoran.com
Leading Age of Michigan2014 Annual Conference
Presented by
Brenda Sowash , Senior Manager, Plante Moran, PLLC
Beth Sullivan, Senior Manager, Plante Moran, PLLC
Financials for Directorsof Nursing“The Power of Knowledge”
plantemoran.com
Discuss effective case management for Medicare and Medicare replacement plans
Review upcoming industry changes and the potential impact on facility financial performance
Discuss clinical operations impact on facility financial outcomes
Objectives
2
plantemoran.com
Cost Reporting
Reviewing Benchmarking Reports
ICO and ACO
Governmental Audits
Managed Care
Agenda
3
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 2
plantemoran.com
What is A Cost Report?
Annual Summary of Key Facility Financial information
Census
Revenue
Expenditures
Assets/Liabilities Fixed Assets
Debt
plantemoran.com
Medicaid Requires it
Cost report establishes Medicaid reimbursement rates
Basis for determining Medicaid limits
Variable Cost Limit (VCL)
Support to Base Ratio Limit (S/B Ratio)
Used by program to monitor SNF financial performance
Valuable Information for Decision Making
Why Prepare a Cost Report?
plantemoran.com
Medicaid Cost Reporting
Total Facility Costs
Skilled Nursing “Routine” Costs
Dietary, NursingLaundry, Housekeeping,
etc.
Subject to Variable CostLimit and Support to
BaseRatio Limit
Ancillary Costs
Therapies (PT, OT, Speech),
Prescription Drugs, Radiology,Lab, etc.
Not Reimbursable –Some Service Billable
WithPreauthorization
Non-reimbursable Costs
Barber & Beauty, Gift Shop
Physician Office, etc.
Not Reimbursable –Hopefully Paid by
Resident
Plant Costs
Property Taxes, Interest,Depreciation
Subject to Current Asset Value
Limit (Class I) or Plant Cost
Limit (Class III)
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 3
plantemoran.com
TPN formula, equipment and supplies
Oxygen expense
Customized medical equipment
Wound vacs and complex dressings
Ambulance
Bariatric equipment
Orthotics
Prosthetics
Dental Services
Services that are NOT reimbursed
7
plantemoran.com
Cable TV
Resident Room Phone
Marketing
Penalties
Bad Debts
Provider Tax
Owner Compensation
Items Not Reimbursed Through Medicaid
8
plantemoran.com
Benchmark Report - Revenue
9
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 4
plantemoran.com
Benchmark – Allocated Operating Costs
10
plantemoran.com
Benchmarks – Staffing Costs PPD
11
plantemoran.com
Benchmarks – Other Departments
12
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 5
plantemoran.com
Benchmarks – Staffing Hours PPD
13
plantemoran.com
Benchmark – Avg Hourly Wages
14
plantemoran.com
Benchmarks – Other Items
15
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 6
plantemoran.com
Medicare – RUGs IV
16
plantemoran.com
RUG Concentrations
17
plantemoran.com
Pharmacy Costs
18
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 7
plantemoran.com
Accountable Care OrganizationsConsumer
Consumer Care “attributed” to ACO through Physician relationship
Consumer Does not “Enroll”
Consumer’s Care will be Coordinated or Managed by Physician
Consumer still has Full Choice-
Provider ACOs will seek partner providers
that will control utilization, be cost efficient and provide optimal outcomes
Providers still paid by Medicare FFS – i.e. RUG
ACOs may include partner providers in financial risks/rewards related to the ACO agreement with CMS
19
plantemoran.com
Managed Care Organizations
Consumer
Consumer Chooses MCO
Consumer’s Care will be Coordinated or Managed by Physician
Consumer’s choices are limited to those offered by the MCO
Provider
Providers paid by MCO according to agreed upon terms
MCOs CHOOSE their partner providers
MCOs may choose to risk share with partner providers
20
plantemoran.com
Managed Care Is Here to Stay
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 8
plantemoran.com
State of Michigan SNF Trends
22
14.8%
3.1%
66.1%
16.0%
Medicare
Medicare HMO
Medicaid
Other
Statewide Payer Mix SNF Occupancy of 82%
plantemoran.com
Moving Medicare from FFS to Managed Care
23
Source - Avalere Health, Leading Age PEAK Summit 2014
plantemoran.com
FY 2013 “Fun” Michigan Facts and Figures
24
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 9
plantemoran.com
Navigating Payer Shifts
25
What is transition point to become dual eligible? What about Coinsurance and Patient Pays?
plantemoran.com
Medicaid Transitions
26
1. Currently Cost Based Reimbursement
2. Transitioning to MI Health Link
3. Where Will the Crystal Ball Take Us….
plantemoran.com
Current Medicaid Rates
27
RoutineCosts
Plant Costs
QualityAssuranceAdd On
Still applied to Medicaid FFS residents
Rate doesn’t include non-reimbursables
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 10
plantemoran.com
CMS MOU – What is a “Standard Medicaid Rate” – Region Four
28
Provider Name County
Medicaid Reimbursement
Rate QAS
Medicaid Reimbursement
Rate w/QAS Silverbrook Manor Berrien 117.63$ 23.05$ 140.68$ South Haven Nursing and Rehabilitation Community Van Buren 124.77$ 23.67$ 148.44$ Countryside Nursing and Rehabilitation Community Van Buren 127.16$ 25.56$ 152.72$ Plainwell Pines Nursing and Rehabilitation Comm Kalamazoo 132.02$ 26.51$ 158.54$ Fairview Living Centre St. Joseph 135.42$ 25.94$ 161.36$ The Laurels of Coldwater Branch 140.86$ 28.16$ 169.01$ Marshall Nursing and Rehabilitation Community Calhoun 140.98$ 27.33$ 168.31$ The Laurels of Bedford Calhoun 142.25$ 28.53$ 170.78$ Heartland Health Care Center - Kalamazoo Kalamazoo 146.75$ 29.29$ 176.04$ Orchard Grove Extended Care Center Berrien 151.87$ 30.53$ 182.40$ Tendercare Marshall Calhoun 156.99$ 31.69$ 188.68$ Tendercare - Portage Kalamazoo 158.01$ 32.59$ 190.60$ Tendercare of Westwood Kalamazoo 158.19$ 32.20$ 190.39$ Heartland Health Care Center - Three Rivers St. Joseph 160.48$ 32.56$ 193.04$ Magnum Care of Albion Calhoun 162.22$ 32.05$ 194.28$ Tendercare - Kalamazoo Kalamazoo 162.46$ 33.21$ 195.66$ The Laurels of Galesburg Kalamazoo 167.39$ 33.93$ 201.32$ Evergreen Manor Senior Care Center Calhoun 168.10$ 34.67$ 202.77$ Jordans Nursing Home Inc Berrien 168.23$ 35.00$ 203.23$ Riverridge Manor Inc Berrien 168.47$ 33.84$ 202.31$ Froh Community St. Joseph 170.47$ 34.48$ 204.95$ Riverview Manor St. Joseph 171.50$ 34.07$ 205.58$ Lakeland Continuing Care Center St. Joseph Berrien 173.75$ 36.14$ 209.88$ Magnumcare of Hastings, LLC Barry 176.64$ 34.85$ 211.49$ Heartland Health Care Center - Battle Creek Calhoun 176.92$ 35.98$ 212.90$ Alamo Nursing Home Inc Kalamazoo 179.18$ 36.41$ 215.59$ The Oaks at Northpointe Woods Calhoun 181.32$ 35.99$ 217.31$ Manor of Battle Creek Skilled Nrsg & Rehab Center Calhoun 188.74$ 38.30$ 227.04$ Royalton Manor Berrien 189.63$ 36.35$ 225.98$ Harold & Grace Upjohn Community Care Center Kalamazoo 191.99$ 39.34$ 231.33$ Borgess Gardens Kalamazoo 193.79$ 41.11$ 234.90$ Meadow Woods Nursing & Rehabilitation Center Van Buren 196.76$ 38.73$ 235.49$ The Springs at the Fountains Kalamazoo 196.77$ 41.12$ 237.89$ Bronson Nursing and Rehabilitation Center Van Buren 198.91$ 41.12$ 240.03$ West Woods of Niles Berrien 202.70$ 39.46$ 242.16$ Maple Lawn Medical Care Facility Branch 222.04$ 41.11$ 263.15$ Calhoun County Medical Care Facility Calhoun 248.40$ 41.11$ 289.51$ Thornapple Manor Barry 258.75$ 41.11$ 299.86$
171.28$ 205.15$
plantemoran.com
Differentiating Your SNF
29
What is Your Price?
What is the Value Proposition?
plantemoran.com
Step # 1 – Understand Your Cost Structure
30
Compare costs to Peer Organizations
Determine whether cost differentials relate to:
◊Acuity Differentials
◊Efficiency and Process Issues
◊Price
Don’t forget to consider cost that is not currently reimbursed by Medicaid (non allowables)
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 11
plantemoran.com
Should I Reduce Operating Expense?
31
Reducing Expenses will reduce the calculated Medicaid Rate in the future. This has implications for any remaining Fee For Service Medicaid residents as well as MI Health Link.
Reductions in operating expenses will reduce the Quality Assurance Add-On.
plantemoran.com
What About Medicare?
32
It is unlikely that the MOU will require the MI Health Link Health Plan to pay Medicare Fee For Service Rates
CMS allows Medicare Advantage Plans (MAPS) to establish payment rates that are not commensurate with Medicare RUG rates
In Most States, many MAPs reimburse at less than RUG rates
In the future, there may be opportunities to trigger Medicare like reimbursement for long term residents that do not go out to the Hospital first
Currently, all SNFs in Michigan are paid the same for fee for service (RUGS). Less of an issue initially relative to competition
plantemoran.com
Medicare MCO Rates – Future Considerations
33
• Rates vary by MAP provider.
• Contracts are important!
• Must understand care plan implications if prices are not RUGS based
• Are there carve outs?
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 12
plantemoran.com
Step #2….Collect and Analyze Other Data
34
1. Acuity Data
▪MDS Data for Medicaid Residents
▪Clinical Episode/MS DRG
2. Average Length of Stay
3. Re-hospitalization Rates
4. Per Episode Costs
5. Make sure your IT systems will support data collection
plantemoran.com 35
What’s Nursing Administration to Do?
plantemoran.com
Higher Patient
Acuity/More Chronic
Conditions
Manage Utilization-Length of
StayManage other
Utilization Admissions/
Readmission
Higher Focus on
Cost EfficiencyNeed for More
Sophisticated Management Information
Additional Quality
Measures
Increase Technology
EHR
Other
The Influence of Managed Care on Operations
Enhanced Intake and Referral
Management of Care Transitions
36
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 13
plantemoran.com
Assess your business model Internal strengths, external threats and opportunities, and
partner/provider network options
Expand clinical competencies
Increase finance/business office capabilities and skills
Improve data analytics with respect to cost and clinical outcomes
Focus on marketing and public relations
Preparing for the Inevitable
37
plantemoran.com
Physical Attractiveness
Private rooms, amenities, rehab
Reputation and Character
Clinical competencies
Quality Indicators
Regulatory performance
Outcomes measurements
Courting Hospitals and Health Plans
38
plantemoran.com
Earning Potential
Manage and reduce lengths of stay
Minimize readmissions
Partnership
Manage risk on difficult to place residents
Could you provide a market niche?
Courting Hospitals and Health Plans
39
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 14
plantemoran.com 40
“In God we trust; all others must bring data.”
Dr. W. Edwards Deming
The Father of the Quality Evolution
plantemoran.com
Criteria for Preferred Designation Certification/Survey Performance
Utilize INTERACT
Root Cause Analysis of Readmissions
Utilize Specific Electronic Health Records
Minimum Staff Training and Competency Levels
Staffing Levels
Quality Assurance and Performance Improvement Activities
Case Management/Care Coordination Requirements
What are ACOs, MCO, ICOs, Demonstration Plans Looking For?
41
Based on Based on Recent
Request by Health Plan
plantemoran.com
So Let’s Talk Government Focus
42
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 15
plantemoran.com
Office of the Inspector General in November 2012 report called “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More than a Billion Dollars in 2009” focused on importance of medical record supporting the need for skilled care and the accuracy of MDS coding. The RUG system forces them to be connected. Some statistics:
SNFs reported inaccurate information not supported in medical record for at least one MDS item for 47% of claims. Therapy was the source of most errors, but also special care and ADLs showed mistakes
The Focus on Skilled Nursing
43
plantemoran.com
Centers for Medicare & Medicaid Services (CMS) has implemented numerous initiatives to prevent improper payments before a claim is processed and to identify and recoup improper payments after the claim is processed
Overall goal of CMS’ claim review programs is to reduce payment error by identifying billing errors (coverage and billing) made by providers
Government estimates that 8.6% of all Medicare Fee-For-Service (FFS) claim payments are improper
Improper Payment Initiative
44
plantemoran.com
Payments made for services that do not meet Medicare’s medical necessity criteria
Payments made for services that are incorrectly coded
Providers failed to submit documentation when requested or enough documentation to support the claim
Provider was paid twice because duplicate claims were submitted
What is an Improper Payment?
45
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 16
plantemoran.com
Skilled Nursing Facility FocusOIG recommendations to CMS included:
Monitor payments to SNFs;
Strengthen monitoring of SNFs that are billing for higher paying RUGs (PEPPER Letters recently available to providers);
Follow-up on the SNFs identified as having questionable billing
46
plantemoran.com
Program for Evaluating Payment Patterns Electronic Report
First release of SNF PEPPER (Q4FY12) was 8/30/13
Summarizes Medicare claims data in areas that may be at risk for improper Medicare payments
Compares the SNF’s statistics with aggregate state, MAC/FI jurisdiction, and national data
Release: targeted for May 6 through May 12, 2014 (staged release)
Nothing to Sneeze at
47
plantemoran.com
As part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the SNF’s auditing and monitoring activities.
48
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 17
plantemoran.com
Focus on areas where the facility is an outlier: At or above the 80th percentile or
At or below the 20th percentile
Target areas:
49
Therapy RUGs with High ADLs Ultrahigh therapy RUGs
Non-therapy RUGs w/High ADLs Therapy RUGs
Change of Therapy Assessment 90+ Day Episodes of Care
plantemoran.com
A high target area percent does not necessarily indicate the presence of improper payment or that the provider is doing anything wrong, although the provider may wish to review medical record documentation to ensure that services beneficiaries receive are appropriate and necessary and that documentation in the medical record supports the level of care and services for which the SNF received Medicare reimbursement.
50
plantemoran.com
Long Term Care Scrutinized From All Sides
51
The Health Care Reform Act provides $350 million to fight fraud, waste and abuse
LTC
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 18
plantemoran.com
CMS employs a variety of contractors to process claims and submits payment to providers in accordance with the Medicare and Medicaid rules and regulations
Who Else Is Watching?
52
And the private sector managed care insurance reviews are very busy scrutinizing as well
plantemoran.com
Type of Contractor Responsibility
Affiliated Contractors (ACs) – Medicare claims processing contractors such as carriers and Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs)
(Michigan has WPS and NGS)
Process claims submitted by physicians, hospitals, and other HC providers/suppliers, and submit payment to those providers in accordance with Medicare regulations. This includes identifying and correcting underpayments and overpayments. The purpose of MACs is to educate providers, process and conduct billing, correct the behavior in need of change and prevent future inappropriate billing, and recover payments.
Medicare Contractors
53
plantemoran.com
Type of Contractor Responsibility
Recovery Auditors (RAs)
Michigan RA - CGI
Identify and correct improper payments, find overbilling practices, fraudulent activities –all Medicare Fee for Services Providers (FFS), i.e., Part A and B, DME, physician, hospital, therapy, home health, hospice• Some limitation on the documents they
can request, and• Paid on a contingency fee basis
Medicare Contractors
54
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 19
plantemoran.com
Contractor Responsibility
Zone Program Integrity Contractors (ZPICs) / Program Safeguard Contractors (PSCs)
(Cahaba ZPIC for Michigan )
Identify cases of suspected fraud and take appropriate corrective actions across entire MCR program. ZPIC responsible for program integrity –Part A & B, hospitals, home health, hospice, DME, Part C - Medicare Advantage & Part D.• Do not conduct random audits• No specification regarding look-back periods• Can make unlimited document requests• Not paid on a contingency fee basis, although
they do get performance bonuses
RAs Bark, but ZPICs Bite
plantemoran.com
Type of Contractor Responsibility
Comprehensive Error Rate Testing (CERT)
Collect documentation; perform reviews on a statistically-valid random sample of Medicare FFS claims to produce annual improper payment rate FIs & MACs, but still review SNFs’ claims and the providers have to repay any overpayments found
Payment Error Rate Measurement (PERM)
Perform statistical calculations, data processing reviews of FFS, managed care and beneficiary eligibility in both the Medicaid program and CHIP (Children’s Health Insurance Program)
Medicare Contractors
plantemoran.com
Contractor Responsibility
Medicaid Integrity Contractors (MICs)
Payment watchdogs auditing nursing homes and other providers. The MICs will use a data-driven approach to focus efforts on aberrant billing practices. Facilities may be more likely to get medical requests the MICs than the RACs. Three types of contractors:1. Review – mine the data to find issues indicative
of erroneous claims2. Audit – conducts audits onsite or as desk audits3. Education – Pick up concerns from the other 2 to
educate providers and others
And Last but Certainly Not Least
57
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 20
plantemoran.com
Once an initial claims determination is made by a contractor, providers have the right to appeal the determination
All appeal requests must be writing
All time frames critical for process to have success at all
If you feel the care was appropriately provided -APPEAL
Medicare Appeals Process
58
plantemoran.com
1. Redetermination – performed by Medicare Administrative Contractor (MAC) - must be requested within 120 days of decision. They have 60 days to complete review.
2. Reconsideration – performed by qualified independent contactor (QIC)– must be requested within 180 days of redetermination decision. They have 60 days to complete the review.
Appeals Process – Five Levels
59
plantemoran.com
3. Administrative Law Judge (ALJ) Hearing* - must be requested within 60 days of QIC decision. They have 90 days to complete the review. *$140 for CY 2014
4. Medicare Appeals Council (MAC) (aka Departmental Appeals Board) - must be requested within 60 days of ALJ decision. They have 90 days to complete the review.
5. Federal Court Review* - Federal District Court. Must be requested within 60 days of MAC decision. *$1,430 for CY 2014
Appeals Process(continued)
60
* Minimum dollar amount required to enter level
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 21
plantemoran.com
The Importance of Appeals
61
plantemoran.com
Medicaid Recovery Auditors Overlapping Services
Billing Focus
MPRO PASARR
LOCD with Signed Freedom of Choice
Ongoing demonstration that LOC continues to be met
Other Considerations Physician orders for nursing facility care within 30 days of Medicaid
application (for residents converting to Medicaid after admission)
Care plans
What About Medicaid?
62
5-Star Rating
63
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 22
plantemoran.com
Health inspections star rating forms the starting point for the overall rating and creates the foundation for final rating (most important)
Based on substantiated deficiencies from annual state inspections and complaint surveys
Use the number, scope and severity of deficiencies during the three (3) most recent annual surveys AND substantiated findings from most recent 36 months of complaint investigations
Calculations Basics
64
plantemoran.com
Staffing star based on nursing home staffing levels
RN hours per resident day
Total staffing hours (RN + LPN + nurse aides)/resident day
Case mix adjusted based on the distribution of MDS 3.0 assessments by RUG-III group: more acute = more staff
2-week snapshot – CMS Staffing Studies demonstrated evidence of relationship of nurse staffing to quality of care
Calculations Basics
65
Impacts the basic score (inspections) by adding or subtracting stars based on levels of staff
plantemoran.com
A downloadable file that contains the expected and reported hours used in the staffing calculations is posted here:
The file referred to as the “Expected and Adjusted Staff Time Values Data Set” contains data for both RNs and total staff for each individual nursing home
Download Staffing Data
66
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.html
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 23
plantemoran.com
CMS form CMS-671 (LTCF Application for Medicare and Medicaid) – RN, LPN, and nurse aide hours
RN hours: include RNs (F41), RN DON (F39), and nurses [RNs and LPNs] with administrative duties (MDS, too) (F40)
LPN hours: licensed practical nurses (F42) Nurse aide hours: certified NAs (F43), aides in training
(F44) and medication aides/technicians (F45)
Staffing Data
67
Includes facility employees (full and part time) and individuals under an organization (agency) contract or an individual contract. Does NOT include: “private duty” nursing staff, hospice staff and feeding assistants.
plantemoran.com
Data
68
CMS-671(12/02)
plantemoran.com
Calculations:
Case-Mix Adjusted Staffing
69
Reported = hours reported during annual survey
Expected = reported hours with case mix adjustments (RUG-III)
National average = mean across all facilities
Total nursing staff = 4.0309
Registered nurses = 0.7472Will remain constant
for 2 years
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 24
plantemoran.com
Quality Measures star based on MDS quality measures for 9 of the 18 QMs that are currently posted on the Nursing Home Compare website
7 long-stay measures
2 short-stay measures
Calculations Basics
70
Impacts the basic score (inspections) by adding or subtracting stars based on the facility’s performance
with the Quality Measures
plantemoran.com
Five-Star Quality MeasuresLong stay measures (7):ADL help needs have increased
High-risk PU
Long-term catheter use
Physical restraints
UTIs
Pain – self-report moderate to severe pain
Fall with major injury
Short stay measures (2):Pain – self-report
moderate to severe
Pressure Ulcers – new or worsened
71
plantemoran.com
Five Star Quality MeasuresShort Stay QM% QM Value Points
Moderate to severe pain 28.1 0.281 32
New / worse pressure ulcer 0.8 0.008 84
Long Stay
Moderate to severe pain 6.9 0.069 71
High-risk with pressure ulcer 4.8 0.048 68
Urinary tract infection 3.6 0.036 84
Urinary catheter 3.0 0.03 65
Falls with major injury 0.7 0.007 95
Physically restrained 0.0 0.000 100
ADL help increased (State–based) 24.6 0.246 20
TOTAL 615
72
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 25
plantemoran.com
Health Inspection
(survey)
Add 1 star if staffing = 4 or 5 and greater than survey
Subtract1 star if staffing = 1 star
Add 1 star if QM= 5 stars
Subtract1 star if QM = 1 star
To Determine Overall Rating = 5 Steps
73
Most important!!
Staffing only impacts overall score if 4, 5, or 1
QMs only impact overall score if 5 or 1
UNLESS…….
1 2 3 4 5
plantemoran.com
If the health inspection rating is 1 star, then the Overall Quality rating cannot be upgraded by more than 1 star based on staffing and QM ratings
If the NH is a Special Focus Facility that has not graduated, the maximum Overall rating is 3 stars
Calculating the Overall Rating (more rules)
74
plantemoran.com
Finding More Stars To improve star rating:
Achieve better survey results
Mock surveys
Use QIS critical element pathways as QA tools
Evaluate staffing levels, especially look at RN time – does staffing match acuity
Use instructions when completing the 671 and 672 forms
Effective Quality Assurance process to improve resident outcomes quantified by the Quality Measures
75
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 26
plantemoran.com
Pay For Performance Ties it All Together
76
"Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. These arrangements provide financial incentives to hospitals, physicians, and other health care providers to carry out such improvements and achieve optimal outcomes for patients
plantemoran.com
Patient Protection and Affordable Care Act: §3006 mandated CMS develop plan to implement Value Based Purchasing (VBP) for SNF Medicare payments with preliminary report to Congress on 10/1/11 – mixed results
Assess NH in 4 domains: nurse staffing, appropriate hospitalizations, outcome measures from MDS, and survey deficiencies
Final Evaluation 2013: limited quality improvement and savings found under the demonstration
Background
77
plantemoran.com 78
Skilled Nursing Facility Value-Based Purchasing Program.A Hospital Readmissions Reduction Program for SNFs
Included in H.R. 4302, the Protecting Access to Medicare Act of 2014, a one-year patch of the sustainable growth rate (also known as the “doc fix”), was a value-based purchasing (VBP) program for skilled nursing facilities (SNFs). This program establishes a hospital readmissions reduction program for these providers, encouraging SNFs to address potentially avoidable readmissions by establishing an incentive pool for high performers. The Congressional Budget Office scored the program to save Medicare $2 billion over the next 10 years.
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 27
plantemoran.com 79
plantemoran.com 80
plantemoran.com
Decision Support
Advance Care Planning
Quality ImprovementCommunication
Tools
81
http://interact2.net/
INTERACT
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 28
plantemoran.com
How Does The Program Improve Care?
Identifies situations that commonly result in transfers to the hospital
Encourages working together to manage the residents effectively and safely in the nursing home without transfer whenever possible
82
plantemoran.com
Overview of INTERACT
The goal of INTERACT is to improve care quality, NOT to prevent all hospital transfers
In fact, INTERACT can result in more rapid transfer of residents who need hospital care
83
plantemoran.com
Why Do You Need to Take Advantage of this QI Program?
QI Programs
Tools
Incentives
Infrastructure
Safe Reduction in Unnecessary Acute Care Transfers
Increase Quality
Decrease Morbidity
Decrease Costs
84
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 29
plantemoran.com
Quality Improvement Program
Quality Improvement Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Includes evidence and expert-recommended clinical practice tool, strategies to implement them, and
related educational resources
85
plantemoran.com
As you work with your hospital and upgrade your services, this will be helpful information to prove your value as
a partner
Talk to them as to what would be best for you to focus on for their
needs
86
plantemoran.com
1. List all hospitals your facility sends to or receives from2. Identify the “readmissions champion” for each hospital
a.Chief Quality Officerb.Chief Financial Officerc. Chief Nursing Officerd.Director of Case Managemente.Director of Quality
3. Host or join a “cross-continuum” group. Start by inviting hospitals to your facility to see your capabilities – meet in person; may be one person at a time
Reach out to one of these folks and they will know who is the organization’s lead
87
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 30
plantemoran.com
4. State facility’s goals to reduce avoidable transfers, admissions and readmissions – recognize the hospital’s goals for readmission reduction. Show brief set of numbers:a. Average # of patients received from the hospital each monthb. Current 30-day readmission rate among those patientsc. Facility’s goal to reduce preventable and unnecessary
transfers5. Describe the set of quality improvements underway in the
facility through INTERACT and other initiatives6. Ask the hospital to be an active partner in your INTERACT
improvements 88
plantemoran.com
Become Your Hospitals’Best Friend Implement your system to identify those at risk for readmission Gather your data and statistics to provide strong evidence of your
system and reduction of unnecessary hospitalizations Tell your story to the hospital administrators and/or chief financial
officer (not the discharge planners) First appointment may not be easy to get - be persistent Know anyone that could open the door for you Live and in person – communicate what processes you have
in place to improve quality of care you provide and how you can work together to reduce avoidable readmissions
Plan follow-up meetings to enhance collaboration and communications about your acute care transfers
89
plantemoran.com
Speaking of Incentives
FY 2013 FY 2015
• Acute Myocardial Infarction• Chronic Obstructive Pulmonary
Disease
• Heart Failure • Coronary Artery Bypass Graft
• Pneumonia• Percutaneous Transluminal
Coronary Angioplasty
• Other Vascular Conditions
As of October 1, 2012 CMS began penalizing hospitals based on readmissions for 3 conditions and by FY 2015 will expand
the program to include 4 additional conditions:
Now looking at readmissions from all causes
90
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 31
plantemoran.com
Why Do Hospitals Care?
Medicare Reimbursement
VBPCore/HAI/HCAHPS1% FY13 to 2% FY15
HAC1% starts 2015
ReadmissionAMI/HF/PNA/CABG+
1% FY13 to 3% FY15
ACOs are asking about implementation
of INTERACT, too
Tidbit
91
plantemoran.com
What Can the Facility Tell the Hospital, ACO, Managed Care?
92
The organizations
asking the questions and trying to find
partners – want to see data, not
just hear talk
plantemoran.com 93
Bottom Line
The DON pieces it all together!
Plante Moran PLLC 5/13/2014
[email protected]@plantemoran.com 32
94
734-652-8759
248.223.3835
Questions??
plantemoran.com
MDS 3.0 Quality Measures - USER’S MANUAL at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/downloads/MDS30QM-Manual.pdf
RAI MDS Manual http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
CGI https://racb.cgi.com/Issues.aspx
Resources
plantemoran.com
Initiative to Reduce Unnecessary Hospitalizations http://innovation.cms.gov/initiatives/rahnfr/index.html
Centers for Medicare and Medicaid http://cms.gov
Michigan Medicaid Manual
Interact Version III http://interact2.net/index.aspx
2011 and 2012 Medicaid Cost Report filings
2011 and 2012 Medicare Cost Report filings
SNF PPS Spotlight http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Spotlight.html
Office of the Inspector General https://oig.hhs.gov/oei/reports/oei-01-12-00150.pdf
Resources
96