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August 2017 Advisor Newsletter

CMS Update: Bundled Payments Cancelled?Quality Measures Revealed: Where Do "QMs" Come From? RCS-1 Myth Busters!  Are You Up On Your BR?

CMS Update: CMS Proposes Cancellation of Bundled Payments

Recent news that CMS may be planning to walk back plans for bundled payment models for cardiac and orthopedic care came on August 17, 2017, amidst mixed responses from the healthcare community.

A proposed rule titled, “Cancellation of Advancing Care Coordination through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model,” is now officially under review. While this rule proposes a cancellation of these models altogether, many thought-leaders suspect CMS will instead make participation in these payment models voluntary (rather than mandatory, as previously defined).

The models, originally slated to begin in July 2017, have been delayed multiple times over the past year and have inspired skeptics and supporters alike to speak out. Many healthcare experts believe mandatory bundles would create complicated hurdles for many cardiac and orthopedic specialty practices, while others uphold the value of the bundled payment models as ways to significantly improve quality of care at lower costs.

Stay tuned for more details related to CMS’ 180 degree tap-and-turn decision, or visit the CMS website to read more.

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Quality Measures Revealed: Where Do “QMs” Come From?

Access to quality health care for Medicare recipients has been a high priority for Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) since 2001. In fact, the government empowers consumers by publicly reporting out on Quality Measures (QMs) for skilled nursing facilities (SNFs) and home health agencies (HHAs) to facilitate those Medicare beneficiaries in making important healthcare-related choices. (Information about SNFs and HHAs QMs can be found at www.medicare.gov.)

Importantly, QMs are also used by members of the care continuum to evaluate the relative performance of those SNFs and HHAs within their own network. Poor QMs could gravely affect the status with referral sources who want to only align themselves with high performing providers. Alternatively, those SNFs and HHAs with above-average QMs should leverage their positive performance measures to differentiate themselves in a competitive marketplace.

Nursing Home Quality Measures
QMs are based on information from (1) MDS assessments and (2) Medicare claims and are used to quantify the quality of care provided within nursing homes.

Two categories exist, based on the cumulative days within the facility: Short-Stay (less than or equal to 100 days) and Long-Stay (101+ days).

24 measures exist, and are recalculated and updated quarterly. Important to note: these QMs (nine in the Short-Stay category and 15 in the Long-Stay category) impact the facility’s QMs and overall 5 Star Rating.

QMs is a simple ratio (expressed as a percentage) that captures a facility’s performance relative to each indicator at a given point in time:

Number that triggered QM Divided by Number that could trigger QM equals % of residents with QM condition

Each QM calculation is based on whether the MDS does/does not indicate a resident has the QM condition.

  • A facility’s score increases when residents’ MDS responses indicate resident has the QM condition;
  • Lower scores indicate less occurrences of the QM condition, reflective of better care (except for vaccinations ). Higher scores indicate possible problems.
  • For vaccination QMs, higher scores reflect better care (i.e.: a higher proportion of residents in receipt of a vaccine.)
Each QM has certain criteria that must be met during the “target period,” or time that defines the QM reporting period. For example, in order to classify as a “Fall with Major Injury,” the fall must include a bone fracture, joint dislocation, closed head injury with altered consciousness, or subdermal hematoma.

Home Health Quality Measures
HHAs are assigned QMs to indicate whether patients demonstrated improvement while in their care. Each QM is derived from OASIS assessment data for process and outcome of care, and in most categories, a HIGHER percentage is better. Please note two exceptions where LOWER percentages are considered better: rehospitalization rates and emergency care.

An OASIS assessment is completed upon initiation and discharge of home health services. Outcome measures are determined by whether a patient improves. For process measures, the OASIS assessment items related to this measure are either met or not met. Process and outcome measures are reported for each individual agency and also compared to state and national averages.

Current publicly reported process and outcome measures where high % is better:
  • Improvement with ambulation
  • Improvement with bed transfers
  • Improvement with bathing
  • Improvement in pain with activity
  • Improvement with breathing/shortness of breath
  • Improvement with surgical wounds
  • Timely initiation of care – within 48 hours of order/referral
  • Completion of drug education
  • Improvement with management of oral medications
  • Falls risk assessment completed
  • Depression assessment completed
  • Flu vaccination received
  • Pneumonia vaccination received
  • Diabetic foot care education completed

Current publicly reported process and outcome measures where low % is better:

  • Hospital admission rates as well as readmission rates
  • Emergency care without hospital admission as well as this rate after a recent hospitalization

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RCS-1 Myth Busters!

As HealthPRO®/Heritage continues to peel away the layers on RCS-1, several “myths” are bubbling up that may create either a false sense of security or potentially misguided decision-making. This month, our subject-matter experts kick-off a series of communications related to the most common misconceptions about RCS-1. Reminder: RCS-1 is currently in proposal phase and may change; our commentary reflects the current state of system design.

Myth # 1: “RCS-1 is a simpler reimbursement system that decreases the management complexity for providers.”

Perhaps the most dangerous of all the current misconceptions is the impression that RCS-1 is less complex or confusing than our current system. In fact, RCS-1 brings more reimbursement complexity with 139,000+ potential patient classification combinations (as compared to today’s 66) and a much greater universe of clinical conditions that can impact reimbursement.

While the MDS continues to drive reimbursement, initial rate setting under RCS-1 is more rigid with new requirements. E.g.: clinical information from the prior acute care stay, accurate diagnostic coding as early as Day 1, etc. Key drivers of reimbursement under RCS-1 include: ADL and cognitive scoring, ICD10 coding, and overall MDS assessment accuracy.

Importantly, once the initial rate is set, only a significant change assessment (for which there are specific criteria) can modify it. New data elements and changes related to timing of data capture for initial rate setting will require a complete redesign of care management and documentation processes to accurately classify patients and ensure appropriate clinical reimbursement.

While there may, in theory, be fewer assessments to be completed, the complexity involved in documentation and proper MDS coding will be challenging. In the RCS-1 system, there will be increased possibilities for error and limited ability to correct. As a result, ensuring accurate processes to skill patients and a progressive case management approach is critical.

Lastly, auditors will be looking closely for changes in utilization patterns that could signal a significant departure in care delivery from historical trends, and networks continue to narrow requiring providers to perform at a high level of care management.

In July 2017, CMS released a provider-specific impact analysis tool to estimate the impact of RCS-1 using provider and patient data. The calculator represents estimated payments under RCS-1 and assumes no change in provider behavior, case-mix, etc. (Note: All facility traits in the calculator, from Provider Name through bed size, are current as of the last day of FY 2014.)

For providers to truly understand specifics related to the RCS-1 impact on their own facilities, HealthPRO®/Heritage recommends a crosswalk analysis from RUGS to RCS-1 using current MDS data should be performed.

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Are You Up On Your BR?

A BR (Business Review) is our opportunity to review three months of data (vs. the past month). It allows us to identify changes in trends and is better for strategic long-term forecasting.

The BR can touch on various topics, including:

  • Business intelligences & ops review (reports, revenue/margin, trend reports, staffing, etc.)
  • Clinical excellence & development
  • Regulatory updates & clinical initiatives
  • QA/Compliance & auditing process
  • Customer service & accomplishments
  • Wellness & marketing initiatives
  • Goals & opportunities

Questions? Contact your RVP today!

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