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MEDICARE UPDATES: VBP, SNF QRP, BUNDLING
PRESENTED BY:
ROBIN L. HILLIER, CPA, STNA, LNHA, RAC-MT
[email protected] (330)807-2850
MEDICARE VALUE BASED PURCHASING
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PROTECTING ACCESS TO MEDICARE ACT OF 2014 (PAMA)
• IMPLEMENTS A VALUE BASED PURCHASING PROGRAM (SNF VBP)
• 2% WITHHOLD TO PART A PAYMENTS THAT CAN BE PARTIALLY EARNED BACK BASED ON
REHOSPITALIZATION RATE AND LEVEL OF IMPROVEMENT
• PASSED IN 2014, RATES NOT IMPACTED UNTIL FY 2019 (OCTOBER 1, 2018); DETAILS TO BE
DEVELOPED BY CMS RULEMAKING
PAMA VBP IMPLEMENTATION TIMELINE
• FY 2016 – MEASURE DEVELOPMENT, DATA COLLECTION
• FY 2017 – SNF PREVIEW OF DATA
• FY 2018 – PUBLIC REPORTING OF DATA
• FY 2019 – (OCTOBER 1, 2018) WITHHOLD IMPLEMENTED
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FY 2016 PPS UPDATE RULE
• CMS SELECTED THE SKILLED NURSING FACILITY 30-DAY ALL-CAUSE READMISSION MEASURE RISK
ADJUSTED REHOSPITALIZATION MEASURE (SNFRM NQF #2510)
• WILL MOVE TO “POTENTIALLY PREVENTABLE REHOSPITALIZATION MEASURE”
SNFRM BACKGROUND
• HOSPITAL READMISSIONS OF MEDICARE VBENEFICIARIES DISCHARGED FROM A SNF ARE
COMMON, STUDIES SUGGEST A LARGE PROPORTION ARE PREVENTABLE
• HOSPITAL READMISSIONS ALSO PUT BENEFICIARIES AT RISK FOR COMPLICATIONS
• THE INTENT OF THE SNFRM IS TO ENCOURAGE SNF PROVIDERS TO MONITOR AND REDUCE
HOSPITAL READMISSIONS, THEREBY REDUCING COSTS AND IMPROVING THE QUALITY OF CARE
MEDICARE BENEFICIARIES RECEIVE DURING THEIR SNF STAY
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SNFRM MEASURE OVERVIEW
• SNFRM ESTIMATED THE RISK-STANDARDIZED RATE OF ALL-CAUSE, UNPLANNED HOSPITAL
READMISSIONS FOR SNF BENEFICIARIES WITHIN 30 DAYS OF DISCHARGE FROM THEIR PRIOR
PROXIMAL SHORT-STAY ACUTE HOSPITAL DISCHARGE
• SNF ADMISSION MUST HAVE OCCURRED WITHIN 1 DAY AFTER DISCHARGE FROM THE PROXIMAL
HOSPITAL STAY
• MEASURE BASED ON DATA FOR 12 MONTHS OF SNF ADMISSIONS
• BENEFICIARIES WITH MORE THAN ONE ELIGIBLE ADMISSION MAY BE INCLUDED IN THE MEASURE
MULTIPLE TIMES WITHIN A GIVEN YEAR
SNFRM MEASURE OVERVIEW - EXCLUSIONS
• SNFRM EXCLUDES CERTAIN STAYS:
• STAYS FOR WHICH PATIENT HAD INTERVENING PAC ADMISSION BETWEEN HOSPITAL STAY AND SNF
OR AFTER SNF DISCHARGE
• PATIENTS WHO DID NOT HAVE FFS PART A ENROLLMENT BEFORE PROXIMAL HOSPITAL DISCHARGE
• PATIENTS WHO DID NOT HAVE FFS PART A ENROLLMENT FOR ENTIRE 30 DAY RISK WINDOW
• PATIENTS WHOSE HOSPITALIZATION WAS FOR THE MEDICAL (NONSURGICAL) TREATMENT OF CANCER
OR RECEIVING REHABILITATION CARE OR PROSTHESIS FITTING
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SNFRM MEASURE OVERVIEW
• SNF RM PRODUCES A RISK-ADJUSTED READMISSION RATE FOR EACH FACILITY, EXCLUDING
PLANNED READMISSION FROM THE SNF
• MEASURE IS COMPUTED BY CALCULATING THE STANDARDIZED RISK RATIO (SRR): THE PREDICTED
NUMBER OF READMISSIONS AT THE FACILITY DIVIDED BY THE EXPECTED NUMBER OF
READMISSIONS FOR THE SAME PATIENTS IF THESE SAME PATIENTS HAD BEEN TREATED BY THE
AVERAGE SNF
• SRR IS THEN MULTIPLIED BY THE MEAN RATE OF READMISSION IN THE POPULATION TO
GENERATE THE FACILITY-LEVEL STANDARDIZED READMISSION RATE, REFERRED TO AS THE RISK-
STANDARDIZED READMISSION RATE OR RSRR
SNFRM MEASURE OVERVIEW
• MEASURE IS DESIGNED TO CAPTURE THE OUTCOME OF UNPLANNED ALL-CAUSE HOSPITAL
READMISSIONS OCCURRING WITHIN 30 DAYS OF DISCHARGE FROM THE PATIENTS PRIOR
PROXIMAL ACUTE HOSPITALIZATION
• HOSPITAL OBSERVATION STAYS DO NOT COUNT AS A READMISSION
• READMISSIONS IDENTIFIED AS BEING PLANNED USING THE CMS PLANNED READMISSION
ALGORITHM ARE EXCLUDED
• SNFRM IS EVALUATED ON A 1-YEAR CYCLE
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SNFRM – PLANNED READMISSION
• PLANNED READMISSION IS DEFINED AS ANT NON-ACUTE READMISSION IN WHICH ONE OF A
SET OF TYPICALLY PLANNED PROCEDURES OR DIAGNOSES OCCURRED
• IF ANY OF THE PROCEDURES DENOTED AS PLANNED OCCUR IN CONJUNCTION WITH A
DIAGNOSIS THAT DISQUALIFIES A READMISSION FROM BEING CONSIDERED PLANNED, THE
READMISSION WILL BE CONSIDERED TO BE UNPLANNED
SNFRM – PLANNED READMISSION• PLANNED READMISSION PROCEDURES:
• ONE OF A PRE-SPECIFIED LIST OF PROCEDURES TOOK PLACE, OR
• READMISSION FOR BONE MARROW, KIDNEY OR OTHER TRANSPLANT
• PLANNED READMISSION DIAGNOSES:
• MAINTENANCE CHEMOTHERAPY AND REHABILITATION
• READMISSIONS TO PSYCHIATRIC HOSPITALS OR UNITS
• ADMISSIONS FOR ACUTE ILLNESS OR FOR COMPLICATIONS OF CARE ARE NOT
CLASSIFIED AS “PLANNED,” EVEN IF A TYPICALLY PLANNED PROCEDURE IS
PERFORMED DURING THE STAY
• PRINCIPAL DIAGNOSIS AND ALL PROCEDURE CODES FROM THE READMISSION ARE
UTILIZED TO IDENTIFY PLANNED READMISSIONS
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SNFRM RISK ADJUSTMENT
• COVARIATES USED IN THE MEASURE:
• AGE, GENDER
• PROXIMAL HOSPITALIZATION LOS
• TIME IN ICU?
• ESRD
• # ACUTE CARE HOSPITALIZATIONS IN 365
DAYS BEFORE PROXIMAL HOSPITALIZATION
• PRINCIPAL DIAGNOSIS
• SYSTEM-SPECIFIC SURGICAL INDICATORS
• KIDNEY, CARDIAC, VASCULAR PATIENTS WITH
SURGICAL INDICATORS ARE HIGHER RISK
• ORTHO WITH SURGICAL INDICATOR ARE LOWER
RISK
• INDIVIDUAL COMORBIDITIES
• ESRD, DIABETES, HEART FAILURE, PRESSURE
ULCERS
• MULTIPLE COMORBIDITIES
• CHARLSON COMORBIDITY INDEX IS CALCULATED
USING BOTH THE NUMBER AND SERIOUSNESS
OF COMORBIDITIES
FY 2017 PPS UPDATE RULE
• FY 2016 PPS UPDATE RULE SPECIFIED THE USE OF THE SNF REHOSPITALIZATION MEASURE (SNF
RM) FOR VALUE BASED PURCHASING RATE ADJUSTMENTS EFFECTIVE OCTOBER 1, 2018
• FY 2017 UPDATE RULE ANNOUNCES TRANSITION TO A POTENTIALLY PREVENTABLE
REHOSPITALIZATION MEASURE (“SNFPPRM”) “AT SOME POINT”
• 30 DAY MEASURE SIMILAR TO THE SNF RM, BUT ONLY COUNTS REHOSPITALIZATIONS WITH A
DIAGNOSIS ON HOSPITAL CLAIM THAT IS CONSIDERED POTENTIALLY PREVENTABLE (I.E., COPD, CHF)
• THIS IS A SPECIFIC LIST OF DIAGNOSES, COVERS MOST ADMISSIONS
RLH Consulting 14
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FY 2017 PPS UPDATE RULE
• PERFORMANCE PERIOD
• JANUARY 1, 2017 TO DECEMBER 31, 2017
• IMPROVEMENT PERIOD
• IMPROVEMENT TO BE CALCULATED OVER RATE FROM TWO YEARS BEFORE PERFORMANCE PERIOD
• CY 2017 IMPROVEMENT OVER CY 2015
• CMS ANNOUNCED PLANS TO TRANSITION FROM A CALENDAR YEAR MEASUREMENT PERIOD TO
A FISCAL YEAR MEASUREMENT PERIOD BEGINNING OCTOBER 2017, SO THE QUARTER FROM
OCTOBER 1 THROUGH DECEMBER 31, 2017 WILL COUNT IN TWO DIFFERENT RATE YEAR
ADJUSTMENTS
RLH Consulting 15
FY 2017 PPS UPDATE RULE
• REHOSPITALIZATION SCORE USED TO CALCULATE PAYMENT RATE CAN RANGE FROM 0 TO 100
POINTS
• IT WILL BE THE HIGHER OF THE FACILITY “ACHIEVEMENT” SCORE OR “IMPROVEMENT” SCORE
• FACILITIES WILL BE RANKED BASED ON REHOSPITALIZATION SCORE TO DETERMINE PAYMENT
ADJUSTMENT
RLH Consulting 16
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FY 2017 PPS UPDATE RULE
• ACHIEVEMENT SCORE OF 0 TO 100 IS AWARDED BASED ON RANKING OF THE
REHOSPITALIZATION RATE IN THE PERFORMANCE PERIOD
• SNFS IN LOWEST 25% RECEIVE 0 POINTS
• SNFS IN TOP 5% RECEIVE 100 POINTS
• FORMULA PROPOSED FOR ALLOCATING POINTS TO REMAINING SNFS
RLH Consulting 17
FY 2017 PPS UPDATE RULE
• IMPROVEMENT SCORE OF 0 TO 90 POINTS AWARDED BASED ON IMPROVEMENT OVER A TWO-
YEAR PERIOD
• A UNIQUE IMPROVEMENT RANGE IS ESTABLISHED FOR EACH SNF THAT DEFINES THE DIFFERENCE
BETWEEN THEIR BASELINE PERIOD SCORE AND THE NATIONAL BENCHMARK ESTABLISHED
RLH Consulting 18
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FY 2017 PPS UPDATE RULE
• IMPROVEMENT SCORE, CONTINUED
• IF PERFORMANCE PERIOD SCORE IS EQUAL TO OR LOWER THAN IMPROVEMENT THRESHOLD, 0
POINTS AWARDED
• IF PERFORMANCE PERIOD SCORE IS EQUAL TO OR HIGHER THAN THE BENCHMARK, 90 POINTS
AWARDED
• IF PERIOD SCORE IS GREATER THAN IMPROVEMENT SCORE, BUT LESS THAN THE BENCHMARK,
BETWEEN 0 AND 90 POINTS WILL BE AWARDED USING A PROPOSED FORMULA
RLH Consulting 19
FY 2017 PPS UPDATE RULE
• SNF PART A PAYMENT ADJUSTMENT WILL BE BASED ON REHOSPITALIZATION SCORE RANKING
• FACILITIES WILL BE TOLD THE PAYMENT ADJUSTMENT AT LEAST 60 DAYS PRIOR TO RATE
EFFECTIVE DATE
• REMEMBER, FIRST PAYMENT ADJUSTMENTS EFFECTIVE OCTOBER 1, 2018
RLH Consulting 20
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UPCOMING SNF VBP COMPONENTS
• CMS IS NOW PROVIDING QUARTERLY CONFIDENTIAL FEEDBACK REPORTS SO THAT FACILITIES CAN
MONITOR THEIR PERFORMANCE
• CMS HAS POSTED A FILE WITH EVERY SNF 2015 BASELINE (2015) RISK STANDARDIZED READMISSION
RATE
• THE FY2018 PPS UPDATE RULE WILL PROVIDE ADDITIONAL INFORMATION RELATED TO THE PAYMENT
SPECIFICS
IMPACT ACT
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• THE IMPACT ACT (2014) REQUIRED CMS TO SPECIFY STANDARD
ASSESSMENT TOOLS ACROSS PAC PROVIDERS (HH, SNF, IRF, LTCH)
ALONG WITH CROSS-SETTING QMS BY OCTOBER 2015 IN FOUR
DOMAINS:
• FUNCTIONAL STATUS
• COGNITIVE FUNCTION AND CHANGES IN COGNITION
• SKIN INTEGRITY AND CHANGES IN SKIN INTEGRITY
• INCIDENCE OF MAJOR FALLS
IMPACT ACT
• COLLECTION AND SUBMISSION OF DATA REQUIRED WITHIN TWO
YEARS OF FINAL MEASURE SPECIFICATION (OCTOBER 2017)
• PROPOSED MEASURES REQUIRE TWELVE MONTHS OF DATA, SO
DATA SUBMISSION REQUIRED BEGINNING OCTOBER 2016
• 2% PENALTY FOR FAILURE TO REPORT REQUIRED DATA
• (IMPLICATION OF DASHES ON MDS)
• FUTURE IMPLICATIONS FOR VBP
SNF QUALITY REPORTING PROGRAM (QRP)
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SNF PART A DISCHARGE ASSESSMENT
• THE MEASURES SPECIFIED FOR SNFQR REQUIRES AN ASSESSMENT BE COMPLETED AT THE END
OF EACH PART A STAY TO CAPTURE QUALITY MEASURE ITEMS. DISCHARGE ASSESSMENTS ARE
COMPLETED FOR PART A BENEFICIARIES WHO GO HOME AT THE END OF THE EPISODE OF CARE,
BUT THERE IS CURRENTLY NOT AN END OF CARE ASSESSMENT REQUIRED FOR THOSE WHO WILL
REMAIN IN THE FACILITY AT THE END OF PART A COVERAGE
• EFFECTIVE OCTOBER 1, 2016 A NEW “SNF PART A PPS DISCHARGE ASSESSMENT” IS REQUIRED
IN THESE CIRCUMSTANCES
SNF PART A DISCHARGE ASSESSMENT
• THE MEASURES SPECIFIED FOR SNFQR REQUIRES AN ASSESSMENT BE COMPLETED AT THE END
OF EACH PART A STAY TO CAPTURE QUALITY MEASURE ITEMS. DISCHARGE ASSESSMENTS ARE
COMPLETED FOR PART A BENEFICIARIES WHO GO HOME AT THE END OF THE EPISODE OF CARE,
BUT THERE IS CURRENTLY NOT AN END OF CARE ASSESSMENT REQUIRED FOR THOSE WHO WILL
REMAIN IN THE FACILITY AT THE END OF PART A COVERAGE
• EFFECTIVE OCTOBER 1, 2016 A NEW “SNF PART A PPS DISCHARGE ASSESSMENT” IS REQUIRED
IN THESE CIRCUMSTANCES
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• REVIEW CODING INSTRUCTIONS FOR A2400C AS WELL AS RETURN ANTICIPATED VS. RETURN
NOT ANTICIPATED
• FOR A MEDICARE PART A DISCHARGE WHERE THE BENEFICIARY LEAVES THE FACILITY, THIS
ASSESSMENT WILL BE COMBINED WITH THE OBRA DISCHARGE ASSESSMENT
• FOR A RESIDENT WHO WILL REMAIN IN THE FACILITY AFTER BEING DISCHARGED FROM
MEDICARE, THIS WILL BE A STAND ALONE ASSESSMENT
SNF PART A DISCHARGE ASSESSMENT
SNF QRP ASSESSMENT-BASED QUALITY MEASURES
• NQF #0674: APPLICATION OF PERCENT OF RESIDENTS EXPERIENCING ONE OF MORE FALLS
WITH A MAJOR INJURY
• NQF #0678: PERCENT OF PATIENTS OR RESIDENTS WITH PRESSURE ULCERS THAT ARE NEW OR
WORSENED
• NQF #2631 APPLICATION OF PERCENT OF LONG-TERMCARE HOSPITAL ADMISSIONS WITH AN
ADMISSION AND DISCHARGE FUNCTIONAL ASSESSMENT AND A CARE PLAN THAT ADDRESSES
FUNCTION
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SNF QRP CLAIMS-BASED MEASURES
• DISCHARGE TO COMMUNITY – POST ACUTE CARE (PAC) SKILLED NURSING FACILITY QUALITY
REPORTING PROGRAM (QRP)
• POTENTIALLY PREVENTABLE 30-DAYS POST-DISCHARGE READMISSION MEASURE FOR SKILLED
NURSING FACILITY QUALITY REPORTING PROGRAM
• MEDICARE SPENDING PER BENEFICIARY – POST ACUTE CARE (PAC) SKILLED NURSING FACILITY
MEASURE
SNF QRP MEASURES
• CMS HAS POSTED SEVERAL RESOURCES:
• TABLE OF MDS ITEMS USED TO GENERATE SNF QRP MEASURES
• SNF QRP QUALITY MEASURES USER’S MANUAL
• REVIEW AND CORRECT REPORTS
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BUNDLING UPDATE
Bundled Payments
for Care
Improvement (BPCI)
Comprehensive Care
for Joint Replacement
(CJR)
Episode Payment
Models (EPMs)
• Voluntary for all Medicare
acute and PAC providers
• 4 models: acute, PAC, and
acute+PAC
• Providers can select from 48
clinical episodes to test within a
specific timeframe (ranging
from inpatient acute care to 30,
60, or 90 days after discharge)
• 5-year demo
• Mandatory bundles in 67
markets for Medicare
beneficiaries who receive hip
and knee replacements (also
called lower extremity joint
replacements or LEJR)
• Hospital is risk-bearer, impacts
~800 hospitals
• 90-day episodes
• 5-year demo
• Mandatory bundles in 98
markets for heart attack, bypass
surgery
• Mandatory surgical hip/femur
fracture treatment episode
added to 67 CJR markets
• Proposed in 2016, subsequently
delayed twice (current start date
is January 2018)
• Hospital is risk-bearer
• 90-day episodes
April 2013April 2016
January 1, 2018…?
MAJOR BUNDLING INITIATIVES
?
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CMS SCALES BACK MANDATORY BUNDLING DEMOS
1. Completely withdraw
proposed AMI, CABG, and
SHFFT episodes
2. Reduce mandatory CJR
markets from 67 to 34
(remaining 33 become
voluntary)
3. No longer mandatory for rural
and low-volume hospitals
August 17, 2017
Proposed Rule
Source: https://www.gpo.gov/fdsys/pkg/FR-2017-08-17/pdf/2017-17446.pdf
HALF OF CJR MARKETS WOULD GO VOLUNTARY
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IS SCALE-BACK A GOOD THING?
• SCALING BACK OF MANDATORY BUNDLING PROGRAMS COULD EASE
THE PRESSURE ON SNFS, PARTICULARLY IN REFORM-HEAVY MARKETS
WITH MANY COMPETING OVERLAPPING VALUE-BASED INITIATIVES
• SNF OPPORTUNITY TO SHARE RISK IN HOSPITAL-CONTROLLED,
MANDATORY PROGRAMS IS LIMITED
• CONCERNS OVER UNINTENDED CONSEQUENCES ON PATIENT ACCESS
TO SNF SERVICES
• DOESN’T MEAN BUNDLING GOES AWAY…
CMS TO EXPAND VOLUNTARY OPTIONS
“…WE EXPECT TO CONTINUE TO OFFER
OPPORTUNITIES FOR PROVIDERS TO
PARTICIPATE IN VOLUNTARY INITIATIVES,
INCLUDING EPISODE PAYMENT
MODELS.”
“BUILDING ON THE BPCI INITIATIVE,
CMMI EXPECTS TO DEVELOP NEW
VOLUNTARY BUNDLED PAYMENT
MODEL(S) DURING CY 2018 THAT
WOULD BE AN ADVANCED APM.”
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ADVANCED BPCI: DETAILS STARTING TO EMERGE
• MODELS 1 AND 4 OF BPCI NOT LIKELY TO BE CONTINUED
• LOOKING TO BUILD OFF EXISTING BPCI RISK-BEARING ARCHITECTURE
• LIKELY TO CONTINUE TO USE CONVENER AND EPISODE INITIATORS STRUCTURE
• TWEAKS UNDER CONSIDERATION BY CMS INNOVATION CENTER:
• ALLOWING NEW PARTICIPANTS
• NEWLY DEFINED EPISODES
• LONGER PERFORMANCE PERIODS
• TARGET PRICE CALCULATION
• ENSURING THAT THE NEW MODEL QUALIFIES AS MACRA ADVANCED APM
ADVANCED BPCI: WHAT WE’RE WATCHING FOR…
• DOES IT MAINTAIN A MODEL 3-LIKE OPTION FOR PAC PROVIDERS TO
DIRECTLY BEAR RISK FOR A PAC-ONLY EPISODE OF CARE?
• WILL EPISODE OPTIONS BE MAINTAINED? WILL THERE BE NEW EPISODE
OPTIONS? (E.G., CHRONIC CARE EPISODE)
• WILL THERE BE BETTER RISK ADJUSTMENT AND RISK MITIGATION?
• WHAT TYPE OF DATA AND HOW FREQUENTLY WILL CMS PROVIDE TO
APPLICANTS/PARTICIPANTS?
• WHAT WILL THE TECHNOLOGY REQUIREMENTS BE?
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WHY ENGAGE IN VOLUNTARY BUNDLES?
Learn by doing; force culture change
Understand markets through data
Improve quality through care redesign
Earn positive margins
Master skills for gainsharing in other arenas
ACTION STEPS
Consider participating in Advanced BPCI
Understand who in your market is
bearing downside risk
Find out if referral hospitals are
staying in CJR –could impact BPCI
Evaluate potential convener
relationship
Identify clinical/ episode
focus areas
Systematically reach out with your (quality &
cost) value proposition
If you are serious about participating in Advanced BPCI…
Immediate…