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Plante Moran PLLC 5/13/2014 [email protected] [email protected] 1 plantemoran.com Leading Age of Michigan 2014 Annual Conference Presented by Brenda Sowash , Senior Manager, Plante Moran, PLLC Beth Sullivan, Senior Manager, Plante Moran, PLLC Financials for Directors of Nursing “The Power of Knowledgeplantemoran.com 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 Objectives 2 plantemoran.com Cost Reporting Reviewing Benchmarking Reports ICO and ACO Governmental Audits Managed Care Agenda 3

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Page 1: Plante Moran PLLC 5/13/2014

Plante Moran PLLC 5/13/2014

[email protected]@plantemoran.com 1

plantemoran.com

Leading Age of Michigan2014 Annual Conference

Presented by

Brenda Sowash , Senior Manager, Plante Moran, PLLC

Beth Sullivan, Senior Manager, Plante Moran, PLLC

Financials for Directorsof Nursing“The Power of Knowledge”

plantemoran.com

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

Objectives

2

plantemoran.com

Cost Reporting

Reviewing Benchmarking Reports

ICO and ACO

Governmental Audits

Managed Care

Agenda

3

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What is A Cost Report?

Annual Summary of Key Facility Financial information

Census

Revenue

Expenditures

Assets/Liabilities Fixed Assets

Debt

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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

Why Prepare a Cost Report?

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Medicaid Cost Reporting

Total Facility Costs

Skilled Nursing “Routine” Costs

Dietary, NursingLaundry, Housekeeping,

etc.

Subject to Variable CostLimit and Support to

BaseRatio Limit

Ancillary Costs

Therapies (PT, OT, Speech),

Prescription Drugs, Radiology,Lab, etc.

Not Reimbursable –Some Service Billable

WithPreauthorization

Non-reimbursable Costs

Barber & Beauty, Gift Shop

Physician Office, etc.

Not Reimbursable –Hopefully Paid by

Resident

Plant Costs

Property Taxes, Interest,Depreciation

Subject to Current Asset Value

Limit (Class I) or Plant Cost

Limit (Class III)

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TPN formula, equipment and supplies

Oxygen expense

Customized medical equipment

Wound vacs and complex dressings

Ambulance

Bariatric equipment

Orthotics

Prosthetics

Dental Services

Services that are NOT reimbursed

7

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Cable TV

Resident Room Phone

Marketing

Penalties

Bad Debts

Provider Tax

Owner Compensation

Items Not Reimbursed Through Medicaid

8

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Benchmark Report - Revenue

9

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Benchmark – Allocated Operating Costs

10

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Benchmarks – Staffing Costs PPD

11

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Benchmarks – Other Departments

12

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Benchmarks – Staffing Hours PPD

13

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Benchmark – Avg Hourly Wages

14

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Benchmarks – Other Items

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Medicare – RUGs IV

16

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RUG Concentrations

17

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Pharmacy Costs

18

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Accountable Care OrganizationsConsumer

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-

Provider 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

19

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Managed Care Organizations

Consumer

Consumer Chooses MCO

Consumer’s Care will be Coordinated or Managed by Physician

Consumer’s choices are limited to those offered by the MCO

Provider

Providers paid by MCO according to agreed upon terms

MCOs CHOOSE their partner providers

MCOs may choose to risk share with partner providers

20

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Managed Care Is Here to Stay

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State of Michigan SNF Trends

22

14.8%

3.1%

66.1%

16.0%

Medicare

Medicare HMO

Medicaid

Other

Statewide Payer Mix SNF Occupancy of 82%

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Moving Medicare from FFS to Managed Care

23

Source - Avalere Health, Leading Age PEAK Summit 2014

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FY 2013 “Fun” Michigan Facts and Figures

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Navigating Payer Shifts

25

What is transition point to become dual eligible? What about Coinsurance and Patient Pays?

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Medicaid Transitions

26

1. Currently Cost Based Reimbursement

2. Transitioning to MI Health Link

3. Where Will the Crystal Ball Take Us….

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Current Medicaid Rates

27

RoutineCosts

Plant Costs

QualityAssuranceAdd On

Still applied to Medicaid FFS residents

Rate doesn’t include non-reimbursables

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CMS MOU – What is a “Standard Medicaid Rate” – Region Four

28

Provider Name County

Medicaid Reimbursement

Rate QAS

Medicaid Reimbursement

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$

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Differentiating Your SNF

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What is Your Price?

What is the Value Proposition?

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Step # 1 – Understand Your Cost Structure

30

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)

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Should I Reduce Operating Expense?

31

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.

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What About Medicare?

32

It is unlikely that the MOU will require the MI Health Link Health Plan to pay Medicare Fee For Service Rates

CMS allows Medicare Advantage Plans (MAPS) to establish payment rates that are not commensurate with Medicare RUG rates

In Most States, many MAPs reimburse at less than RUG rates

In the future, there may be opportunities to trigger Medicare like reimbursement for long term residents that do not go out to the Hospital first

Currently, all SNFs in Michigan are paid the same for fee for service (RUGS). Less of an issue initially relative to competition

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Medicare MCO Rates – Future Considerations

33

• Rates vary by MAP provider.

• Contracts are important!

• Must understand care plan implications if prices are not RUGS based

• Are there carve outs?

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Step #2….Collect and Analyze Other Data

34

1. Acuity Data

▪MDS Data for Medicaid Residents

▪Clinical Episode/MS DRG

2. Average Length of Stay

3. Re-hospitalization Rates

4. Per Episode Costs

5. Make sure your IT systems will support data collection

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What’s Nursing Administration to Do?

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Higher Patient

Acuity/More Chronic

Conditions

Manage Utilization-Length of

StayManage other

Utilization Admissions/

Readmission

Higher Focus on

Cost EfficiencyNeed for More

Sophisticated Management Information

Additional Quality

Measures

Increase Technology

EHR

Other

The Influence of Managed Care on Operations

Enhanced Intake and Referral

Management of Care Transitions

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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

Preparing for the Inevitable

37

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Physical Attractiveness

Private rooms, amenities, rehab

Reputation and Character

Clinical competencies

Quality Indicators

Regulatory performance

Outcomes measurements

Courting Hospitals and Health Plans

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Earning Potential

Manage and reduce lengths of stay

Minimize readmissions

Partnership

Manage risk on difficult to place residents

Could you provide a market niche?

Courting Hospitals and Health Plans

39

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“In God we trust; all others must bring data.”

Dr. W. Edwards Deming

The Father of the Quality Evolution

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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

What are ACOs, MCO, ICOs, Demonstration Plans Looking For?

41

Based on Based on Recent

Request by Health Plan

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So Let’s Talk Government Focus

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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

The Focus on Skilled Nursing

43

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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

Improper Payment Initiative

44

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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

What is an Improper Payment?

45

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Skilled Nursing Facility FocusOIG recommendations to CMS included:

Monitor payments to SNFs;

Strengthen monitoring of SNFs that are billing for higher paying RUGs (PEPPER Letters recently available to providers);

Follow-up on the SNFs identified as having questionable billing

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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

Release: targeted for May 6 through May 12, 2014 (staged release)

Nothing to Sneeze at

47

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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.

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Focus on areas where the facility is an outlier: At or above the 80th percentile or

At or below the 20th percentile

Target areas:

49

Therapy RUGs with High ADLs Ultrahigh therapy RUGs

Non-therapy RUGs w/High ADLs Therapy RUGs

Change of Therapy Assessment 90+ Day Episodes of Care

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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.

50

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Long Term Care Scrutinized From All Sides

51

The Health Care Reform Act provides $350 million to fight fraud, waste and abuse

LTC

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CMS employs a variety of contractors to process claims and submits payment to providers in accordance with the Medicare and Medicaid rules and regulations

Who Else Is Watching?

52

And the private sector managed care insurance reviews are very busy scrutinizing as well

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Type of Contractor Responsibility

Affiliated Contractors (ACs) – Medicare claims processing contractors such as carriers and Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs)

(Michigan has WPS and NGS)

Process claims submitted by physicians, hospitals, and other HC providers/suppliers, and submit payment to those providers in accordance with Medicare regulations. This includes identifying and correcting underpayments and overpayments. The purpose of MACs is to educate providers, process and conduct billing, correct the behavior in need of change and prevent future inappropriate billing, and recover payments.

Medicare Contractors

53

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Type of Contractor Responsibility

Recovery Auditors (RAs)

Michigan RA - CGI

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

Medicare Contractors

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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

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Type of Contractor Responsibility

Comprehensive Error Rate Testing (CERT)

Collect documentation; perform reviews on a 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)

Medicare Contractors

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Contractor Responsibility

Medicaid Integrity Contractors (MICs)

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 claims2. Audit – conducts audits onsite or as desk audits3. Education – Pick up concerns from the other 2 to

educate providers and others

And Last but Certainly Not Least

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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

Medicare Appeals Process

58

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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.

Appeals Process – Five Levels

59

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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

Appeals Process(continued)

60

* Minimum dollar amount required to enter level

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The Importance of Appeals

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Medicaid Recovery Auditors Overlapping Services

Billing Focus

MPRO 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

What About Medicaid?

62

5-Star Rating

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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

Calculations Basics

64

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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

Calculations Basics

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Impacts the basic score (inspections) by adding or subtracting stars based on levels of staff

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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

Download Staffing Data

66

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.html

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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)

Staffing Data

67

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.

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Data

68

CMS-671(12/02)

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Calculations:

Case-Mix Adjusted Staffing

69

Reported = hours reported during annual survey

Expected = reported hours with case mix adjustments (RUG-III)

National average = mean across all facilities

Total nursing staff = 4.0309

Registered nurses = 0.7472Will remain constant

for 2 years

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Quality Measures star based on MDS quality measures for 9 of the 18 QMs that are currently posted on the Nursing Home Compare website

7 long-stay measures

2 short-stay measures

Calculations Basics

70

Impacts the basic score (inspections) by adding or subtracting stars based on the facility’s performance

with the Quality Measures

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Five-Star Quality MeasuresLong 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

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Five Star Quality MeasuresShort 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

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Health Inspection

(survey)

Add 1 star if staffing = 4 or 5 and greater than survey

Subtract1 star if staffing = 1 star

Add 1 star if QM= 5 stars

Subtract1 star if QM = 1 star

To Determine Overall Rating = 5 Steps

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Most important!!

Staffing only impacts overall score if 4, 5, or 1

QMs only impact overall score if 5 or 1

UNLESS…….

1 2 3 4 5

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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

Calculating the Overall Rating (more rules)

74

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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

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Pay For Performance Ties it All Together

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"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

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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

Background

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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.

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Decision Support

Advance Care Planning

Quality ImprovementCommunication

Tools

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http://interact2.net/

INTERACT

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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

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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

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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 Morbidity

Decrease Costs

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Quality Improvement Program

Quality Improvement Tools

Communication Tools

Decision Support Tools

Advance Care Planning Tools

Includes evidence and expert-recommended clinical practice tool, strategies to implement them, and

related educational resources

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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

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1. List all hospitals your facility sends to or receives from2. Identify the “readmissions champion” for each hospital

a.Chief Quality Officerb.Chief Financial Officerc. Chief Nursing Officerd.Director of Case Managemente.Director of Quality

3. Host or join a “cross-continuum” group. Start by inviting hospitals to your facility to see your capabilities – meet in person; may be one person at a time

Reach out to one of these folks and they will know who is the organization’s lead

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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 monthb. Current 30-day readmission rate among those patientsc. Facility’s goal to reduce preventable and unnecessary

transfers5. Describe the set of quality improvements underway in the

facility through INTERACT and other initiatives6. Ask the hospital to be an active partner in your INTERACT

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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) First appointment may not be easy to get - be persistent Know anyone that could open the door for you 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

Plan follow-up meetings to enhance collaboration and communications about your acute care transfers

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Speaking of Incentives

FY 2013 FY 2015

• Acute Myocardial Infarction• Chronic Obstructive Pulmonary

Disease

• Heart Failure • Coronary Artery Bypass Graft

• Pneumonia• Percutaneous Transluminal

Coronary Angioplasty

• Other Vascular Conditions

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:

Now looking at readmissions from all causes

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Why Do Hospitals Care?

Medicare Reimbursement

VBPCore/HAI/HCAHPS1% FY13 to 2% FY15

HAC1% starts 2015

ReadmissionAMI/HF/PNA/CABG+

1% FY13 to 3% FY15

ACOs are asking about implementation

of INTERACT, too

Tidbit

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What Can the Facility Tell the Hospital, ACO, Managed Care?

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The organizations

asking the questions and trying to find

partners – want to see data, not

just hear talk

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Bottom Line

The DON pieces it all together!

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[email protected]

734-652-8759

[email protected]

248.223.3835

Questions??

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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.html

CGI https://racb.cgi.com/Issues.aspx

Resources

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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-Fee-for-Service-Payment/SNFPPS/Spotlight.html

Office of the Inspector General https://oig.hhs.gov/oei/reports/oei-01-12-00150.pdf

Resources

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