Isn t LTC Complicated Enough: Transitions from Fee for Service to Value Based Payment Models Presented by: Robert Nasso & Kathleen Angelone EFPR Group/RHHC Consulting, LLC Sponsored by:
Outline Value Based Payment Models Medicare PPS Final Rule 2018/PAMA Medicaid/DSRIP SNF/MLTC transition issues MLTC VBP Current Issues Update 2
Value Based Purchasing Medicare goal of 50% VBP by 2019 and they re ahead of schedule Reward quality and outcomes over volume. Share risk, pay for performance. Pay for healthy outcomes, not for services provided. Increased capitation, reduced fee for service 3
CMS Quality Measures (SNF QRP) Quality Measures reported - SNFs, IRFs, HHAs, LTCHs Pay for reporting (10/1/17) - 2% rate reduction for failure to report 4
SNF VBP Payment Features Performance includes achievement and improvement SNF performance scores ranked low to high 2% of SNF payments withheld to fund incentives beginning 10/1/18 Incentive payments must equal 60% of amount withheld 5
Previous finalized measure SNF 30 Day All-Cause Hospital Re-Admission Measure (SNFRM) All cause, risk adjusted unplanned hospital readmissions within 30 days of hospital discharge. Re-Admissions identified through claims Medicare FFS only 6
Performance Definitions (Proposed) Term Definition Points Achievement Threshold 25 th - 89 th percentile 1 99 points Benchmark 90 th percentile 100 points Improvement Improve over previous performance, above 25 th percent Base period CY 2015 1 100 points Performance period CY 2017 7
SNFRM/SNFPPR Facilities will be notified of payment adjustment no later than 8/1/18 Impacts payments beginning 10/1/18 Performance will be posted on NH Compare 8
Other Medicare VBP models Bundled Payments for Care Initiative Comprehensive Care for Joint Replacement (CJR) Other Bundles ISNP s 9
New Medicare Payment System Resident Classification System (RCS) to replace RUGS IV. Effective FY 2019 Five components PT/OT Speech Nursing Non Therapy Ancillary Room & Board/Overhead 10
Know your payors QM s improved outcomes SNFRM Bundling Medicare Fee for Service Medicare Advantage ISNP s Traditional plans Private Medicaid Quality metrics Reputation MRT/DSRIP Case Mix (Therapies) NYSQI Medicaid managed care 11
Medicaid FFS transitions 2017 Last year of SWP CMI/Capital/Rate updates Benchmark safe harbor 2020 Nursing Home Rate cell MLTC utilization climbing Regional pricing 12
Medicaid VBP Roadmap DSRIP Goal to be 80-90% VBP by 2019 Level Payment structure Level 0 VBP Level 1 VBP Level 2 VBP Level 3 VBP FFS with bonus and/or withhold based on quality scores Upside only arrangements, built on FFS, retroactive reconciliation Upside and Downside arrangements FFS, retroactive reconciliation Per Member/Patient per Month payments (capitation/prospective bundles) 13
Clinical Advisory Groups (CAG) Maternity Chronic Heart Conditions Diabetes Chronic Pulmonary Conditions Behavioral Health HIV/Aids Managed Long Term Care (MLTC) Health and Recovery Plans (HARP) 14
MLTC Members Dual eligible over 21 In need of community based LTC >120 days Enrollment mandatory after 7/1/15 Sub-population Nursing Home care Home health care 15
DSRIP VBP Roadmap Level 0 Level 1 VBP Level 2 VBP Level 3 VBP (feasible later) FFS with bonus and/or withhold based on quality scores FFS with upside only shared savings FFS with risk sharing (upside and downside) Prospective capitation PMPM or Bundle (outcome based) FFS Payments FFS Payments FFS Payments Prospective total budget payments No risk sharing Upside risk only Upside and downside risk Upside and downside risk Level 0 not considered to be sufficient for counting as VBP 16
MLTC CAG Value (over volume) Full continuum home care through NH transition Prevention Vaccinations, Medication management, depression interventions Person Focused individualized care (surveys) Health functioning measures outcomes (improvements in ADL s, interpersonal skills) 17
MLTC Value challenges Chronically ill population Outcomes difficult to measure/achieve i.e. improving quality of life, ADL improvement Lack of Medicare/Medicaid integration Population Health too much risk Value of MLTC providers generally accrues to other providers/payors (Hospitals/Medicare) Member cost profile Home care vs Nursing Home very different 18
MLTC CAG (prior reports) Nursing Home Prevent All-Cause hospitalizations Transition lower acuity members to community settings Home Care Care planning to enhance members ADL s and reduce care needs Prevent/delay institutional care Prevent All-Cause hospitalizations 19
SNF transition to home? Safety Access Home Care Choice Cost 20
MTLC - CAG Quality Incentive Pool Part II (3 5 year plan: MLTC grow from 2% to 5% of total dollars Additional dollars tied to avoidable hospitalizations Will count as Level 1 VBP model 21
Quality Measures proposed Category 1 Clinically relevant, reliable, valid and feasible P4P Category 2 Clinically relevant, valid, probably reliable, feasibility problematic P4R Category 3 Insufficiently relevant, valid reliable or feasible. 22
QM s - Category 1(P4P) 1. Percentage of members who did not experience pain (UAS) 2. Percentage of members who did not have an emergency room visit in the last 90 days (UAS) 3. Percentage of members who did not have falls resulting in medical intervention in the last 90 days (UAS) 4. Percentage of members who received and influenza vaccination in the last year (UAS) 5. Percentage of members who remained stable or demonstrated improvement in Nursing Facility Level of Care (NFLOC) score (UAS) 6. Percentage of members who remained stable or demonstrated improvement in pain intensity (UAS) 7. Percentage of members who remained stable or demonstrated improvement in shortness of breath (UAS) 8. Percentage of members who remained stable or demonstrated improvement in urinary continence (UAS) 9. Percentage of members who were not lonely and not distressed (UAS) 10. Potentially Avoidable Hospitalizations (primary diagnosis of heart failure, respiratory infection electrolyte imbalance, sepsis, anemia or UTI) (UAS/SPARCS) 23
QM s - Category 2 (P4R) 1. Care of Older Adults Medication Review (NCQA) 2. Percent of long stay high risk residents with pressure ulcers (MDS) 3. Percent of low risk residents who lose control of their bowel or bladder (MDS) 4. Percent of long stay residents experiencing one or more falls with major injury (MDS) 5. Percent of long stay residents who have depressive symptoms (MDS) 6. Percent of long stay residents who lose too much weight (MDS) 7. Percent of long stay residents who received the pneumococcal vaccine (MDS) 8. Percent of long stay residents who received the seasonal influenza vaccine (MDS) 9. Percent of long stay residents who self-report moderate to severe pain (MDS) 10. Percent of long stay residents whose need for help with daily activities has increased (MDS) 24
QM s - Category 2 (P4R) Cont. 11. Percent of long stay residents with a urinary tract infection (MDS) 12. Percent of long stay residents with dementia who received an antipsychotic medication (MDS) 13. Percentage of members who rated the quality of home health aide or personal care aide services within the last 6 months as good or excellent (MLTC survey) 14. Percentage of members who reported that within the last 6 months the home health aide or personal care aide services were usually on time (MLTC survey) 15. Percentage of members who responded that a health plan representative talked to them about appointing someone to make decisions about their health if they are unable to do so (MLTC survey) 16. Percentage of members who responded that they were usually or always involved in making decisions about their plan of care (MLTC survey) 17. Use of High-Risk Medications in the Elderly (NCQA) 25
MLTC Value Based Payments State requires Category 1 QM s to be measured, but MLTC s can choose how they want to link to payment and how they want to pay for them (P4P or P4R). Implementation year is 2017, but no details on dollars, timing, etc. Process is dynamic, will be reviewed annually. 26
Other VBP Models Telemedicine opportunities DSRIP payments, reduced hospitalizations Look for opportunities to serve distinct populations or specialty areas. Discharge planning warm handoff, follow up in patients home, medication review Population health opportunities for capitation 27
Isn t LTC Complicated Enough: Current Reimbursement Issues June 26, 2017 Kathie Angelone/Rob Nasso 28
Cost Report Everything Else. Medicaid Rates OMIG Universal Settlement 29
RHCF-4 Cost Reports What s Important? Due Date 7/3/2017 Timely, complete, Certified filing required for Quality Initiative scoring of five points. 30
RHCF-4 Cost Reports What s Important? Capital Reimbursement Schedules Schedule 9, 9A Schedule 8D Schedule 10, 11 Schedule 17 Related Companies Schedule Q???? Notepad 31
RHCF-4 Cost Reports What s Important? Nursing Hours Schedule 4, 5 & 5A, O Nursing Admin % Not Currently Used Nursing Hrs. Per Day Quality Initiative RN, LPN, Aides Hrs / Total Days Nursing Hrs. Per Day PBJ All Nursing Hours / Total Days Not Currently Used RN Hrs. Per Day PBJ RN Hrs / Total Days Not Currently Used 32
RHCF-4 Cost Reports What s Important? Make sure you submit report using most recently available software. Schedule 17 new line for 2018 Schedule O & Part III, Schedule of Amortization Schedules share a common field Col and Line # Schedule O overwrites Part III DOH has not fixed this error and recommended that you ensure Schedule O is correct. 33
% Agency RHCF-4 Cost Reports What s Important? Total Agency RN, LPN, Aide Hrs./ Total Hours Used in Quality Initiative Scoring Max Points if % <10% Points if % => 10% 34
RHCF-4 Cost Reports What s Important? Staff Retention & Turnover Schedule P Retention % # of Employees @ 12/31 less Lines 1, 2, 15, 16 / # of Employees @ 1/1 less Lines 1, 2, 15, 16 = Retention % ATI Yr 1 Threshold = 80.37% (224 Facilities) ATI Yr 2 Threshold = 78.80% (230 Facilities) 35
RHCF-4 Cost Reports What s Important? Schedule P Potential Problems Per Diem/Casual Employees Transfers between Depts Errors in Data Employees @ 1/1 + Hires - Terminations = Employees at 12/31 36
Medicaid Rates How Can I Improve My Medicaid Rate? Ship Has Sailed: Rebasing WEF Trend Factor What s Left: CMI Capital 37
Medicaid Rates Statewide Pricing What s Next? 2017: 100% of Pricing rates No increases to prices anticipated Capital continues for now MLTC Benchmark Rates Extended to 2020 Include Quality Initiative & Cash Receipts Assessment 38
Rate Revisions: CMI Minimum Wage 1% Other Funding: Medicaid Rates Advanced Training Initiative Quality Initiative 39
Office of the Medicaid Inspector General Audits Capital Audits Rate Years 2012 & Forward MDS/Case Mix Documentation Audits Hearings Therapy ADL s Rollover Audits: 2009-2011 2002 Rebasing Scaleback Universal Settlement 40
Universal Settlement OMIG Audits Year 3 installment due by March, 2018 Special Appeals Fund 41
Questions Rob Nasso/Kathie Angelone EFPR Group/RHHC Consulting, LLC (585) 295-0540 rnasso@efprgroup.com kangelone@efprgroup.com
Thank you to our Sponsor!