2010 Presentation on Nursing Home Pay for Performance to Washington Health Care Association

8/7/2019 2010 Presentation on Nursing Home Pay for Performance to Washington Health Care Association

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State Trends in Nursing Home Pay

for Performance

Washington Health Care Association

Annual Convention 2010 Spokane, WA.

Leslie Hendrickson

Hendrickson Developmentwww.hendricksondevelopment.biz

[email protected]


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Goals Depends on Point of View

Individual -- Want to learn something

interesting about Pay for Performance.

Building -- Want to understand what changes

I should encourage in my building.

State -- Identify issues to consider in

encouraging state to adopt a P4P program.

State organizing and lobbying effort.

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Takeaways Individual Level

Fifteen states, eight stable ones, three are

project based.

Culture change hard to get at in uniform way.Easier measures are CMS MDS quality of care

measures, survey results, staffing data and

occupancy from cost reports.

Medicare may or may not use pay for

performance. Will use it, if use of P4P reduces

hospital expenditures.3


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Takeaways Building Level

Staff retention key variable in all states.

Medicaid occupancy frequently used.

Emphasis on quality of life, culture change,self-direction and their reporting is increasing.

Colorado using very interesting measures:

dining, bathing, consistent staffing, staff inputin care planning, community involvement and

volunteers, neighborhoods.

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Takeaways State Level

2008 Task Force Recommendations

How P4P is funded is major determinant of

success. If it comes out of current rate dontbother, e.g. Ohio difficulties. If it is new $ on

top of current rate, then worthwhile to do.

See 2008 Tim Graves Texas comments.

Project based approaches Minnesota,

Vermont, Utah good way to go.

Voluntary or collect data on all homes.5


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CMS Value Based Purchasing

A three-year demonstration beginning in

summer 2009.

As of March 1, 2010 Demonstration states:Arizona 38 homes, New York 78 homes, and

Wisconsin 61 homes.

Nursing homes within these states were

solicited to participate in the demonstration.

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CMS Value Based

Purchasing Aim 1: To examine the organizational characteristics and patientdemographic and clinical characteristics of treatment and control

group nursing homes.

Aim 2: To analyze the organizational and patient demographic and

clinical characteristics of nursing homes eligible for performance

payments, the amount of performance payments received, andsubsequent impacts on nursing homes quality improvement and

financial status.

Aim 3: To examine the impact of the demonstration on incidence of

avoidable hospitalization and quality of care levels in participating

nursing homes.

Aim 4: To assess the impact of the demonstration on nursing home

management, organization, delivery of services and financial status.

Aim 5: To assess the impact of the demonstration, Medicare and

Medicaid program expenditures and savings, and evaluate the cost-

effectiveness of the demonstration.


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CMS Evaluation Activities

Literature

ReviewNursing Home Site Visits

Evaluation Findings:

Structure, Process, Cost

and Quality Outcomes

Longitudinal Nursing Home Interviews

Merged Data Set Analysis (MDS,

OSCAR, Medicare/Medicaid Claims, etc.)


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How CMS will Measure Cost

Effectiveness CMS will compare risk-adjusted Medicare PartA and B expenditures between the

demonstration and comparison groups in each

State. CMS will calculate the difference

between the demonstration groups actual

Medicare expenditures and the target

expenditures (i.e., what we would expectMedicare expenditures for beneficiaries in

demonstration homes to be in the absence of

the demonstration). 9


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How CMS will Measure Cost

Effectiveness #2 The target expenditures will be calculatedusing base year expenditures for the

demonstration group and the rate of change

in expenditures for the comparison group

since the base year.

Stingy savings, basically must be in the 80th

percentile and above to qualify for paymentfrom the state savings pool.

Unlike state efforts this is not culture change.10


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New Federal Requirements

in H.R. 3590 H.R. 3590 can get text at www.thomas.gov Nursing Home Transparency Title I Part 1

Sections 6101 through 6107. Sec. 6101. Required disclosure of ownership

and additional disclosable parties information.

Sec. 6102. Accountability requirements forskilled nursing facilities and nursing facilities.

Sec. 6103. Nursing home compare Medicare

website.11


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New Federal Requirements

in H.R. 3590 #2 Sec. 6104. Reporting of expenditures. Sec. 6105. Standardized complaint form.

Sec. 6106. Ensuring staffing accountability. Sec. 6107. GAO study and report on Five-Star

Quality Rating System.

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Section 6102 of H.R. 3590

Not later than December 31, 2011, the

Secretary shall establish and implement a

quality assurance and performance

improvement program shall establish

standards relating to quality assurance and

performance improvement with respect to

facilities and provide technical assistance tofacilities on the development of best practices

in order to meet such standards.

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Medicaid and Pay for Performance

Best stats are from Kuhmerker 2007Commonwealth Fund study

50% of states used P4P, 85% will by 2012.

70% of uses are in managed care and primarycare case management (PCCM)

Used in pay for participation in health

information technology (HIT) programs Unlike CMS, state focus is often on improving

quality, not reducing cost

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Pay for Performance Themes

Staffing Retention, Turnover, and Consistency

Quality of Care

Survey Data Nursing Home Compare Data

Culture Change

Medicaid Occupancy Surveys of staff, residents and families

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Summary Comments

Roughly Fifteen States

Arizona, funding on hold

California largest P4P in country but doesnt

know it. (labor driven operating allocation) Colorado, stable, new $

Georgia, stable, new $

Iowa- stable, $ in base Kansas stable, new $

Maryland, supposed to be new $, but isnt,

being phased in.17


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Summary Comments

Roughly Fifteen States # 2

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Massachusetts in limbo now,

Minnesota, stable, $ in base, project based

Ohio, not new $, cap limits receipt of incentive Oklahoma, stable

Texas, out for bid, 72,000 interviews required

Utah stable, two programs one reimbursescosts, other is project based

Vermont stable, phased in, project based

Virginia discussed in 2007, dead now


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Colorado 2010 P4P Application

Really interesting. Well worth looking at

http://www.colorado.gov/cs/Satellite/HCPF/H

CPF/1219400774885

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2009 P4P Studies

2009 State of Colorado Nursing Facility Pay-

for-Performance Application Review (For

Applications Submitted 1/31/09) at

http://www.colorado.gov/cs/Satellite/HCPF/H

CPF/1219400774885

Spring 2009 Pay-for-Performance in Nursing

Homes HCFA article athttp://www.cms.hhs.gov/HealthCareFinancing

Review/downloads/09Springpg1.pdf

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2009 P4P Studies #2

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2009 P4P Studies Slide #3

2009 Oklahoma Focus On Excellence

Independent Evaluation Easiest way to get this

is to Google it. Hard to find on Oklahoma and

Pacific Health Group site.

2009 article in Medical Care Review State

Adoption of Nursing Home Pay-for-

Performance. Ask Rachel Werner lead author

for copy at [email protected].

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2009 P4P Studies #4

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2008 P4P Studies #1

Bailit 2008 study of P4P for TX at

http://www.hhsc.state.tx.us/reports/Pay-for-

Performance_0209.pdf

Testimony of Tim Graves on Behalf of The

Texas Health Care Association House Human

Services Committee May 1, 2008 at

http://www.txhca.org/testimony/FINAL%20House%20050108%20TG%201.pdf

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2008 P4P Studies #2

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Washington

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http://www.leg.wa.gov/jointcommittees/LTCRFP

S/Pages/default.aspx


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Voluntary or Mandatory

Voluntary

Kansas

Oklahoma-survey part is

voluntary

Minnesota

Colorado

Utah

Mandatory

Iowa

Georgia

Ohio calculated for everybody

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Three States use Project Funding

Vermonts Gold Star Program

Minnesotas

Utah

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Vermont Gold Star Employer

Improvement Program Homes get Gold Stars The best practices were identified in seven

different areas: staff recruitment, orientation,staffing levels and work hours, professional

development and advancement, supervision

training and practices, team approaches and

staff recognition and support. Uses workbookwith application instruction.

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Vermont Gold Star Employer

Improvement Program Slide #2

To win a Gold Star, nursing homes must

conduct a self-assessment, select a best

practice area and develop a work plan. After

one year, a council review team reviews the

nursing facilitys progress through site visits

and telephone interviews. The council awards

Gold Star Employer Recognition based onachievement of designated goals or

achievement of unanticipated goals that have

measurable quality outcome improvements.30


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Vermont Quality Incentive Awards

#3

Five of the states forty homes can get award

of up to $25,000 each year.

1. The most recent health survey reportresulted in a score of five or less, no deficiency

with a scope and severity greater than AD@

level, with no more than two AD@ level

deficiencies in the general categories ofQuality of Care, Quality of Life, or Resident

Rights.

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Vermont Quality Incentive Awards

#4

2. No substantiated complaints in previous 12

months related to quality of care, quality of

life, or residents= rights.

3. Designated Gold Star Provider.

4. Resident satisfaction survey results above

the statewide average

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Minnesota

Performance-based Incentive

Payments

Each Fall the State issues an RFP. Homes can

get up to a 5% increase in per diem. Improve the quality of care and quality of life

in a measurable way.

Deliver good quality care more efficiently. Rebalance long-term care and make more

efficient and effective use of resources.

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Minnesota Slide Quality Add-on

Program

Minnesota had quality add-ons in 2006 and

2007 which made payments based on 24 risk-

adjusted quality indicators, for example:

Prevalence of Indwelling Catheters

Prevalence of Urinary Tract Infection

Prevalence of Infections

Prevalence of Residents who Have Fallen

Prevalence of Burns, Skin Tears or Cuts

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Utah Quality Incentives

$1,000,000 paid out of provider tax.

If you spend the money you get some back.

In 2010 can get additional funds for ninecosts: for example, nurse call systems, patient

lift systems, electronic records, HVAC, van and

van equipment, resident enhancing activities,

dining improvements.

http://health.utah.gov/medicaid/stplan/Nursi

ngHomes/UHCA%202009-

04%20Revised%20Presentation.pdf36


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Arizona

Arizona has 134 licensed nursing homes

contracted with the AHCCCS program.

Pay $50,000 to the top 40% based on one ortwo performance measures such as pressure

ulcers or use of restraints.

Total $2.7 million plus $500,000 additional

administrative costs--$3.2 million.

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Colorado

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Colorado

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Georgia

Nursing Home Quality Initiative

First Phase

Nursing Home Quality Initiative in 2003.

Training needs identified and paid for from

Civil Monetary Penalties (CMP).

Next phase started in 2007.

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Georgias

Quality Incentive Rate System % of high risk long-stay residents pressure sores;

% of long-stay residents physically restrained;

% of long-stay residents moderate to severe pain;

% of short-stay residents moderate to severe

pain;

% of residents who received influenza vaccine;

and

% of low risk long-stay residents pressure sores.

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Georgias

Quality Incentive Rate System #2

Exceeding the threshold of 85 percent or

higher of good or excellent ratings on the

family satisfaction question would you

recommend this facility?

Participation in the employee satisfaction

survey.

Above the state average on either RN/LPNstability or certified nursing assistant stability.

In 2007, 78% of homes received payments43


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Iowa

Significant Change in 2009

Added Culture Change as reported in self

certification form showing measures of

Person Directed Care.

Added three Nationally Reported Quality

Measures of quality of care:

High-Risk Pressure Ulcer

Physical Restraints

Chronic Care Pain

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Iowa Nursing Facility Pay-for-

Performance Program

Quality of life.

Person-Directed Care, Resident Satisfaction

Quality of care. Survey, Staffing, Nationally Reported QualityMeasures

Access. Efficiency.

Most providers are only eligible for 1-3%

increase. It is hard to get the full 5%. $1.40 a

day to $1.50 a day is average add on that

homes get.45


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Kansas Changes in 2009

Deemphasized focus on efficiency

Added culture change but doesnt pay much

for it

Eliminated

Operating expenses

Staff retention but still keeps heavy emphasis on

number of staff per se and staff turnover

Total occupancy

Survey outcomes now used as gate keeper

rather than measure 46


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Kansas 2009

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Massachusetts

Initiated by the state

Is on hold because of budget problems

The last published document onMassachusetts P4P was the MassHealth

Nursing Facility Bulletin 129 December 2008.

http://www.mass.gov/Eeohhs2/docs/masshea

lth/bull_2008/nf-129.pdf

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Ohio Quality Incentive Program

Deficiency free on the most survey results.

Resident and family satisfaction surveys are

above the statewide average.

Number of hours nurses are employed is

above the statewide average;

Employee retention rate is above the average

Occupancy rate, Medicaid utilization and case

mix are above the statewide average.

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Ohio 2009 Results #1

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Oklahoma

Focus on Excellence

Well documented effort because of Pacific

Health Group study.

Focus on Excellence has two components an

incentive payment methodology and a five

star rating system published on a website.

Significant disadvantage is that money for FOE

comes out of existing reimbursement and isnot new dollars. Homes facing 6.9% reduction

in remainder of FY 10 and 10% in FY 2011.

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Oklahoma #2

1. Quality of Life.

2. Resident/Family Satisfaction.

3. Employee Satisfaction. 4. System-wide Culture Change.

5. Certified Nursing Assistant/Nursing

Assistant Turnover and Retention. 6. Nurse Turnover and Retention.

7. State Survey Compliance.

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Companies

Georgia and Oklahoma using My Innerview to

collect family and resident interview.

Oklahoma pays $646,000 a year to My

InnnerView.

Minnesota and Ohio used Vital Research to do

resident interviews.

In last two months, both Colorado and Texasissued RFPs for contractors.

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Documents

2010 Presentation on Nursing Home Pay for Performance to Washington Health Care Association