GAO Report on Nursing Home Quality Published Oct 30, 2016

What GAO Found

In recent years, trends in four key sets of data that give insight into nursing home quality show mixed results, and data issues complicate the ability to assess quality trends. Nationally, one of the four data sets—consumer complaints—suggests that consumers' concerns over quality have increased, while the other three data sets—deficiencies, staffing levels, and clinical quality measures—indicate potential improvement in nursing home quality. For example, the average number of consumer complaints reported per home increased by 21 percent from 2005-2014, indicating a potential decrease in quality. Conversely, the number of serious deficiencies identified per home with an on-site survey, referred to as a standard survey, decreased by 41 percent over the same period, indicating potential improvement. The Centers for Medicare & Medicaid Services' (CMS) ability to use available data to assess nursing home quality is complicated by various issues with these data, which make it difficult to determine whether observed trends reflect actual changes in quality, data issues, or both. For example, clinical quality measures use data that are self-reported by nursing homes, and while CMS has begun auditing the self-reported data, it does not have clear plans to continue. Federal internal control standards require agencies to monitor performance data to assess the quality of performance over time.

In recent years, CMS has made numerous modifications to its nursing home oversight activities, but has not monitored the potential effect of these modifications on nursing home quality oversight. Some of the modifications have expanded or added new oversight activities, while others have reduced existing oversight activities. According to CMS, some of the reductions to oversight activities are in response to an increase in oversight responsibilities and limited number of staff and financial resources. However, CMS has not monitored how the modifications might affect CMS's ability to assess nursing home quality. For example, CMS reduced the number of nursing homes participating in the Special Focus Facility program—which provides additional oversight of homes with a history of poor performance—from 152 in 2013 to 62 in 2014. State survey agency officials who conduct surveys for CMS also made modifications which could have either a positive or negative effect on oversight, but CMS does not have an effective mechanism for monitoring. Federal internal control standards require ongoing monitoring as a part of normal program operations; without this monitoring, CMS cannot ensure that any modifications in oversight do not adversely affect its ability to assess nursing home quality.

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New SNF Booklet Published by CMS September 2015

CMS has published a new SNF booklet here.  Note that it mentions SNF QRP,  because we will  lose 2% of our FY 2018 SNF payment if we do not report at least 80% of the three QMs with 100% of the data fields on the MDS. The collection period for these three QMs to establish penalties for FY18 is Oct, Nov and Dec of 2016.

Comprehensive Care for Joint Replacement (CJR) Model

FACT SHEET 

FOR IMMEDIATE RELEASE

November 16, 2015                                                                                                                          

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

Comprehensive Care for Joint Replacement (CJR) Model

Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone.

Yet, the quality and cost of care for these hip and knee replacement surgeries still varies greatly. For instance, the rate of complications like infections or implant failures after surgery can be more than three times higher for procedures performed at some hospitals than others. And the average total Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.

This variation is due partly to the way Medicare beneficiaries receive care. Incentives to coordinate the whole episode of care – from surgery to recovery – are not strong enough, and a patient’s health may suffer as a result. When approaching care without seeing the big picture, there is a risk of missing crucial information or not coordinating across different care settings. This approach leads to more complications after surgery, higher readmission rates, protracted rehabilitative care, and variable costs. These are not the health outcomes patients want.

The Comprehensive Care for Joint Replacement (CJR) model addresses low quality and high costs that come from fragmentation by promoting coordinated, patient-centered care. This model aims to improve the care experience for the many and growing numbers of Medicare beneficiaries who receive joint replacements, making the patient’s successful surgery and recovery a top priority for the health care system.

How the CJR model helps—and protects—beneficiaries:

• Patients can benefit from their hospitals and other health care providers (e.g., physicians, home health agencies, and nursing facilities) working together more closely to coordinate their care. Coordination of care leads to better outcomes, a better experience, and fewer complications, such as preventable readmissions, infections, or prolonged rehabilitation and recovery.

• Beneficiaries will benefit from protections including: additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services; continued protection of patient data under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable privacy laws; and patient notification by providers and suppliers. Further, all existing safeguards to protect beneficiaries and patients will remain in place. If a beneficiary believes that his or her care has been adversely affected, he or she can call 1-800-MEDICARE or contact his or her state’s Quality Improvement Organization (QIO) by going to http://www.qioprogram.org/contact-zones. If concerns are identified, CMS will initiate audits and corrective action under existing authority.

• Patients can continue to choose their doctor, hospital, skilled nursing facility, home health agency, and other provider, but now with the CJR model, their providers have incentives to better coordinate their care. From surgery to recovery, patients can receive more comprehensive, coordinated care from their providers focusing on the most appropriate options for their recovery and rehabilitative care.

How the CJR Model works:

• CMS has learned from other models and projects already underway and has incorporated successful design elements from other initiatives into the CJR model design. The CJR model also reflects best practices in the private sector.

• Under this model, the hospital in which the hip or knee replacement and/or other major leg procedure takes place will be accountable for the costs and quality of related care from the time of the surgery through 90 days after hospital discharge—what is called an “episode” of care.

• Depending on the hospital’s quality and cost performance during the episode, the hospital will either earn a financial reward or, beginning with the second performance year, be required to repay Medicare for a portion of the spending above an established target. This payment structure gives hospitals an incentive to work with physicians, home health agencies, skilled nursing facilities, and other providers to make sure beneficiaries receive the coordinated care they need with the goal of reducing avoidable hospitalizations and complications. Hospitals in the model will be provided access to additional tools – such as spending and utilization data and sharing of best practices -- to improve the effectiveness of care coordination.       The model also gives providers additional flexibilities that are not otherwise available under Medicare so they can better manage the care of patients, including patients who are at home.

• By “bundling” payments for an episode of care, hospitals, physicians, and other providers have an incentive to work together to deliver more effective and efficient care.

• This model is being tested in 67 geographic areas throughout the country, and nearly all hospitals in those geographic areas are required to participate.

Reasons for the CJR Model:

• Lower extremity joint replacements are the most commonly performed Medicare inpatient surgery, and utilization is predicted to continue to grow. These surgeries can require long recoveries that may include extensive rehabilitation or other post-acute care, which provides many opportunities to reward providers that improve patient outcomes.

• By including all eligible hospitals in 67 geographic areas across the country, this model drives significant movement towards new payment and care delivery models for an important set of conditions and surgeries for Medicare beneficiaries.

• This model supports HHS efforts to transform the health care system towards one focused on better quality care, smarter spending, and healthier people through care transformation and payment reform.

For more information, visit: https://innovation.cms.gov/initiatives/cjr

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2016 Medicare Parts A & B Premiums and Deductibles Announced

CMS NEWS

FOR IMMEDIATE RELEASE

November 10, 2015

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

2016 Medicare Parts A & B Premiums and Deductibles Announced

Today, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 premiums and deductibles for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

Part B Premiums/Deductibles

As the Social Security Administration previously announced, there will no Social Security cost of living increase for 2016. As a result, by law, most people with Medicare Part B will be "held harmless" from any increase in premiums in 2016 and will pay the same monthly premium as last year, which is $104.90.

Beneficiaries not subject to the "hold harmless" provision will pay $121.80, as calculated reflecting the provisions of the Bipartisan Budget Act signed into law by President Obama last week. Medicare Part B beneficiaries not subject to the "hold-harmless" provision are those not collecting Social Security benefits, those who will enroll in Part B for the first time in 2016, dual eligible beneficiaries who have their premiums paid by Medicaid, and beneficiaries who pay an additional income-related premium. These groups account for about 30 percent of the 52 million Americans expected to be enrolled in Medicare Part B in 2016.

"Our goal is to keep Medicare Part B premiums affordable. Thanks to the leadership of Congress and President Obama, the premiums for 52 million Americans enrolled in Medicare Part B will be either flat or substantially less than they otherwise would have been," said CMS Acting Administrator Andy Slavitt. "Affordability for Medicare enrollees is a key goal of our work building a health care system that delivers better care and spends health care dollars more wisely."

Because of slow growth in medical costs and inflation, Medicare Part B premiums were unchanged for the 2013, 2014, and 2015 calendar years. The "hold harmless" provision would have required the approximately 30 percent of beneficiaries not held harmless in 2016 to pay an estimated base monthly Part B premium of $159.30 in part to make up for lost contingency reserves, according to the 2015 Trustees Report. However, the Bipartisan Budget Act of 2015 mitigated the Part B premium increase for these beneficiaries and states, which have programs that pay some or all of the premiums and cost-sharing for certain people who have Medicare and limited incomes. The CMS Office of the Actuary estimates that states will save $1.8 billion as a result of this premium mitigation.

CMS also announced that the annual deductible for all Part B beneficiaries will be $166.00 in 2016. Premiums for Medicare Advantage and Medicare Prescription Drug plans already finalized are unaffected by this announcement.

To get more information about state-by-state savings, visit the CMS website at

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-11-10.html.  

Since 2007, beneficiaries with higher incomes have paid higher Part B monthly premiums. These income-related monthly adjustment amount (IRMAA) affect fewer than 5 percent of people with Medicare. Under the Part B section of the Bipartisan Budget Act of 2015, high income beneficiaries will pay an additional amount. The IRMAA, additional amounts, and total Part B premiums for high income beneficiaries for 2016 are shown in the following table:

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $85,000	Less than or equal to $170,000	$0.00	$121.80
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000	48.70	170.50
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000	121.80	243.60
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	194.90	316.70
Greater than $214,000	Greater than $428,000	268.00	389.80

Premiums for beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouse at any time during the year, but file a separate tax return from their spouse:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $85,000	$0.00	$121.80
Greater than $85,000 and less than or equal to $129,000	194.90	316.70
Greater than $129,000	268.00	389.80

Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not pay a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A annual deductible that beneficiaries pay when admitted to the hospital will be $1,288.00 in 2016, a small increase from $1,260.00 in 2015. The Part A deductible covers beneficiaries' share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. The daily coinsurance amounts will be $322 for the 61^st through 90^th day of hospitalization in a benefit period and $644 for lifetime reserve days. For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 in a benefit period will be $161.00 in 2016 ($157.50 in 2015).  

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to receive coverage under Part A. Individuals with 30-39 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $226.00 in 2016, a $2.00 increase from 2015. Those with less than 30 quarters of coverage pay the full premium, which will be $411.00 a month, a $4.00 increase from 2015.

Deductibles and Coinsurance for 2016

Part A Deductible and Coinsurance Amounts for Calendar Years 2015 and 2016 Type of Cost Sharing
	2015	2016
Inpatient hospital deductible	$1,260	$1,288
Daily coinsurance for 61st-90th Day	315	322
Daily coinsurance for lifetime reserve days	630	644
SNF coinsurance	157.50	161.00

For more information on the 2016 Medicare Parts A and B premiums and deductibles (CMS-8059-N, CMS-8060-N, and CMS-8061-N), visit: https://www.federalregister.gov/public-inspection.  

Helpful Weblinks:

Federal Register Links:

Part A CMS-8059-N (PDF)- https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29207.pdf and on 11/16/2015 and available online at http://federalregister.gov/a/2015-29207

8060-N PDF- https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29176.pdf and 11/16/2015 and on available online at http://federalregister.gov/a/2015-29176

Part B CMS-8061-N (PDF) https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29181.pdf and on 11/16/2015 and available online at http://federalregister.gov/a/2015-29181

SNF Therapy Payment Model expands to consider SNF non-therapy related refinement possibilities

Phase Two

In the second phase of the project, which is now in process, the contractor is using the findings from this Base Year Final Summary Report as a guide to identify potential models suitable for further analysis.  We have considered stakeholder comments and concerns as we continue to investigate alternative therapy payment approaches and plan to solicit additional feedback on this aspect of our SNF payment research.  As noted above, we expanded the scope of this project during this phase to include ideas for revising the overall SNF PPS and plan to include additional and separate opportunities to obtain stakeholder input on non-therapy related refinement possibilities.  

As the contractor began the process of further narrowing the scope of therapy payment models in this second phase of the project, Acumen hosted a Technical Expert Panel in February 2015 to discuss questions and issues related to the therapy payment research. The following report summarizes the discussion and recommendations of the Technical Expert Panel:

Skilled Nursing Facility Therapy Payment Models Technical Expert Panel Summary Draft [PDF, 264KB] 

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

Analysis of Medicare Part A SNF PPS Payment Model

In an effort to establish a comprehensive approach to Medicare Part A SNF payment reform, we are expanding the scope of the SNF Therapy Payment Research project.  Although we always intended to ensure that any revisions to therapy payment would consider an integrated approach with the remaining payment methodology, we now plan to examine potential improvements and refinements to the overall SNF PPS payment system. This expansion will allow for improving the ability for Medicare to pay adequately and appropriately for all services provided during a Medicare Part A SNF stay.  

Overview

Since 1998, Medicare has paid for services provided by skilled nursing facilities (SNFs) under the Medicare Part A benefit on a per diem basis through the skilled nursing facility prospective payment system (SNF PPS). Currently, therapy payments under the SNF PPS are based primarily on the amount of therapy provided to a patient, regardless of the specific patient characteristics and care needs. CMS has contracted with Acumen, LLC to identify potential alternatives to the existing methodology used to pay for services under the SNF PPS. Below, we will post information about this project as it progresses.
 

Phase One

In the first phase of the project, the contractor reviewed past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services. The following report summarizes the analysis and findings from this first phase of the project:

SNF Therapy Payment Models – Base Year Final Summary Report, April 2014

The contractor is continuing with further refinements of the therapy model development, based on the panel's recommendations, as well as considering potential improvements to the nursing component and overall SNF PPS payment structure, we welcome your comments and feedback. Comments on the SNF PPS payment methodology may be submitted anytime to:

SNFTherapyPayments@cms.hhs.gov