changes to cms’ five-star: what investors and operators ......mobile app •home page •session...

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Thursday, March 8, 20184:00 PM – 5:15 PMDallas Ballroom F

Changes to CMS’ Five-Star:What Investors and Operators

Need to Know

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Speakers

Steven Littlehale, MS, GCNS-BCEVP & Chief Clinical Officer

PointRight Inc.

Eric Gillis, MBADirector of Asset Management

CareTrust REIT

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Why do we bother with clinical outcomes data?

From Volume to Value and Its Impact on SNFs Viability

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Reho

spita

lizat

ion

Success is:– Determined on clinical

outcomes playing field– Requires metrics be

monitored and properly managed

Swish!

Key Metrics from PointRight Available Soon to NIC MAP Subscribers and Skilled Nursing Data Contributors

State/Metro Level Report Property Level Report

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Five StarA Quick Overview

“The primary goal in launching 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.”

CMS’s Technical Users’ Guide July 2009

“I need a nursing home for my wife. I cannot afford a Five-Star or even a Four-Star home, can you recommend a Three-Star?”

Consumer in Florida March 2010

CMS’ Five-Star Program

The rating system features an overall Five-Star rating based on facility performance for three types of performance measures: Health Inspection Staffing Quality Measures

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The rating system has been available to the public on CMS website Nursing Home Compare since December 18, 2008

1.3 million page views per month

Five-Star does nothing to match the right person to the right SNF

All SNFs are not the same• De facto specialty care centers• Acute Medical/Rehab• Alzheimer's/Cognitive Impairment• Mental Health• End of Life/Frail Elders

All consumers coming into a SNF are not the same• Some are patients and will be going

home• Some are residents and will not• All have unique needs

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5

Add 1 Star to Overall

1

Minus 1 Star to Overall

QM Rating

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4 or 5 and >HI

Add 1 Star to Overall

1

Minus 1 Star to Overall

Staffing Rating

2Overall Five Star

Rating

4Initial Health

Inspection Rating (HI)

1

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Who’s Using It and Why?

Five-Star Uses (and Abuses) are Far Ranging

Intended Uses

• Consumer placement• Consumer monitoring

of care

Unintended Uses• APM (ACOs, Bundles)• HUD• Commercial payers• Plaintiff Attorney• REITs

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APM: What is a Three-Day Requirement & Waiver?

Requirement:Qualifying inpatient hospital stay of 3 consecutive days (midnights) or more (plus additional criteria)

Waiver:For eligible programs, CMS will waive the requirement for a 3-day inpatient hospital stay prior to a Medicare-covered, post-hospital extended care service for eligible beneficiaries

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A Waiver is a good thing

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For the ACO/Bundle it means the possibility of transitioning patient to lower cost center (the SNF)

For the SNF, it means a potentially better referral stream of higher acuity residents

The “spill over effect” – a hospital discharge planner knows what she knows… other FFS patients may turn up in same hospital to SNF stream

So how do you get one?

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Who Gets a Three Day Waiver?

• SNF must have a 3 or better Overall Star Rating• ACO Track +1, Track 3 and Next Gen• Bundles: For Model 2/Model 3 participants

…but there is always a catch!

Five-Star Ratings & Rehospitalization Rates

Overall RatingJun-17

Median Observed Rehospitalization Rate

Median Adjusted Rehospitalization Rate

5 14.1 15.24 15.9 16.13 17.1 16.92 17.6 17.21 19.3 18.1

PointRight Inc. ©2018

Five-Star Ratings & Rehospitalization Rates


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Litigation

Are PL Claims >250K Correlated to Five-Star?

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Five-Star Domain

overall

Yes!

health inspection

Yes!

quality

No!

staffing

Yes!

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REIT: The Role of Five-Star

Evaluating

Monitoring

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Change is in the Air

Health Inspection and Staffing Domains• Remember that HI has most significant impact on Five-Star• Staffing domain has the second impact score• Anytime these domains are “touched”, facility-level five-star

changes occur• CMS has not released technical manuals that reflect these

impending changes

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Health Inspection• Deficiency data* from complaint or standard surveys post Nov 28th

are not included until further notice (effective: Jan 2018)• Traditionally three survey cycles were used in calculation, this will

reduce to two (effective: March 1)• Most recent survey cycle/year will be weighted 60%, second most

recent, weighted 40%.• Technical specification was released March 2nd

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* This deficiency data is posted on NHC

The Winners and the Losers – An ApproximationHealth Inspection DomainAbout 20% of SNFs will see a change in their health inspection domain

– 1329 will see a decrease– 1726 will see an increase

Overall Five-Star15% of SNFs will see a change in Overall Stars

– 1017 will see a decrease in Star Rating– 1266 will see an increase in Star Rating– 303 will lose their 3 Star Rating– 348 will obtain a 3 Star Rating

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If in Jan ‘18 three cycles were to reduce to two

Electronic Submission of Staffing Data

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The Affordable Care Act requires facilities to electronically submit direct care staffing information based on payroll and other auditable data. •Combined with census information will be used to report on staffing levels

•Includes agency and contract staff

CMS deployed system to allow for submission of staffing: the Payroll-Based Journal (PBJ). •Staffing is submitted quarterly•It will also be auditable to ensure accuracy and compliance

•Noncompliance will be subject to CMS enforcement actions

Staffing Data

The Potential Five-Star Impact

Staffing Type N Mean Median

RN HPRD from CMS 671 (Sep-17) 14,153 0.82 0.71RN HPRD from Q3 2017 PBJ file when LPNs with admin duties are still counted under RN 14,153 0.71 0.61RN HPRD from Q3 2017 PBJ file 14,153 0.64 0.55* N only includes providers that have a non-missing value for both CMS-671 and PBJ staffing. PointRight Inc. ©2018

PBJ vs CMS - 671

Staff Type NMedian

CMS - 671Median

PBJ

Median Difference(PBJ – 671)

Median Percent

Difference

RN HPRD 14,153 0.71 0.55 -0.16 -22.5%LPN HPRD 14,153 0.83 0.85 0.02 2.4%Aide HPRD 14,153 2.37 2.23 -0.14 -5.9%Total HPRD 14,153 3.95 3.67 -0.28 -7.1%

* N only includes providers that have a non-missing value for both CMS-671 and PBJ staffing. PointRight Inc. ©2018

Removing LPN w/Admin Duties from RN “Bucket”

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RN Staffing Rating Sep-17

% of SNFs - Today % of SNFs - PBJ data(removing LPN with admin duties)

5 21.6 13.14 26.6 16.73 26.6 21.12 16.0 19.11 9.2 30.0


Then Recalculate Staffing Domain

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Staffing Rating Sep-17

% of SNFs - Today % of SNFs - PBJ data(removing LPN with admin duties)

5 12.2 6.74 31.6 18.53 30.1 26.42 14.2 18.71 11.9 29.7


Then Recalculate “Overall Five-Star”

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Overall Rating Sep-17 % of SNFs - Today % of SNFs - PBJ data(removing LPN with admin duties)

5 27.1 21.84 22.3 20.13 17.9 18.52 19.0 20.91 13.7 18.7


PBJ Staffing Data: Key Differences to Keep in Mind• Salaried workers that pick up additional shifts will not have those hours counted, unless

paid a “bonus” for those hours• If an employee performs multiple job functions, code them to primary function• Focus is on auditable data that can be verified• Hours paid for services performed onsite, not including lunch, sick leave, vacation• Corporate staff can be counted in some instances but must be auditable• Contract/agency staff must be reported• Census is calculated by MDS – essential that discharge assessments be completed

Staffing and Rehospitalization, and other key findings

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• ↓pain, pressure ulcers • ↓ ER use• ↑immunizations• ↓ pressure ulcers• ↓ pain

MHPsNP FTE ≥0.5 • ↓ ER use• ↓ rehosp• ↑ ROC• ↓ pressure ulcers• ↓ antipsychotics

Medical Director > 0.2 FTE • ↓ ER use• ↓ rehosp• ↑ ROC• ↓ pressure ulcers • ↓ antipsychotics

NP

Higher RN staffing is by far the most powerful thing in better PAC

outcomes

RN Staffing

Pharmacists• ↑immunizations• ↓ pressure ulcers• ↓ pain

Medical Director

How do these changes impact the REIT?

Evaluating Monitoring

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Conclusion

What is Certain• Key clinical outcomes are essential

KPIs to track• Five-Star has an impact on a SNFs

success• Five-Star is changing

What is Less Certain• Technical details around Five-Star

changes• Timing of Five-Star changes• Future impact on SNFs of volume to

value

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Audience Questions

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Thank You!

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Steven LittlehaleEVP & Chief Clinical Officer, PointRight

781.457.5900 [email protected]

Eric GillisDirector of Asset Management, CareTrust REIT

949.542.3139 [email protected]

changes to cms’ five-star: what investors and operators ......mobile app •home page •session...

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