SNF * Readmissions Bootcamp The SNF Readmission Penalty, Post-Acute Networks, and Community Collaboratives Lindsay Holland, MHA Associate Director, Care Transitions Health Services Advisory Group (HSAG) Monday, April 24, 2017 *Skilled Nursing Facility (SNF)
Objectives Describe the SNF Value-Based Purchasing (VBP) Program Discuss the post-acute network model to reducing readmissions. Discuss the QIN-QIO * community collaborative approach to improving care transitions. 2 *Quality Innovation Network-Quality Improvement Organization
HSAG: Your Partner in Healthcare Quality HSAG is California s Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO). QIN-QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS). The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level. 3
About HSAG Nearly 25 percent of the nation s Medicare beneficiaries HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands. 4
California Care Coordination Communities 5
The Changing Healthcare Environment Historical State Key Characteristics Fee-For-Service (FFS) payment systems Incentives for volume Fragmented care Systems and Policies Unsustainable Evolving Future State Key Characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care Systems and Policies Value-based purchasing Accountable Care Organizations (ACOs) Episode-based payments Medical homes Quality/cost transparency Result: Better care, smarter spending, and healthier people 6 Source: Centers for Medicare & Medicaid Services
California Medicare FFS Hospital Readmission Rates Calendar Readmission Year Rate 2013 18.5% 2014 18.3% 2015 18.5% Q1 2016 18.4% Q2 2016 18.5% 0% relative improvement rate 7 The ASAT data file representing calendar year 2013 to Q2 20146 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.
California Medicare FFS Days to Readmission: Q3 2015 Q2 2016 Setting 0 7 8 14 15 21 22 30 Count Rate Count Rate Count Rate Count Rate Home 22,476 37.50% 14,869 24.8% 11,330 18.9% 11,304 18.8% SNF * 12,212 32.80% 9,608 25.8% 7,598 20.4% 7,863 21.1% HHA ** 9,462 36.00% 6,674 25.4% 5,197 19.8% 4,916 18.7% Hospice 245 40.20% 137 22.5% 122 20.0% 105 17.2% Other 4,601 42.90% 2,332 21.7% 1,772 16.5% 2,027 18.9% Total 48,996 36.40% 33,620 24.9% 26,019 19.3% 26,215 19.4% 36.4% returning within one week of discharge * Skilled nursing facility (SNF) ** Home health agency (HHA) 8 The ASAT data file representing Q3 2015 to Q2 2016 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.
California Medicare FFS Discharge Distribution: Q3 2015 Q2 2016 Group California Setting Discharged to 30-Day Readmit Rate Readmits to Same hospital Readmits to different hospital Home 17.1% 67.8% 32.2% SNF 21.4% 67.9% 32.1% HHA 19.2% 75.7% 24.3% Hospice 3.4% 63.7% 36.3% Other 21.8% 53.6% 46.4% Total 18.5% 68.2% 31.8% 9 The ASAT data file representing Q3 2015 to Q2 2016 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.
Hospital Readmission Penalties Number of Years Penalized (FY * 2013 2017) Number of CA Hospitals Penalized 5 years 139 4 years 43 3 years 36 2 years 26 1 year 15 0 years 35 Total 294 10 *Fiscal Year
Hospital Readmission Penalties (cont.) Section 3025 Affordable Care Act of 2010 October 2014 2017: 139 California hospitals were penalized ALL 5 years for excess readmissions Congestive heart failure Coronary artery bypass graft Acute myocardial infarction Pneumonia Chronic obstructive pulmonary disease Total knee and hip arthroplasty 11
Nursing Home Readmission VBP Program H.R. 4302 Protecting Access to Medicare Act of 2014 October 2017 Readmission rates go public on Nursing Home Compare October 2018 VBP program for nursing homes begins 12
SNF Readmission Penalty Timeline 2014 Passed Oct. 2016 Potentially preventable adjusted rate Oct. 2018 Ranked scores provided to SNFs Oct. 2018 Incentive/ penalty goes live 40% of SNFs nationally will receive a penalty 2014 Oct. 2015 Oct. 2016 Oct. 2017 October 2018 $2B Savings/ 10 years Oct. 2015 All-cause readmission measure defined Oct. 2017 Public reporting of SNF readmissions Oct. 2018 2% withhold of SNF payments begin 50 70% of the withhold will go to incentive payments to SNFs 30 50% of the withhold will go to Medicare for savings 13 https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/other-vbps/snf-vbp.html
Nursing Home Readmission VBP Program (cont.) 40% Reduction amount: 2% Lowest performers may lose 2% of Medicare funding Program is designed to save money for CMS Top performers incentive payments 50 70% of the reduction amount (1.0 1.4%) SNFs will be ranked Bottom 40% will be in the penalty-eligible range CMS provides reports on the measure So SNFs can review and plan for action Began 10/1/2016 14
Nursing Home Readmission VBP Program (cont.) One measure: an all-condition, risk-adjusted, potentially avoidable hospital readmission rate Payment differentials begin FY 2019 Payments on or after 10/1/2018 Calculation of VBP amount will use the achievement/improvement methodology used for hospital VBP Rates will be compared to thresholds and benchmarks SNFs will be awarded points for either achievement or improvement, whichever is higher 15
30-Day All-Cause SNF Readmission Measure (SNF-RM) FY 2016 SNF Prospective Payment System (PPS) final rule, CMS adopted the SNF-RM as the first measure for the SNF VBP Program. The measure is the risk-standardized rate of all-cause, unplanned hospital readmissions of Medicare beneficiaries within 30 days of discharge from their prior hospitalization. Hospital readmissions are identified through Medicare hospital claims (not SNF claims). Readmission data is not collected from SNFs and there are no additional reporting requirements for the measure. 16
30-Day All-Cause SNF-RM (cont.) Readmissions to a hospital within the 30-day window are counted if: The beneficiary is readmitted directly from the SNF, or After discharge from the SNF As long as the beneficiary was admitted to the SNF within 1 day of discharge from a hospital stay Excludes planned readmissions Is risk-adjusted based on: Patient demographics Principal diagnosis from the prior hospitalization Comorbidities Other health status variables that affect probability of readmission 17
30-Day SNF Potentially Preventable Readmission (SNF-PPR) Measure July 29, 2016, CMS adopted the SNF-PPR measure for future use in the SNF VBP Program The SNF-PPR measure assesses: Risk-standardized rate of unplanned, potentially preventable readmissions Medicare FFS SNF patients Within 30 days of discharge from a prior hospitalization 18
30-Day SNF-PPR Measure (cont.) The key difference between the SNF-RM and SNF-PPR measures: SNF-RM All-Cause Readmissions SNF-PPR Potentially Preventable Readmissions CMS will replace the SNF-RM with the SNF-PPR as soon as practicable. 19
Performance Scoring CMS has adopted these scoring methodologies to measure SNF performance that includes levels of achievement and improvement: Achievement scoring Compares an individual SNF s performance rate in a performance period against all SNFs performance during the baseline period Improvement scoring Compares a SNF s performance during the performance period against its own prior performance during the baseline period 20
Definitions for SNF VBP Program Term Achievement Threshold Benchmark Improvement Threshold Performance Period CY 2017 Baseline Period CY 2015 Proposed Definition The 25th percentile of national SNF performance on the quality measure during CY 2015 The mean of the best decile of national SNF performance on the quality measure during CY 2015 The specific SNF s performance on the measure 21
Performance Standards Standard 2013 2014 2015 25th Percentile 20.8% 20.54% 20.41% Threshold 79.2% 79.46% 79.59% Mean of the Best Decile 16.76% 16.6% 16.4% Benchmark 83.24% 83.4% 83.6% 22
SNF VBP Scoring Methodology Achievement Scoring Achievement Score: For FY 2019, points awarded by comparing the facility s rate during the performance period (CY 2017) with the performance of all facilities nationally during the baseline period (CY 2015) CY 2015 Baseline Period CY 2017 Performance Period Time 100 points Rate better or equal to benchmark 0 points Rate worse than achievement threshold 1 99 points Rate between the two (formula in final rule) 23 https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/other-vbps/snf-vbp.html
SNF VBP Scoring Methodology Improvement Scoring Improvement Score: Points awarded by comparing the facility s rate during the performance period (CY 2017) with its previous performance during the baseline period (CY 2015) CY 2015 Baseline Period Me! Time CY 2017 Performance Period Me! 1 89 points Awarded according to the formula described in the final rule 24 https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/other-vbps/snf-vbp.html
Additional Information For more information about the SNF VBP Program: https://www.cms.gov/medicare/quality- Initiatives-Patient-Assessment-Instruments/Value- Based-Programs/Other-VBPs/SNF-VBP.html Refer to: FY 2016 SNF-PPS final rule and FY 2017 SNF-PPS final rule For additional questions, email: SNFVBPinquiries@cms.hhs.gov. 25
Putting It All Together 26
Doing things the same way will NOT reduce readmissions. 27
28 Successful Partnerships
Shared Accountability Transition is a period of shared accountability Sending provider has to ensure that key information has been appropriately received and acknowledged by the receiving provider Receiving provider has to understand and execute a care plan based on the key information received 29 National Transition of Care Coalition
Elements of a Successful Hospital and SNF Partnership Utilizes, trends, and tracks readmission data Conducts root cause analysis Meets consistently Improves communication processes Reviews case studies Provides training/education Uses scorecards/dashboards Develops multi-faceted strategy 30 Interventions to Reduce Acute Care Transfers (INTERACT)
There is Never One Reason for Readmission Study reviewed over 500 readmissions across 18 Northern California Kaiser Permanente hospitals 250 (47%) deemed potentially preventable An average of 9 factors contributed to each readmission Evaluated factors related to 5 domains 73% care transitions planning and care coordination 80% clinical care 49% logistics of follow-up care 41% advance care planning and end-of-life care 28% medications 250 readmissions identified 1,867 factors 31 Feingenbaum et al Medical Care 50(7): July 2012
Thank you! Lindsay Holland Associate Director, Care Transitions, HSAG Lholland@hsag.com 32
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.3-04192017-01