The beautiful, fascinating thing about health policy in the U.S. is its cycle of evolution. It evolves, sometimes slowly and other times quickly but always, in a progressive (not in the political sense) direction. Providers today can be lulled to sleep (quickly) by the vacuum drone of big policy lectures, webinars, etc., easily thinking for example, PDPM is the two-ton gorilla in the room (we need to deal with). Perhaps because reimbursement and survey/certification issues are so large that they shadow, seemingly eclipse, other trends and issues. Yet, think of these other trends and issues like mosquitoes (the state “summer” bird in Wisconsin where I am from); omnipresent, annoying, nipping, but not large enough to cause much damage. Still, mosquito bites can be a real nuisance and in rare cases, rather debilitating.
None of the following trends/issues weigh-out like PDPM but each has a potential impact for the post-acute sector, namely SNFs.
- QRP and VBP: Both can, with poor performance or lackadaisical compliance, reduce Medicare reimbursement. Today, 73% of the SNFs are feeling some kind of Medicare reimbursement reduction due to VBP performance (lack thereof) in terms of readmissions. Come October 1, the penalty for non-QRP reporting at a certain threshold kicks-in with a penalty/reduction equal to 2% of Medicare payments Combine the two and the reduction can mount to 4% of Medicare payments (fee-for-service) to an SNF.
- Medicare Advantage and Readmissions: Tying one to the other for VBP is an interesting proposition. Here’s how this works. While VBP only positively or negatively impacts fee-for-service Medicare payments, the Medicare Advantage impact that the SNF market is seeing with respect to readmission rates, encompasses Medicare Advantage patients. Convoluted, I know. In short-hand: All Medicare patient days count toward the readmission (avoidable) calculation, fee-for-service and/or Advantage. Based on a recent study published in the Annals of Internal Medicine, Medicare Advantage patients have a higher readmission experience than their fee-for-service counterparts. To be clear, the readmission contrast was for patient diagnostic categories of acute myocardial infarction, congestive heart failure and pneumonia. Still, the issue here is that facilities with a high percentage of Medicare Advantage patients need to be aggressive with these payers in terms of care coordination; particularly as the same intersects with length of stay. Medicare Advantage plans often look to aggressively shorten lengths of stay, perhaps too aggressively. Similarly, their networks may not coordinate post-inpatient care via home health agencies as well as one would expect. They simply don’t have the best agencies in network or they don’t work to consistently integrate the post-acute providers in collaborative coordination efforts.
- More SNF VBP?: In a bill recently proposed in the House (bipartisan sponsors) known as the BETTER Act (Beneficiary Education Tools Tele-health Extender Reauthorization), Section 204 includes direction to the Secretary to adopt additional performance measures for reimbursement purposes beginning on or after, October 2021. The language implies the categories (“additional measures determined appropriate”) to include functional status, patient safety, care coordination and/or patient experience. As I have written before: Quality and revenue are directly connected today and more is coming. SNFs better be “on” their Quality Measures and laser-focused on their outcomes or suffer the reimbursement (reduction) consequences.
- Quality Measures: Any SNF that hasn’t looked for a while at their Five Start report and specifically, their Quality Measures section is literally, asleep at the wheel. The numbers now are broken down between long-stay and short-stay measures, with applicable detail. It isn’t the aggregate rating any more that matters. The reality is the categorical ratings matter most and for SNFs hoping to play “big” in the post-acute arena, the short-stay ratings are KEY. Today, referral networks are reshaping how and where patients go, post-hospitalization. Not a day goes by that I don’t hear from hospital and health system folks about their current reviews of SNF QMs, and in particular, the short-stay measure performance. In a recent discussion with a convener for a Bundled Payment project, she relayed how one SNF was beside itself when she said basically, “no inclusion in their preferred network”. The SNF was unaware that their short-stay QM rating was only two stars. The convener was only interested in SNFs with short-stay measures rating four and five stars.
- Phase 3 Conditions of Participation Requirements: Though not as impactful as Phase 2 requirements, there are a few here that could bite facilities surveyed post November 28 of this year. The inspection star ratings are unfrozen now so survey performance will impact star ratings again…no hiatus. The biggies? Infection control with a designated, trained preventionist is required. Remember, infection control citations tend to be widespread in scope. A compliance and ethics program is required after November 28. Staff need to be trained on the program and infection control. The facility assessment is required to tie with the facility’s QAPI program. The facility must develop a person-centered, baseline care plan within 48 hours of admission. With respect to dietary/food service, the facility must designate a director of food service who will have training/certification as a certified dietary manager, certified food service manager, a dietitian, or some other equivalent certification and training in food service management or hospitality from an accredited institution. A good resource that covers all Phase 3 requirements (as well as Phases 1 and 2) is available (download) here: 3-RoP-Checklist-overview-FINAL.101416