1. SNF Value-Based Purchasing & Quality Reporting Program Overview
August 2018 **Updated to reflect FY2019 SNF PPS final rule changes

2. SNF Value-Based Program for Readmissions (FY2019)
Measure: 30-day all-cause, all-condition, unplanned hospital readmissions from date of original hospital discharge
Risk adjusted starting by 10/1/16
Measures only for Medicare FFS
Measure to be reported on Nursing Home Compare
How it works: Hospital readmission rates for SNFs will be compared nationally – using the higher of a SNF’s achievement or improvement score
60% of withheld funds available for distribution back to SNFs in top 60%
SNF VBP payment adjustments will apply to services provided on or after 10/1/2018
Penalty/Incentive: Earn back up to 2% of Medicare FFS payment based upon performance on readmissions relative to peers and/or SNF year-over-year improvement. Top performers will be eligible to earn more than the 2% withhold (FY2019 = 2.33%)
Data Used: Medicare fee-for-service claims data. Providers do not need to submit additional documentation
Performance Reports: Quarterly reports available to SNFs via CASPER beginning 10/1/2016
Born from PAMA
Note: Claims-based data being used so does not include Medicare Advantage patients.
CMS has yet to finalize the specifications of the exchange function, which will translate SNF performance scores into individualized SNF VBP incentive payments. For this reason, we are not yet able to provide detailed projections regarding the incentive payment scheme. However, the highest ranked facilities will receive the highest payments, and the lowest ranked 40 percent of facilities will receive less than what they otherwise would have received without the Program.

3. SNF VBP Data Collection
Payment Impact in
Performance Period
Baseline Period
FY2019
CY2017
CY2015
FY2020
FY2018
FY2016
FY2021
FY2017
FY2022
CMS will determine readmission rates using its formula and round performance scores on both achievement and benchmark to the nearest 1/10,000 (or 5 digits past the decimal)
Performance scores will be…

4. FY2019 SNF VBP Value-Based Incentive Calculation Process
Estimate SNF Medicare spending for FY2019
Calculate the 2% withhold amount for above
Take 60% of the above as the total for redistribution for value- based incentive payments (VBIP)
Order SNFs based on their performance scores
Assign VBIP amount based upon the logistics function
FY2019 incentives range from negative 1.97 % to positive 2.33%
2% SNF Medicare FFS
40% Medicare Trust Fund
60% SNF VBIP
Example
$27,000,000,000
x 2.0%
$540,000,000
x 60%
$324,000,000
*Divided by 9,000 of 15,000 SNFs

5. Key Terms for SNF VBP Term Proposed Definition Achievement Score
Your SNF’s performance compared to all SNFs nationally during the same performance period.
Improvement Score
Your specific SNF’s performance from one performance period to the next performance period. Did you get better or worse compared to last year?
Benchmark is the average of the performance of those in the top 10%

6. Remember that your standardized risk adjusted rate is inverted so a higher number is better.
Because of the way they calculate the measure sometimes you may have 0 readmissions out of a low number of readmissions and they will assign you the mean readmission score. We are working on this

7. FY2019 Value Based Incentive Payment
SNFRM - SNF 30-Day All-Cause Readmission Measure (NQF #2510)
Achievement Threshold
Benchmark
 FY2019
FY2020
FY2021
Achievement: The 25th percentile of national SNF performance on the quality measure during performance period
Benchmark: The mean of the best decile of national SNF performance on the quality measure during performance period
CMS will determine readmission rates using its formula and round performance scores on both achievement and benchmark to the nearest 1/10,000 (or 5 digits past the decimal)
Achievement threshold = is intended to set an empirically-based performance standard of top performing SNFs as an achieveable goal for all SNFs that incents improvement.

8. Performance Score Calculation Exceptions
Insufficient Baseline Data
Low Volume
Applies to: SNFs with fewer than 25 eligible stays because it is newly-opened, or under an extraordinary circumstances exception
Policy: CMS will not measure these SNFs on their year-to-year improvement, only on their performance for the current period
Applies to: SNFs with fewer than 25 eligible stays during the performance period
Policy: CMS will assign a performance score in these cases that will ensure the SNF’s Value-Based Incentive Payment results in no reduction to the SNF’s Medicare FFS rate

9. Extraordinary Circumstances Exception(ECE) Policy for SNF VBP
Extraordinary circumstances… natural or man-made disasters, “which causes damages of sufficient severity and magnitude to partially or completely destroy or delay access to medical records and associated documentation or otherwise affect the facility’s ability to continue normal operations.”
Establish in FY2019 final SNF PPS rule to provide relief to SNFs impacted by natural disasters or other circumstances beyond their control that affect the care provided to individuals in their facilities
Requires SNFs submit an ECE request form within 90 days after the event identifying the impacted months and the effects the incident had on care
CMS may also grant regional or local exceptions in circumstances where SNFs did not request the ECE
VBP improvement and achievement performance scores will be calculated when there are at least 25 eligible stays during the performance period and based upon the data from the unaffected months
Aligns with a similar process adopted for the SNF Quality Reporting Program

10. VBP Confidential Feedback Reports
The June 2017 quarterly confidential feedback reports and supplemental workbooks included the following patient-level data:
Patient identifiers (Health Insurance Claim Number [HICN], Sex, Age)
Index SNF information (admission/discharge dates, discharge status code)
Prior proximal hospital information (CMS Certification Number [CCN], admission/discharge dates, principal diagnosis)
Readmission hospital information (CCN, admission/discharge dates, principal diagnosis)
SNFRM risk-adjustment factors
Facility-level information is also included:
Number of Eligible Stays
Number of Unplanned Readmissions
Observed Readmission Rate
Predicted Number of Readmissions
Expected Number of Readmissions
Standardized Risk Ratio (SRR)
National Average Readmission Rate, RSRR

11. SNF VBP Quarterly Confidential Feedback Reports
Measure
Your SNF’s Number of Eligible Stays
Your SNF’s Number of Readmissions
Your SNF’s Risk-Standardized Readmission Rate
National average Readmission Rate
SNFRM
Correction requests to be submitted to: and to include:
SNF’s CMS certification number
SNF name
Requested correction and basis for correction
Documentation or other evidence to support the request
Correction requests for any quarterly report can be submitted until the following March 31

12. SNF VBP Corrections Process
Two-phase process
Phase I – SNFs may correct quality measure data in a report until March 31 after receipt of the report
Phase II– SNFs may only challenge performance score and ranking
Reports from CMS at least 60 days prior to payment adjustment – approximately Aug. 1
SNF may submit evidence of error within 30 days of report posting

13. VBP 2018 Key Dates FY2020 VBP Performance Period = 10/1/2017-9/30/2018
June 1: New Confidential Report Data Available
Aug. 2: Performance Score Report with Incentive Adjustment Published
Sept. 1: Phase II Review and Correct Submissions Due
Oct. 1: First SNF VBP Rate Adjustment Applied to FFS Rate & Readmission Rate Published on NH Compare

14. VBP 2019 Key Dates
FY2020 VBP Performance Period = 10/1/2017-9/30/2018
June 1: New Confidential Report Data available
Near Aug. 1: Performance Score Report with Incentive Adjustment published
30-Days from Reports: Phase II Review and Correct Submissions Due
Oct. 1: First SNF VBP Adjustment Applied to FFS Rate & Readmission Rate Published on NH Compare

15. IMPACT Act of 2014 = SNF & HH Quality Reporting Program (QRP)
Introduced March 18, 2014, and passed by Congress on September 26, 2014, called, “Improving Medicare Post-Acute Care Transformation” (IMPACT) Act of 2014
Standardized patient assessment metrics across PAC providers
Required reporting of Standardized Patient Assessment Data and Quality Measures
Public reporting of new metrics and develop reports to provider
New quality metrics including: skin integrity, medication reconciliation, major falls, accurate communication during care transitions
New efficiency measures: total beneficiary costs, discharge to community rate, and hospitalization rate
Studies of alternative payment models including site-neutral payment, etc.
IMPACT Act:
Standardized assessments across SNF, IRF, LTCHs and HHAs
Reporting of new metrics
Site neutral payment
House Ways and Means Chair Rep. Dave Camp (R-MI) + Ranking Member Rep. Sandy Levin (D – MI) and Senate Finance Committee Chair Sen. Ron Wyden (D-OR) and Raking Senator Orrin Hatch (R-UT)
Derived from stakeholder input in 2013.
2017: Standardized quality and resource use measure reporting for PAC providers begins
Standard assessment tool wouldn’t take effect until 2019
This is a pay for reporting program = process measure - Did you complete the MDS process sufficiently at least 80% of the time.

16. Quality Reporting Program (QRP) Implementation Timelines
Measure
Skilled Nursing Facility
Inpatient Rehabilitation Facility
Long-Term Care Hospitals
Home Health
Functional status, cognitive function
10/1/2016
10/1/2018
1/1/2019
Skin integrity & changes
1/1/2017
Medication reconciliation
Major falls
Accurate communication during care transitions
10/1/2019*
Managed Care plans looking at Assisted Living providers too but concerned about the risk of readmissions.
Skin Integrity and Changes in Skin Integrity- January 1, 2017
Functional Status, Cognitive Function, and Changes in Function and Cognitive Function- January 1, 2019
Incidence of Major Falls*- January 1, 2019
Communicating the Existence of & Providing for the Transfer of Health Information and Care Preferences- January 1, 2019
Standardized Patient Assessment Data- January 1, 2019
*Date by which CMS will define measure (revised in FY2019 SNF PPS final rule).

17. SNF QRP MDS-Based Measures
% of Patients or Residents Experiencing One or More Falls with Major Injury (NQF#0674 – application)
Changes in Skin Integrity Post Acute Care: Pressure Ulcer/Injury*
Includes new or worsened unstageable pressure ulcers including deep tissue injuries in the numerator
Replaces % with pressure ulcers that are new or worsened (NQF#0678)
% of Patients with Functional Assessment and Care Plan at Admission and Discharge (NQF#2631 – application of LTCH measure)
Drug Regimen Review Conducted with Follow Up for Identified issues PAC*
Change in Self-Care Score (NQF#2633)*
Change in Mobility Score (NQF#2634)*
Discharge Self-Care Score (NQF#2635)*
Discharge Mobility Score (NQF#2636)*
Specific measures – collected in 2 ways
Pay attention to the MDS completion to ensure don’t lose 2%
*Data collection begins 10/1/18 for FY2020

18. SNF QRP Claims-Based Measures
Total Estimated Medicare Spending Per Beneficiary
Discharge to Community
Potentially Preventable, 30-Day Post- Discharge Hospital Readmissions
Specific measures – collected in 2 ways
Pay attention to the MDS completion to ensure don’t lose 2%

19. FY2018 SNF PPS Rules: Proposed Future Year SNF QRP Measures
% of residents who self-reported moderate to severe pain
% of residents or patients who were assessed and appropriately given the seasonal influenza vaccine
% who newly received an antipsychotic medication
Modification of the discharge to community – PAC SNF

20. SNF QRP Review and Correct Reports
This number displays SNF Performance on the Quality Measure NOT successful reporting tor completion of relevant MDS items to avoid the 2% noncompliance penalty.

22. Noncompliance Notifications
To ensure future compliance, SNFs who provide their CCN and address(es) to: (a CMS contractor) will receive quarterly submission deadline reminders if they are under-reporting
These s are only sent to SNFs if they are not meeting all required reporting thresholds ahead of the submission deadline

23. New Measure Removal Factors for SNF QRP
Factor 1: Measure performance among SNFs is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made
Factor 2: Performance or improvement on a measure does not result in better resident outcomes
Factor 3: A measure does not align with current clinical guidelines or practice
Factor 4: A more broadly applicable measure (across settings, populations, or conditions) for the particular topic is available
Factor 5: A measure that is more proximal in time to desired resident outcomes for the particular topic is available
Factor 6: A measure that is more strongly associated with desired resident outcomes for the particular topic is available
Factor 7: Collection or public reporting of a measure leads to negative unintended consequences other than resident harm
Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program
**Codified in FY2019 SNF PPS final rule

24. Public Reporting of QRP Measures
Beginning January 1, 2018, CMS began reporting SNF performance on the QRP measures to Nursing Home Compare
Beginning in CY2019 or soon after, two of the reported measures will include two years’ worth of data
Medicare Spending Per Beneficiary
Discharge to Community

25. 2018 SNF QRP Reporting
January 1, 2018: Public reporting of SNF QRP measures
May 15, 2018: SNF QRP reporting deadline with any changes for 1/1/ /31/2017
July 2018: Notices of QRP noncompliance distributed
August 7, 2018: Deadline to Request Reconsideration for QRP noncompliance
August 15, 2018: SNF QRP reporting deadline for admissions/discharges from 1/1/2018-3/31/2018
QRP Penalty for Failure to report = FY 2018 – starts 10/1/17

26. SNF VBP & QRP Timeline
October 1, 2018 (FY19): First SNF VBP payment adjustment (2%) & SNF QRP 2% noncompliance penalty for CY2017 data and data collection begins on four new measures and using new pressure ulcer measure
November 15, 2018: SNF QRP Reporting deadline for MDS-based data for admissions/discharges between 4/1/2018 – 6/30/2018
February 15, 2019: SNF QRP Reporting deadline for MDS-based data for admissions/discharges between 7/1/2018 – 9/30/2018
May 15, 2019: SNF QRP Reporting deadline for MDS-based data for admissions/discharges between 10/1/2018 – 12/30/2018
October 1, 2019 (FY2020): SNF VBP - payment adjustment (2%) based upon readmissions performance between 10/1/2017 to 9/30/2018(FY2018) and SNF QRP 2% penalty for failure to report using CY2018 data
New Pressure Ulcer measure includes new or worsened unstageable pressure ulcers including deep tissue injuries (DTIs)

27. Additional Resources
SNF VBP:
SNF QRP:
Nursing Home Compare Quality Measures Technical Guide:

28. Additional Resources (continued)
SNF QRP Final Specifications Effective 10/1/2018:
SNF QRP Crosswalk from MDS item to QRP measure:

29. LeadingAge Articles
August 2018 Next SNF QRP Compliance Deadline: compliance-period
August 2018: FY2019 SNF PPS Final Rule with VBP & QRP updates: snf-pps-what-happens-when
August 15, 2017: Summary of FY 2018 Final VBP & QRP rules: changes-snf-qrp-and-vbp
Sept 11, 2017: SNF QRP clarifications: confusion

30. CONNECT WITH US