Set Yourself Up for Success: How VBP is Changing the Game NYSHFA January 26, 2018 Presented by, Maureen McCarthy, RN, BS, RAC-MT, QCP-MT

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1 Set Yourself Up for Success: How VBP is Changing the Game NYSHFA January 26, 2018 Presented by, Maureen McCarthy, RN, BS, RAC-MT, QCP-MT 1 Maureen McCarthy, RN, BS, RAC-MT, QCP-MT 2 Maureen is the President of Celtic Consulting, LLC and the CEO and Founder of Care Transitions, LLP. She has been a registered nurse for 30 years with experience as an MDS Coordinator, Director of Nursing, Rehab Director and a Medicare biller. McCarthy is a recognized leader and expert in clinical reimbursement in the skilled nursing facility environment. She is dually certified in both the resident assessment process and QAPI by nationally recognized organizations and holds Master Teacher status in both and is a board member of American Association of Post-Acute Nurses (AAPACN) and is an Expert Advisory Panel member for American Association of Nurse Assessment Coordination (AANAC). Maureen and her associates at Celtic Consulting regularly provide the following services for SNFs, state affiliates and provider organizations: 5 Star Quality Improvement Program Quality Auditing Clinical Care Management RCS/PPS/MDS/CMI Services Compliance Solutions Medicare Compliance Auditing Customized Education / In-Services 1

Objectives 3 Explain the SNF Value Based Purchasing Program Discuss how readmission rates are determined Review the timing for the readmission window

2 Objectives 3 Explain the SNF Value Based Purchasing Program Discuss how readmission rates are determined Review the timing for the readmission window penalties Describe payment reductions to PPS rates Provide strategies to consider to improve VBP ratings Quality Measure TIP- Rehospitalization Focus-4 QRP VBP 5 Star 2

3 SNF Value-Based Purchasing The Next CMS Initiative SNF Value Based Purchasing -6 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. Effects claims paid in FY

4 SNF VBP-7 Result of PAMA of 2014 enacted 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 Both measures are based on hospital readmissions SNF PPR- potentially preventable, risk adjusted (?10/1/19) SNF RM- all-cause/condition, original measure (began ) Payments affected 10/1/18 SNF RM-8 Risk- standardized, all cause, all condition, unplanned hospital readmissions within 30 days of hospital discharge/snf admission 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 1 st year of program This is how the data for new re-hospitalization QM was delivered 4

5 SNF PPR-9 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 your SNF Improvement Rating up to 90 points 2015 your SNF Better of the two, Improvement Rating or Achievement Rating 5

41) 2015 ALL SNFs If your SNF meets the BENCHMARK, then your rating can be up to 100.

6 SNF VBP Re-hospitalization measure RM-11 Benchmark: Average top 10% performing SNFs in 2015 (83.6) 2017 your SNF Achievement Rating: SNF reaches 25% threshold (20.41) 2015 ALL SNFs If your SNF meets the BENCHMARK, then your rating can be up to 100. If your SNF doesn t meet at least the 25 th percentile, then your rating is 0. Remainder (1-99) will be disbursed. VBP Revisions-12 FY 2020 will compare 2016 to th quarter 2017 will count twice Convert to Fiscal Year Readmission rate Risk Standardized Readmission Rate (RSRR) Performance Scores 6

SNF VBP Measure-13 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

7 SNF VBP Measure-13 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 (90 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 (100 points) If worse than 2015 (0 points) Performance Scores-14 The lower the readmission rate, the better. Since a lower readmission rate is better, CMS has inverted every SNF s readmission rate using (1 readmission rate) for the purposes of the performance standards (i.e., benchmark and achievement threshold) and performance scoring. Standard th Percentile 20.41% Achievement Threshold 79.59% Mean of the Best Decile 16.40% Benchmark 83.60% 7

8 2015 Performance Data-15 Risk Adjustment-16 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 patient s prior proximal hospitalization) Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html. 8

Excluded Re-hospitalizations-17 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

9 Excluded Re-hospitalizations-17 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 Released Reports-18 9

10 Patient Level Provider Reports-19 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 information CMS Certification Number [CCN], admission/discharge dates, discharges status code, principal diagnosis) Readmission hospital information (CCN, admission/discharge dates, principal diagnosis) SNFRM risk-adjustment factors Patient Level Data Files-20 3 Tabs on each Excel file Cover Sheet Facility Results Eligible Stays Eligible Stay tab has many columns (A-KM) 10

11 Supplemental Workbook -Eligible Stays tab-21 PATIENT CHARACTERISTICS INDEX SNF INFORMATION PRIOR PROXIMAL HOSPITAL INFORMATION ID Number HICN Sex Age Admission Date of Index SNF Stay Discharge Date of Index SNF Stay Index SNF Discharge Status Code Prior Proximal Hospital CCN Admission Date of Prior Proximal Hospital Stay Discharge Date of Prior Proximal Hospital Stay ICD Version of Principal Diagnosis (Prior Proximal Hospital) Principal Diagnosis of Prior Proximal Hospital Stay Modifying Data-22 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 SNF s risk-standardized readmissions rate The national SNF measure performance rate 11

12 Facility Level Data-23 Data Collection Period: FY 2016 Performance Information FY 2016*** Your SNF's Number of Eligible Stays 54 Your SNF's Number of Unplanned Readmissions 9 Your SNF's Observed Readmission Rate % Your SNF's Predicted Number of Readmissions* Your SNF's Expected Number of Readmissions* Your SNF's Standardized Risk Ratio (SRR) National Average Readmission Rate % Your SNF's Risk-Standardized Readmission Rate (RSRR)** % Modifying Data-24 For the first phase, SNFs must submit correction requests for their quality measure data to SNFVBPinquiries@cms.hhs.gov and provide the following: CMS Certification Number Facility name Correction requested and basis for the correction Appropriate documentation or other evidence supporting the request Deadline March 31, 2018 for 2016 data Use SNFVBP Review & Correction Inquiries in the Subject line 12

CMS will propose more specific requirements for Phase Two corrections in the future, and welcomes feedback.

13 Modifying Data-25 Phase One corrections are limited to review and correction of SNFs quality measure information. Phase Two corrections are limited to SNF s 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 report s delivery. If corrections are provided after information is publicly reported but before the March 31 st deadline, corrections will be made retroactively. CMS will review the requests and notify the requesting SNF of the final decision. SNF VBP Preview Reports-26 13

14 2016 Data for Public Reporting-27 FY 2016 Treat inplace Data-28 14

15 Retrieving SNFVBP Reports-29 Provider Reports-30 15

16 Performance Rankings- 31 Performance scores will be used to adjust payment rates Review and Correct period ends March 31, 2018 Placement will be detailed to the 5 th decimal point to break ties Next Steps Monitor readmissions monthly- resident level Look for trends, patterns, specifics Identify opportunities to apply strategies to apply to residents with similar conditions Be aware of facility rankings in the SNFVBP program Keep an eye on readmission rates on a monthly basis to identify increases timely 16

17 Questions?? Maureen McCarthy, RN, BS, RAC-MT, QCP-MT President, CEO Phone (Office):

The Shift is ON! Goodbye PPS, Hello RCS

The Shift is ON! Goodbye PPS, Hello RCS Presented By Maureen McCarthy, RN, BS, RAC-MT, QCP-MT President/CEO Maureen McCarthy, RN, BS, RAC-MT, QCP-MT Maureen is the President of Celtic Consulting, LLC and