Financials for Directors of Nursing The Power of Knowledge Presented by Brenda Sowash, Healthcare Consultant Beth Sullivan, Senior Manager Plante Moran PLLC 2014 MI NADONA LTC Annual Convocation & Expo Objectives 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 2 Agenda Cost Reporting Reviewing Benchmarking Reports ICO and ACO Governmental Audits Managed Care 3 Beth.Sullivan@plantemoran.com 1
Why Prepare a Cost Report? 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 Medicaid Cost Reporting Total Facility Costs Skilled Nursing Routine Costs Ancillary Costs Non-reimbursable Costs Plant Costs Dietary, Nursing Laundry, Housekeeping, etc. Therapies (PT, OT, Speech), Prescription Drugs, Radiology, Lab, etc. Barber & Beauty, Gift Shop Physician Office, etc. Property Taxes, Interest, Depreciation Subject to Variable Cost Limit and Support to Base Ratio Limit Not Reimbursable Some Service Billable With Preauthorization Not Reimbursable Hopefully Paid by Resident Subject to Current Asset Value Limit (Class I) or Plant Cost Limit (Class III) Services that are NOT reimbursed TPN formula, equipment and supplies Oxygen expense Customized medical equipment Wound vacs and complex dressings Ambulance Bariatric equipment Orthotics Prosthetics Dental Services 6 Beth.Sullivan@plantemoran.com 2
Items Not Reimbursed Through Medicaid Cable TV Resident Room Phone Marketing Penalties Bad Debts Provider Tax Owner Compensation 7 MI EDGE Report Revenue 8 MI EDGE Allocated Operating Costs 9 Beth.Sullivan@plantemoran.com 3
MI EDGE Staffing Costs PPD 10 MI EDGE Other Departments 11 MI EDGE Staffing Hours PPD 12 Beth.Sullivan@plantemoran.com 4
MI EDGE Avg Hourly Wages 13 Medicare EDGE RUGs IV 14 EDGE RUG Concentrations 15 Beth.Sullivan@plantemoran.com 5
MI EDGE Pharmacy Costs 16 Accountable Care Organizations Consumer Provider 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 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 17 Managed Care Organizations Consumer Provider Consumer Chooses MCO Consumer s Care will be Coordinated or Managed by Physician Consumer s choices are limited to those offered by the MCO Providers paid by MCO according to agreed upon terms MCOs CHOOSE their partner providers MCOs may choose to risk share with partner providers 18 Beth.Sullivan@plantemoran.com 6
Managed Care Is Here to Stay Moving Medicare from FFS to Managed Care Source Avalere Health, Leading Age PEAK Summit 2014 20 Navigating Payer Shifts What is transition point to become dual eligible? What about Coinsurance and Patient Pays? 21 Beth.Sullivan@plantemoran.com 7
Medicaid Transitions 1. Currently Cost Based Reimbursement 2. Transitioning to MI Health Link 3. Where Will the Crystal Ball Take Us. 22 Current Medicaid Rates Still applied to Medicaid FFS residents Routine Costs Plant Costs Rate doesn t include non reimbursables Quality Assurance Add On 23 CMS MOU What is a Standard Medicaid Rate Region Four Medicaid Medicaid Reimbursement Reimbursement Provider Name County Rate QAS 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 24 Beth.Sullivan@plantemoran.com 8
Differentiating Your SNF What is Your Price? What is the Value Proposition? Are you Collecting Data? 25 Step # 1 Understand Your Cost Structure 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) 26 Should I Reduce Operating Expense? 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. 27 Beth.Sullivan@plantemoran.com 9
Actionable Item Data Collection Collect Data in language that is useful for managing clinical episodes across the Continuum Transition from per patient day measurements to per episode Increase patient data collected at admission Hospital DRG SNF Admitting DRG SNF Diagnoses (More is better) Other Clinical Measurements Admitting Physician Primary Care Physicians Other Physicians Home Health Provider Preference 28 Actionable Item Resident Database Increase patient data collected at admission Insurance Coverage Validate with PHOTO Referring Hospital Hospital DRG SNF Admitting DRG SNF Diagnoses (More is better) Other Clinical Measurements Admitting Physician Primary Care Physicians Other Physicians Home Health Provider Preference 29 Actionable Item Managed Care Market Analysis Number of Facility has Facility Enrollees Distribution Contract Experience Estimated Population 65 plus 27,000 29% Medicare Advantage 15% Berrien H0390 82 PACE OF SOUTHWEST MICHIGAN, INC. National PACE 1% Berrien H1509 UNITEDHEALTHCARE INSURANCE COMPANY Local PPO 188 2% 5% Berrien H2320 PRIORITY HEALTH HMO/HMOPOS 58 1% Berrien H3916 HIGHMARK, INC. Local PPO 14 0% Berrien H4875 PRIORITY HEALTH Local PPO 81 1% Berrien H5216 HUMANA INSURANCE COMPANY Local PPO 2,248 29% o 5% Berrien H5521 AETNA LIFE INSURANCE COMPANY Local PPO 72 1% Berrien H6609 HUMANA INSURANCE COMPANY Local PPO 110 1% Berrien H8145 HUMANA INSURANCE COMPANY PFFS 207 3% Berrien H9572 BCBS OF MICHIGAN MUTUAL INSURANCE COMPANY Local PPO 4,163 54% x 90% Berrien R5826 HUMANA INSURANCE COMPANY Regional PPO 523 7% x Total Enrollment 7,746 100% 100% x o Facility has established contract Individual patient authorization required no contract Integrated Care Estimated Dual Eligible Population * 10,000 37% Meridian Coventry Cares *Guesstimate for Example Total Duals in Region Four = 21000 https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and- Reports/MCRAdvPartDEnrolData/Monthly-MA-Enrollment-by-State-County- Contract.html 30 Beth.Sullivan@plantemoran.com 10
Sample Utilization Dashboard Utilization ALOS Revenue Per Day Actual Budget Actual Budget Actual Budget Facility Profile Overall Performance 90% 92% 180 190 280 295 Short Term Rehabiliation 25% 27% 30 24 465 460 Private/Insurance 2% 1% 30 24 300 300 Medicare 15% 16% 30 24 475 480 Medicare Advantage RUG Based 5% 10% 25 24 460 480 Medicare Advantage Non RUG 2% 0% 24 24 400 380 Duals ICO 1% 0% 30 24 465 480 Payer Sources Long Term Care 60% 60% 270 300 $ 245 $ 250 Private Pay 25% 30% 270 300 250 260 Insurance 9% 5% 270 300 250 260 Medicaid 10% 20% 270 300 230 230 Medicaid Managed Care 4% 2% 270 300 230 230 Duals ICO 10% 3% 270 300 230 230 PACE 2% 0% 270 300 230 230 Hospice/End of Life 15% 13% 45 32 $ 240 $ 240 Private Pay 2% 5% 45 32 270 270 Insurance 3% 0% 45 32 270 270 Medicaid 10% 8% 45 32 230 230 31 Actionable Item Sample Dashboard 30 Day Readmission MY Innerview Actual Budget Benchmark Actual Budget Benchmark 14% 15% 18% 68% 70% 75% Overall Performance Short Term Rehabiliation 14% 15% 18% 68% 70% 75% Private/Insurance 13% 15% 18% 68% 70% 75% Medicare 13% 15% 18% 68% 70% 75% Medicare Advantage RUG Based 13% 15% 18% 68% 70% 75% Medicare Advantage Non RUG 18% 15% 18% 68% 70% 75% Duals ICO 15% 15% 18% 68% 70% 75% Long Term Care 68% 70% 75% Private Pay 68% 70% 75% Insurance 68% 70% 75% Medicaid 68% 70% 75% Medicaid Managed Care 68% 70% 75% Duals ICO 68% 70% 75% PACE Other Items for Consideration Nurse Staffing Hours Five Star Rating Quality Indicators Survey Compliance Hospital Admissions Falls Other Hospice/End of Life 68% 70% 75% Private Pay 68% 70% 75% Insurance 68% 70% 75% Medicaid 68% 70% 75% 32 Moving Toward Risk Based Financial Arrangements Private Pay Services Medicare PPS Program MAP SNF Flat Rate Bundled Payment Demonstration Continuing Care at Home Moderate Risk MAP SNF Medicaid Services RUG Based FFS Low Risk Full Risk PACE Provider PMPM Capitated Rate 33 Beth.Sullivan@plantemoran.com 11
Why Bundling? CMS, MEDPAC and others view bundling as viable solution for payments going forward Encourages longer term management of an episode of care commensurate with population health strategies in general Encourages collaboration and commitment to care coordination and transitions Additional avenue for savings on traditional Medicare fee for service patients (similar to ACOs) 34 Bundled Payment Demonstration Physician Services Model 2 Hospital + PAC SNF Services Hospital Readmissions Model 3 PAC Episode of 30 60 or 90 days 48 Clinical Episodes Home Health Part B Drugs Outpatient DME/Laboratory Episode Identified by Hospital MS DRG Emergency Room Visits Medicare Fee For Service Population Only 35 Establishing the Target Price Joint Replacement of Lower Extremity MS DRG 469, 470 Episodes 200 Average Cost per Episode $ 15,900 SNF $ 10,500 IRF 100 LTCAH 50 HHA 1,800 DME 200 Physician 1,800 Readmissions 1,000 Outpatient 400 Other 50 36 Beth.Sullivan@plantemoran.com 12
Time of Reckoning Reconciliation Average Cost per Episode $ 15,900 $ 14,820 Target Price 15,423 There are some CMS Reporting requirements on participation, outcomes measures, and other items SNF $ 10,500 9,800 IRF 100 150 LTCAH 50 HHA 1,800 2,200 DME 200 200 Physician 1,800 1,600 Readmissions 1,000 500 Outpatient 400 350 Other 50 20 Awardee would receive additional funds from CMS $ 603 37 What s Nursing Administration to Do? 38 The Influence of Managed Care on Operations Management of Care Transitions Increase Technology EHR Other Additional Quality Measures Manage Utilization- Length of Stay Higher Patient Acuity/More Chronic Conditions Need for More Sophisticated Management Information Manage other Utilization Admissions/ Readmission Higher Focus on Cost Efficiency Enhanced Intake and Referral 39 Beth.Sullivan@plantemoran.com 13
Preparing for the Inevitable 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 40 Courting Hospitals and Health Plans Physical Attractiveness Private rooms, amenities, rehab Reputation and Character Clinical competencies Quality Indicators Regulatory performance Outcomes measurements 41 Courting Hospitals and Health Plans Earning Potential Manage and reduce lengths of stay Minimize readmissions Partnership Manage risk on difficult to place residents Could you provide a market niche? 42 Beth.Sullivan@plantemoran.com 14
In God we trust; all others must bring data. Dr. W. Edwards Deming The Father of the Quality Evolution 43 What are ACOs, MCO, ICOs, Demonstration Plans Looking For? 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 Based on Recent Request by Health Plan 44 So Let s Talk Government Focus 45 Beth.Sullivan@plantemoran.com 15
The Focus on Skilled Nursing 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 46 Improper Payment Initiative 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 47 What is an Improper Payment? 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 48 Beth.Sullivan@plantemoran.com 16
Skilled Nursing Facility Focus OIG recommendations to CMS included: Monitor payments to SNFs; Strengthen monitoring of SNFs that are billing for higher paying RUGs (PEPPER Letters available to providers); Follow up on the SNFs identified as having questionable billing 49 Nothing to Sneeze at 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 Released May of 2014 slated to release each May from this point forward 50 What is the An analysis of Medicare Part A claims data for areas that are considered to be vulnerable to improper Medicare payments PEPPER data is from paid UB 04 claims Reports on the most recent three federal fiscal years October 1 st 2010 to September 30 th 2013 Benchmarks your facility to other Skilled Nursing Facilities in your: National State Jurisdiction 51 Beth.Sullivan@plantemoran.com 17
Why the The Center for Medicare and Medicaid Services (CMS) must protect the Medicare Trust Fund from fraud, waste and abuse. PEPPER supports CMS program integrity as the PEPPER is an educational tool to help providers assess their risk for improper payments. The Office of Inspector General (OIG), in review of SNF 2009 claims, identified 25% error rate. PEPPER can not identify improper Medicare payments! 52 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. 53 Focus on areas where the facility is an outlier: At or above the 80 th percentile or At or below the 20 th percentile Target areas: Therapy RUGs with High ADLs Non-therapy RUGs w/high ADLs Change of Therapy Assessment Ultrahigh therapy RUGs Therapy RUGs 90+ Day Episodes of Care 54 Beth.Sullivan@plantemoran.com 18
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. 55 Long Term Care Scrutinized From All Sides The Health Care Reform Act provides $350 million to fight fraud, waste and abuse LTC 56 Who Else Is Watching? CMS employs a variety of contractors to process claims and submits payment to providers in accordance with the Medicare and Medicaid rules and regulations And the private sector managed care insurance reviews are very busy scrutinizing as well 57 Beth.Sullivan@plantemoran.com 19
Medicare Contractors Type of Contractor Responsibility Affiliated Contractors Process claims submitted by physicians, (ACs) Medicare hospitals, and other HC providers/suppliers, claims processing and submit payment to those providers in contractors such as accordance with Medicare regulations. This carriers and Fiscal includes identifying and correcting Intermediaries (FIs) underpayments and overpayments. The and Medicare purpose of MACs is to educate providers, Administrative process and conduct billing, correct the Contractors (MACs) behavior in need of change and prevent future inappropriate billing, and recover payments. (Michigan WPS and NGS carry most of the SNF providers) 58 Medicare Contractors Type of Contractor Recovery Auditors (RAs) Michigan RA CGI (Currently on hold while contracts are being awarded) Responsibility 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 59 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 Beth.Sullivan@plantemoran.com 20
Medicare Contractors Type of Contractor Responsibility Comprehensive Error Collect documentation; perform reviews on a Rate Testing (CERT) 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) And Last but Certainly Not Least Contractor Medicaid Integrity Contractors (MICs) Responsibility 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 claims 2. Audit conducts audits onsite or as desk audits 3. Education Pick up concerns from the other 2 to educate providers and others 62 Medicare Appeals Process 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 63 Beth.Sullivan@plantemoran.com 21
Appeals Process Five Levels 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. 64 Appeals Process (continued) 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 * Minimum dollar amount required to enter level 65 The Importance of Appeals 66 Beth.Sullivan@plantemoran.com 22
What About Medicaid? Medicaid Recovery Auditors Overlapping Services Billing Focus MPRO/KEPro 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 67 5 Star Rating It does make a difference 68 Calculations Basics 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 69 Beth.Sullivan@plantemoran.com 23
Calculations Basics 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 Impacts the basic score (inspections) by adding or subtracting stars based on levels of staff *This may have an increased focus due to alleged up staffing for survey 70 Download Staffing Data 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 http://www.cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/FSQRS.html 71 Staffing Data 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) 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. 72 Beth.Sullivan@plantemoran.com 24
CMS-671(12/02) Data 73 Case Mix Adjusted Staffing Calculations: Reported = hours reported during annual survey Expected = reported hours with case mix adjustments (RUG-III) National average = mean across all facilities o Total nursing staff = 4.0309 o Registered nurses = 0.7472 74 Calculations Basics Quality Measures star based on MDS quality measures for 9 of the 18 QMs that are currently posted on the Nursing Home Compare website o 7 long stay measures o 2 short stay measures Impacts the basic score (inspections) by adding or subtracting stars based on the facility s performance with the Quality Measures 75 Beth.Sullivan@plantemoran.com 25
Five Star Quality Measures Long 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 76 Five Star Quality Measures Short 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 77 To Determine Overall Rating = 5 Steps 1 2 3 4 5 Most important!! Health Inspection (survey) Add 1 star if staffing = 4 or 5 and greater than survey Subtract 1 star if staffing = 1 star Add 1 star if QM = 5 stars Subtract 1 star if QM = 1 star QMs only impact overall score if 5 or 1 Staffing only impacts overall score if 4, 5, or 1 UNLESS. 78 Beth.Sullivan@plantemoran.com 26
Calculating the Overall Rating (more rules) 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 79 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 80 Pay For Performance Ties it All Together "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 81 Beth.Sullivan@plantemoran.com 27
Background 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 82 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. 83 84 Beth.Sullivan@plantemoran.com 28
85 INTERACT http://interact2.net/ Communication Tools Decision Support Advance Care Planning Quality Improvement 86 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 87 Beth.Sullivan@plantemoran.com 29
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 88 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 Costs Decrease Morbidity 89 Quality Improvement Program Includes evidence and expert-recommended clinical practice tool, strategies to implement them, and related educational resources Quality Improvement Tools Communication Tools Decision Support Tools Advance Care Planning Tools 90 Beth.Sullivan@plantemoran.com 30
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 91 1. List all hospitals your facility sends to or receives from 2. Identify the readmissions champion for each hospital a. Chief Quality Officer b. Chief Financial Officer c. Chief Nursing Officer d. Director of Case Management e. Director of Quality Reach out to one of these folks and they will know who is the organization s lead 3. Host or join a cross continuum group. Invite hospitals to your facility to demonstrate your capabilities an in person meeting is best and it can be one at a time if necessary 92 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 month b.current 30 day readmission rate among those patients c.facility s goal to reduce preventable and unnecessary transfers 5. Describe the set of quality improvements underway in the facility through INTERACT and other initiatives 6. Ask the hospital to be an active partner in your INTERACT improvements 93 Beth.Sullivan@plantemoran.com 31
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) o First appointment may not be easy to get be persistent o Know anyone that could open the door for you o 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 o Plan follow up meetings to enhance collaboration and communications about your acute care transfers 94 Speaking of Incentives 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: FY 2013 FY 2015 Acute Myocardial Infarction Heart Failure Pneumonia Chronic Obstructive Pulmonary Disease Coronary Artery Bypass Graft Percutaneous Transluminal Coronary Angioplasty Other Vascular Conditions Now looking at readmissions from all causes 95 Why Do Hospitals Care? VBP Core/HAI/HCAHPS 1% FY13 to 2% FY15 HAC 1% starts 2015 Readmission AMI/HF/PNA/CABG+ 1% FY13 to 3% FY15 Medicare Reimbursement Tidbit ACOs are asking about implementation of INTERACT, too 96 Beth.Sullivan@plantemoran.com 32
What Can the Facility Tell the Hospital, ACO, Managed Care? The organizations asking the questions and trying to find partners want to see data, not just hear talk 97 Bottom Line The DON pieces it all together! 98 Questions? Sowash@RolfConsulting.com 734-731-6031 Beth.Sullivan@plantemoran.com 248.223.3835 99 Beth.Sullivan@plantemoran.com 33
Resources 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.htm l CGI https://racb.cgi.com/issues.aspx Resources 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 Feefor Service Payment/SNFPPS/Spotlight.html Office of the Inspector General https://oig.hhs.gov/oei/reports/oei 01 12 00150.pdf 101 Beth.Sullivan@plantemoran.com 34