2010 presentation on nursing home pay for performance to washington health care association
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State Trends in Nursing Home Pay
for Performance
Washington Health Care Association
Annual Convention 2010 Spokane, WA.
Leslie Hendrickson
Hendrickson Developmentwww.hendricksondevelopment.biz
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Goals Depends on Point of View
Individual -- Want to learn something
interesting about Pay for Performance.
Building -- Want to understand what changes
I should encourage in my building.
State -- Identify issues to consider in
encouraging state to adopt a P4P program.
State organizing and lobbying effort.
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Takeaways Individual Level
Fifteen states, eight stable ones, three are
project based.
Culture change hard to get at in uniform way.Easier measures are CMS MDS quality of care
measures, survey results, staffing data and
occupancy from cost reports.
Medicare may or may not use pay for
performance. Will use it, if use of P4P reduces
hospital expenditures.3
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Takeaways Building Level
Staff retention key variable in all states.
Medicaid occupancy frequently used.
Emphasis on quality of life, culture change,self-direction and their reporting is increasing.
Colorado using very interesting measures:
dining, bathing, consistent staffing, staff inputin care planning, community involvement and
volunteers, neighborhoods.
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Takeaways State Level
2008 Task Force Recommendations
How P4P is funded is major determinant of
success. If it comes out of current rate dontbother, e.g. Ohio difficulties. If it is new $ on
top of current rate, then worthwhile to do.
See 2008 Tim Graves Texas comments.
Project based approaches Minnesota,
Vermont, Utah good way to go.
Voluntary or collect data on all homes.5
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CMS Value Based Purchasing
A three-year demonstration beginning in
summer 2009.
As of March 1, 2010 Demonstration states:Arizona 38 homes, New York 78 homes, and
Wisconsin 61 homes.
Nursing homes within these states were
solicited to participate in the demonstration.
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CMS Value Based
Purchasing Aim 1: To examine the organizational characteristics and patientdemographic and clinical characteristics of treatment and control
group nursing homes.
Aim 2: To analyze the organizational and patient demographic and
clinical characteristics of nursing homes eligible for performance
payments, the amount of performance payments received, andsubsequent impacts on nursing homes quality improvement and
financial status.
Aim 3: To examine the impact of the demonstration on incidence of
avoidable hospitalization and quality of care levels in participating
nursing homes.
Aim 4: To assess the impact of the demonstration on nursing home
management, organization, delivery of services and financial status.
Aim 5: To assess the impact of the demonstration, Medicare and
Medicaid program expenditures and savings, and evaluate the cost-
effectiveness of the demonstration.
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CMS Evaluation Activities
Literature
ReviewNursing Home Site Visits
Evaluation Findings:
Structure, Process, Cost
and Quality Outcomes
Longitudinal Nursing Home Interviews
Merged Data Set Analysis (MDS,
OSCAR, Medicare/Medicaid Claims, etc.)
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How CMS will Measure Cost
Effectiveness CMS will compare risk-adjusted Medicare PartA and B expenditures between the
demonstration and comparison groups in each
State. CMS will calculate the difference
between the demonstration groups actual
Medicare expenditures and the target
expenditures (i.e., what we would expectMedicare expenditures for beneficiaries in
demonstration homes to be in the absence of
the demonstration). 9
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How CMS will Measure Cost
Effectiveness #2 The target expenditures will be calculatedusing base year expenditures for the
demonstration group and the rate of change
in expenditures for the comparison group
since the base year.
Stingy savings, basically must be in the 80th
percentile and above to qualify for paymentfrom the state savings pool.
Unlike state efforts this is not culture change.10
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New Federal Requirements
in H.R. 3590 H.R. 3590 can get text at www.thomas.gov Nursing Home Transparency Title I Part 1
Sections 6101 through 6107. Sec. 6101. Required disclosure of ownership
and additional disclosable parties information.
Sec. 6102. Accountability requirements forskilled nursing facilities and nursing facilities.
Sec. 6103. Nursing home compare Medicare
website.11
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New Federal Requirements
in H.R. 3590 #2 Sec. 6104. Reporting of expenditures. Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability. Sec. 6107. GAO study and report on Five-Star
Quality Rating System.
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Section 6102 of H.R. 3590
Not later than December 31, 2011, the
Secretary shall establish and implement a
quality assurance and performance
improvement program shall establish
standards relating to quality assurance and
performance improvement with respect to
facilities and provide technical assistance tofacilities on the development of best practices
in order to meet such standards.
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Medicaid and Pay for Performance
Best stats are from Kuhmerker 2007Commonwealth Fund study
50% of states used P4P, 85% will by 2012.
70% of uses are in managed care and primarycare case management (PCCM)
Used in pay for participation in health
information technology (HIT) programs Unlike CMS, state focus is often on improving
quality, not reducing cost
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Pay for Performance Themes
Staffing Retention, Turnover, and Consistency
Quality of Care
Survey Data Nursing Home Compare Data
Culture Change
Medicaid Occupancy Surveys of staff, residents and families
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Summary Comments
Roughly Fifteen States
Arizona, funding on hold
California largest P4P in country but doesnt
know it. (labor driven operating allocation) Colorado, stable, new $
Georgia, stable, new $
Iowa- stable, $ in base Kansas stable, new $
Maryland, supposed to be new $, but isnt,
being phased in.17
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Summary Comments
Roughly Fifteen States # 2
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Massachusetts in limbo now,
Minnesota, stable, $ in base, project based
Ohio, not new $, cap limits receipt of incentive Oklahoma, stable
Texas, out for bid, 72,000 interviews required
Utah stable, two programs one reimbursescosts, other is project based
Vermont stable, phased in, project based
Virginia discussed in 2007, dead now
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Colorado 2010 P4P Application
Really interesting. Well worth looking at
http://www.colorado.gov/cs/Satellite/HCPF/H
CPF/1219400774885
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2009 P4P Studies
2009 State of Colorado Nursing Facility Pay-
for-Performance Application Review (For
Applications Submitted 1/31/09) at
http://www.colorado.gov/cs/Satellite/HCPF/H
CPF/1219400774885
Spring 2009 Pay-for-Performance in Nursing
Homes HCFA article athttp://www.cms.hhs.gov/HealthCareFinancing
Review/downloads/09Springpg1.pdf
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2009 P4P Studies #2
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2009 P4P Studies Slide #3
2009 Oklahoma Focus On Excellence
Independent Evaluation Easiest way to get this
is to Google it. Hard to find on Oklahoma and
Pacific Health Group site.
2009 article in Medical Care Review State
Adoption of Nursing Home Pay-for-
Performance. Ask Rachel Werner lead author
for copy at [email protected].
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2009 P4P Studies #4
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2008 P4P Studies #1
Bailit 2008 study of P4P for TX at
http://www.hhsc.state.tx.us/reports/Pay-for-
Performance_0209.pdf
Testimony of Tim Graves on Behalf of The
Texas Health Care Association House Human
Services Committee May 1, 2008 at
http://www.txhca.org/testimony/FINAL%20House%20050108%20TG%201.pdf
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2008 P4P Studies #2
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Washington
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http://www.leg.wa.gov/jointcommittees/LTCRFP
S/Pages/default.aspx
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Voluntary or Mandatory
Voluntary
Kansas
Oklahoma-survey part is
voluntary
Minnesota
Colorado
Utah
Mandatory
Iowa
Georgia
Ohio calculated for everybody
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Three States use Project Funding
Vermonts Gold Star Program
Minnesotas
Utah
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Vermont Gold Star Employer
Improvement Program Homes get Gold Stars The best practices were identified in seven
different areas: staff recruitment, orientation,staffing levels and work hours, professional
development and advancement, supervision
training and practices, team approaches and
staff recognition and support. Uses workbookwith application instruction.
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Vermont Gold Star Employer
Improvement Program Slide #2
To win a Gold Star, nursing homes must
conduct a self-assessment, select a best
practice area and develop a work plan. After
one year, a council review team reviews the
nursing facilitys progress through site visits
and telephone interviews. The council awards
Gold Star Employer Recognition based onachievement of designated goals or
achievement of unanticipated goals that have
measurable quality outcome improvements.30
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Vermont Quality Incentive Awards
#3
Five of the states forty homes can get award
of up to $25,000 each year.
1. The most recent health survey reportresulted in a score of five or less, no deficiency
with a scope and severity greater than AD@
level, with no more than two AD@ level
deficiencies in the general categories ofQuality of Care, Quality of Life, or Resident
Rights.
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Vermont Quality Incentive Awards
#4
2. No substantiated complaints in previous 12
months related to quality of care, quality of
life, or residents= rights.
3. Designated Gold Star Provider.
4. Resident satisfaction survey results above
the statewide average
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Minnesota
Performance-based Incentive
Payments
Each Fall the State issues an RFP. Homes can
get up to a 5% increase in per diem. Improve the quality of care and quality of life
in a measurable way.
Deliver good quality care more efficiently. Rebalance long-term care and make more
efficient and effective use of resources.
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Minnesota Slide Quality Add-on
Program
Minnesota had quality add-ons in 2006 and
2007 which made payments based on 24 risk-
adjusted quality indicators, for example:
Prevalence of Indwelling Catheters
Prevalence of Urinary Tract Infection
Prevalence of Infections
Prevalence of Residents who Have Fallen
Prevalence of Burns, Skin Tears or Cuts
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Utah Quality Incentives
$1,000,000 paid out of provider tax.
If you spend the money you get some back.
In 2010 can get additional funds for ninecosts: for example, nurse call systems, patient
lift systems, electronic records, HVAC, van and
van equipment, resident enhancing activities,
dining improvements.
http://health.utah.gov/medicaid/stplan/Nursi
ngHomes/UHCA%202009-
04%20Revised%20Presentation.pdf36
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Arizona
Arizona has 134 licensed nursing homes
contracted with the AHCCCS program.
Pay $50,000 to the top 40% based on one ortwo performance measures such as pressure
ulcers or use of restraints.
Total $2.7 million plus $500,000 additional
administrative costs--$3.2 million.
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Colorado
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Colorado
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Georgia
Nursing Home Quality Initiative
First Phase
Nursing Home Quality Initiative in 2003.
Training needs identified and paid for from
Civil Monetary Penalties (CMP).
Next phase started in 2007.
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Georgias
Quality Incentive Rate System % of high risk long-stay residents pressure sores;
% of long-stay residents physically restrained;
% of long-stay residents moderate to severe pain;
% of short-stay residents moderate to severe
pain;
% of residents who received influenza vaccine;
and
% of low risk long-stay residents pressure sores.
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Georgias
Quality Incentive Rate System #2
Exceeding the threshold of 85 percent or
higher of good or excellent ratings on the
family satisfaction question would you
recommend this facility?
Participation in the employee satisfaction
survey.
Above the state average on either RN/LPNstability or certified nursing assistant stability.
In 2007, 78% of homes received payments43
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Iowa
Significant Change in 2009
Added Culture Change as reported in self
certification form showing measures of
Person Directed Care.
Added three Nationally Reported Quality
Measures of quality of care:
High-Risk Pressure Ulcer
Physical Restraints
Chronic Care Pain
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Iowa Nursing Facility Pay-for-
Performance Program
Quality of life.
Person-Directed Care, Resident Satisfaction
Quality of care. Survey, Staffing, Nationally Reported QualityMeasures
Access. Efficiency.
Most providers are only eligible for 1-3%
increase. It is hard to get the full 5%. $1.40 a
day to $1.50 a day is average add on that
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Kansas Changes in 2009
Deemphasized focus on efficiency
Added culture change but doesnt pay much
for it
Eliminated
Operating expenses
Staff retention but still keeps heavy emphasis on
number of staff per se and staff turnover
Total occupancy
Survey outcomes now used as gate keeper
rather than measure 46
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Kansas 2009
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Massachusetts
Initiated by the state
Is on hold because of budget problems
The last published document onMassachusetts P4P was the MassHealth
Nursing Facility Bulletin 129 December 2008.
http://www.mass.gov/Eeohhs2/docs/masshea
lth/bull_2008/nf-129.pdf
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Ohio Quality Incentive Program
Deficiency free on the most survey results.
Resident and family satisfaction surveys are
above the statewide average.
Number of hours nurses are employed is
above the statewide average;
Employee retention rate is above the average
Occupancy rate, Medicaid utilization and case
mix are above the statewide average.
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Ohio 2009 Results #1
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Oklahoma
Focus on Excellence
Well documented effort because of Pacific
Health Group study.
Focus on Excellence has two components an
incentive payment methodology and a five
star rating system published on a website.
Significant disadvantage is that money for FOE
comes out of existing reimbursement and isnot new dollars. Homes facing 6.9% reduction
in remainder of FY 10 and 10% in FY 2011.
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Oklahoma #2
1. Quality of Life.
2. Resident/Family Satisfaction.
3. Employee Satisfaction. 4. System-wide Culture Change.
5. Certified Nursing Assistant/Nursing
Assistant Turnover and Retention. 6. Nurse Turnover and Retention.
7. State Survey Compliance.
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Companies
Georgia and Oklahoma using My Innerview to
collect family and resident interview.
Oklahoma pays $646,000 a year to My
InnnerView.
Minnesota and Ohio used Vital Research to do
resident interviews.
In last two months, both Colorado and Texasissued RFPs for contractors.
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