Payers and Billing: Opportunities with Managed Care and Other Entities Section 3.2: Understanding LTPAC Five Star Ratings and How the Pharmacist Can Help The introduction to the User s Guide for Five Star Ratings in Nursing Homes (see link below) states the following: In December 2008, The Centers for Medicare & Medicaid Services (CMS) enhanced its Nursing Home Compare public reporting site to include a set of quality ratings for each nursing home that participates in Medicare or Medicaid. The ratings take the form of several star ratings for each nursing home. The primary goal of this rating system is to provide residents and their families with an easy way to understand assessment of nursing home quality, making meaningful distinctions between high and low performing nursing homes. Why is the Five Star Rating Important in Today s LTPAC Reimbursement World? The CMS Innovations Project entitled Bundled Payment for Care Improvement (BPCI) includes four models of care which define payments for the many services received during an episode of care. Organizations enter into payment agreements with both performance and financial accountability for the various episodes of care. The BPCI retrospective payment Models 2 and 3 directly affect the long term post-acute care sector. Model 2: Each episode of care includes the acute care PLUS the post-acute care stay and all related services up to 90 days post hospital discharge. Model 3: The episode of care is triggered by a hospital but begins at the initiation of post-acute care services with a skilled nursing or inpatient rehabilitation facility, or home health agency. Medicare continues to make fee-for-service (FFS) payments in these models and later reconciles the expense for the episode vs the bundled payment amount determined by CMS. Organization members participating in these payment agreements share the payment or recoupment amount as compared to the target price. LTPAC organizations rely heavily on the five-star rating to demonstrate the quality of care provided and therefore their viability as a healthcare partner. Pharmacists can provide services by offering strategies that emphasize clinical expertise, disease management and cost avoidance. Bundled payment programs are examples where these strategies are necessary and required and where pharmacists can demonstrate their skills to help keep costs down for the healthcare system. Billing for pharmacist services may be achieved under a provider arrangement or as an employee. Understanding the importance of the rating and its calculation can give the pharmacist a valuable tool in assisting the provider customer in maintaining or improving their score and increasing the opportunity to be a viable healthcare partner. Resource: The following link provides information about the CMS Bundled Payment for Care Improvement (BPCI) initiative and describes the various care models with up to date information on the progress of this demonstration project https://innovation.cms.gov/initiatives/bundled-payments/ 1
Resource: The link below leads you to a document which provides a comprehensive description of the design for the Nursing Home Compare Five-Star Quality Rating System, including all three domains: Health Inspection, Staffing and Quality Measures. Certification/CertificationandComplianc/Downloads/usersguide.pdf Resource: Below is a link to CMS.gov website that houses more information on the Five Star Rating process for LTPAC and the three domains. This site is useful as it provides the historical background and includes current information on any changes CMS makes to the three domains of the rating. http://www.cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/FSQRS.html Calculation of LTPAC Five Star Rating The rating driver is Survey aka Health Inspection results. The overall rating is determined as follows: 1: Start with Health Inspection Rating 2: Add 1 star if Staffing Rating is 4 or 5; subtract 1 star if Staffing Rating is 1 star; no change if Staffing Rating is 2 or 3 3: Add 1 star if QM Rating is 5; subtract 1 star if QM rating is 1; no change if QM rating is 2,3 or 4. Health Inspection Domain: Given the weight of the health inspection/survey rating component of the overall score, let s understand how that initial rating is calculated. Each deficiency received on the annual health survey is scored by scope and severity with a higher number of points assigned for higher scope and severity. Additional points are scored for substandard quality of care and failed revisits. This is clearly a case where a higher score is not desirable. The higher the survey points, the lower the Star Rating for this category. The chart below shows the system CMS created to assign points based on the scope and severity (S&S) of each citation received during survey. Note the only S&S s that are not assigned points are levels A,B and C which are not considered deficient practice. 2
Survey Deficiency Score: Weights for Different Types of Deficiencies Severity Scope Isolated Pattern Widespread Immediate jeopardy to resident health or safety J 50 points (75 points) K 100 points (125 points) L 150 points (175 points) Actual harm that is not immediate jeopardy G 20 points H 35 points (40 points) I 45 points (50 points) No actual harm with potential for more than min. harm that is not IJ D 4 points E 8 points F 16 points (20 points) No actual harm with potential for min. harm A 0 point B 0 points C 0 points Staffing Domain: The Staffing Domain introduction in the Users Guide for Five Star Ratings in Nursing Homes (see link below) states the following: There is considerable evidence of a relationship between nursing home staffing levels and resident outcomes. The CMS Staffing Study found a clear association between nurse staffing ratios and nursing home quality of care, identifying specific ratios of staff to residents below which residents are at substantially higher risk of quality problems.. Payroll Based Journal introduced in 2016 incorporates the calculation of hours provided by Consultant Pharmacists. Resource: Read more about the Staffing Domain calculation beginning on page 6 in the Users Guide. Certification/CertificationandComplianc/Downloads/usersguide.pdf Quality Measures (QM) Domain The introduction to the Quality Measures Domain in the Users Guide for Five Star Ratings in Nursing Homes (see link below) states the following: A set of quality measures (QMs) were developed from Minimum Data Set (MDS) and Medicare claims data to describe the quality of care provided in nursing homes. These measures address a broad range of function and health status indicators. The facility QM rating is based on performance in 13 MDS-based QMs and three MDS- and Medicare claims based measures currently posted on Nursing Home Compare. 3
Five additional measures (indicated below) were added to the Five-Star rating system in July 2016. Resource: The following link provides detail from CMS on the 5 additional QMs added to the rating system: Certification/CertificationandComplianc/Downloads/Improvements-NHC-April-2016.pdf As you review the information provided by CMS on the Quality Measures, think about the impact that you can have on the LTPAC facility in improving the QM score. Many of the measures below are impacted by medications and their appropriate use and management (noted in bold type) where a pharmacist s input may have a significant impact on the measure and ultimately the overall rating. 9 Measures for Long-Stay residents (LOS > 100 days) that are derived from Minimum Data Set (MDS) assessments: Activities of daily living Independent movement Presence of pressure ulcers Urinary catheters Physical restraints Urinary Tract Infections Moderate to severe pain reports Falls with major injury Receiving antipsychotic medication 4 Measures for Short-Stay residents that are derived from MDS assessments: Improved physical function New or worsened pressure ulcers Newly received antipsychotic medication Self-reported moderate to severe pain 3 Measures for Short-Stay residents that are derived from claims data and MDS assessments: Emergency department visit Rehospitalization after NH admission Successful discharge to community Nursing Home Compare: Consultant Pharmacists may review the ratings of any of their LTPAC customers on a government site called Nursing Home Compare. This site includes survey results and scores for the quality measure and staffing domains. Review a single customer s information by entering location, city, zip code or name into the search engine. This may be useful in identifying how you may be able to assist your customer in improving their ratings. Resource: Below is the link to Nursing Home Compare: http://www.medicare.gov/nursinghomecompare/search.html Resource: Use CMS Nursing Home Compare Database to download national comparative data and search pharmacy related citations by clicking on this link: https://data.medicare.gov/data/nursing-home-compare 4
Resource: As you review the survey results of your customer, it may be helpful to have this resource at your fingertips. Appendix PP of the State Operations Manual provides information on CMS regulatory requirements for LTC. As of Nov, 2016, and the updated Requirements of Participation, this resource is under revision. This link provides the most recent updated version as of 11/28/16: Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf 5