[Federal Register Volume 81, Number 151 (Friday, August 5, 2016)]
[Rules and Regulations]
[Pages 51970-52053]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-18113]
[[Page 51969]]
Vol. 81
Friday,
No. 151
August 5, 2016
Part II
Department of Health and Human Services
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Centers for Medicare and Medicaid Services
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42 CFR Part 413
Medicare Program; Prospective Payment System and Consolidated Billing
for Skilled Nursing Facilities for FY 2017, SNF Value-Based Purchasing
Program, SNF Quality Reporting Program, and SNF Payment Models
Research; Final Rule
Federal Register / Vol. 81 , No. 151 / Friday, August 5, 2016 / Rules
and Regulations
[[Page 51970]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 413
[CMS-1645-F]
RIN 0938-AS75
Medicare Program; Prospective Payment System and Consolidated
Billing for Skilled Nursing Facilities for FY 2017, SNF Value-Based
Purchasing Program, SNF Quality Reporting Program, and SNF Payment
Models Research
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule updates the payment rates used under the
prospective payment system (PPS) for skilled nursing facilities (SNFs)
for fiscal year (FY) 2017. In addition, it specifies a potentially
preventable readmission measure for the Skilled Nursing Facility Value-
Based Purchasing Program (SNF VBP), and implements requirements for
that program, including performance standards, a scoring methodology,
and a review and correction process for performance information to be
made public, aimed at implementing value-based purchasing for SNFs.
Additionally, this final rule includes additional polices and measures
in the Skilled Nursing Facility Quality Reporting Program (SNF QRP).
This final rule also responds to comments on the SNF Payment Models
Research (PMR) project.
DATES: These regulations are effective on October 1, 2016.
FOR FURTHER INFORMATION CONTACT:
Penny Gershman, (410) 786-6643, for information related to SNF PPS
clinical issues.
John Kane, (410) 786-0557, for information related to the
development of the payment rates and case-mix indexes.
Kia Sidbury, (410) 786-7816, for information related to the wage
index.
Bill Ullman, (410) 786-5667, for information related to level of
care determinations, consolidated billing, and general information.
Stephanie Frilling, (410) 786-4507, for information related to
skilled nursing facility value-based purchasing.
Charlayne Van, (410) 786-8659, for information related to skilled
nursing facility quality reporting.
SUPPLEMENTARY INFORMATION:
Availability of Certain Tables Exclusively Through the Internet on the
CMS Web Site
As discussed in the FY 2017 SNF PPS proposed rule (81 FR 24230),
tables setting forth the Wage Index for Urban Areas Based on CBSA Labor
Market Areas and the Wage Index Based on CBSA Labor Market Areas for
Rural Areas are no longer published in the Federal Register. Instead,
these tables are available exclusively through the Internet on the CMS
Web site. The wage index tables for this final rule can be accessed on
the SNF PPS Wage Index home page, at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html.
Readers who experience any problems accessing any of these online
SNF PPS wage index tables should contact Kia Sidbury at (410) 786-7816.
To assist readers in referencing sections contained in this
document, we are providing the following Table of Contents.
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of Major Provisions
C. Summary of Cost and Benefits
II. Background on SNF PPS
A. Statutory Basis and Scope
B. Initial Transition for the SNF PPS
C. Required Annual Rate Updates
III. Analysis of and Responses to Public Comments on the FY 2017 SNF
PPS Proposed Rule
A. General Comments on the FY 2017 SNF PPS Proposed Rule
B. SNF PPS Rate Setting Methodology and FY 2017 Update
1. Federal Base Rates
2. SNF Market Basket Update
3. Case-Mix Adjustment
4. Wage Index Adjustment
5. Adjusted Rate Computation Example
C. Additional Aspects of the SNF PPS
1. SNF Level of Care--Administrative Presumption
2. Consolidated Billing
3. Payment for SNF-Level Swing-Bed Services
D. Other Issues
1. Skilled Nursing Facility Value-Based Purchasing Program (SNF
VBP)
2. Skilled Nursing Facility (SNF) Quality Reporting Program
(QRP)
3. SNF Payment Models Research
IV. Collection of Information Requirements
V. Economic Analyses
Acronyms
In addition, because of the many terms to which we refer by acronym
in this final rule, we are listing these abbreviations and their
corresponding terms in alphabetical order below:
AIDS Acquired Immune Deficiency Syndrome
ARD Assessment reference date
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999, Pub. L. 106-113
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Pub. L. 106-554
CAH Critical access hospital
CASPER Certification and Survey Provider Enhanced Reporting
CBSA Core-based statistical area
CCN CMS Certification Number
CFR Code of Federal Regulations
CMI Case-mix index
CMS Centers for Medicare & Medicaid Services
FFS Fee-for-service
FR Federal Register
FY Fiscal year
HCPCS Healthcare Common Procedure Coding System
HIQR Hospital Inpatient Quality Reporting
HOQR Hospital Outpatient Quality Reporting
HRRP Hospital Readmissions Reduction Program
HVBP Hospital Value-Based Purchasing
IGI IHS (Information Handling Services) Global Insight, Inc.
IMPACT Improving Medicare Post-Acute Care Transformation Act of
2014, Pub. L. 113-185
IPPS Inpatient prospective payment system
IRF Inpatient Rehabilitation Facility
LTC Long-term care
LTCH Long-term care hospital
MAP Measures Application Partnership
MDS Minimum data set
MFP Multifactor productivity
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Pub. L. 108-173
MSA Metropolitan statistical area
NF Nursing facility
NQF National Quality Forum
OMB Office of Management and Budget
PAC Post-acute care
PAMA Protecting Access to Medicare Act of 2014, Pub. L. 113-93
PBJ Payroll-Based Journal
PMR Payment Models Research
PPS Prospective Payment System
PQRS Physician Quality Reporting System
QIES Quality Improvement Evaluation System
QIES ASAP Quality Improvement and Evaluation System Assessment
Submission and Processing
QRP Quality Reporting Program
RAI Resident assessment instrument
RAVEN Resident assessment validation entry
RFA Regulatory Flexibility Act, Pub. L. 96-354
RIA Regulatory impact analysis
RUG-III Resource Utilization Groups, Version 3
RUG-IV Resource Utilization Groups, Version 4
RUG-53 Refined 53-Group RUG-III Case-Mix Classification System
SCHIP State Children's Health Insurance Program
sDTI Suspected deep tissue injuries
SNF Skilled nursing facility
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SNF QRP Skill nursing facility quality reporting program
SNFRM Skilled Nursing Facility 30-Day All-Cause Readmission Measure
STM Staff time measurement
STRIVE Staff time and resource intensity verification
TEP Technical expert panel
UMRA Unfunded Mandates Reform Act, Pub. L. 104-4
VBP Value-based purchasing
I. Executive Summary
A. Purpose
This final rule updates the SNF prospective payment rates for FY
2017 as required under section 1888(e)(4)(E) of the Social Security Act
(the Act). It also responds to section 1888(e)(4)(H) of the Act, which
requires the Secretary to provide for publication in the Federal
Register before the August 1 that precedes the start of each fiscal
year (FY) certain specified information relating to the payment update
(see section II.C.). This final rule also includes an update on the SNF
PMR project. In addition, it specifies a potentially preventable
readmission measure for the Skilled Nursing Facility (SNF) Value-Based
Purchasing (VBP) Program and finalizes other requirements related to
that Program's implementation, including performance standards, a
scoring methodology, and a review and correction process for
performance information to be made public under the Program. We are
also including four new quality and resource use measures for the SNF
QRP and new SNF review and correction procedures for performance data
that are to be publicly reported.
B. Summary of Major Provisions
In accordance with sections 1888(e)(4)(E)(ii)(IV) and 1888(e)(5) of
the Act, the federal rates in this final rule reflect an update to the
rates that we published in the SNF PPS final rule for FY 2016 (80 FR
46390), which reflects the SNF market basket index, as adjusted by the
multifactor productivity (MFP) adjustment, for FY 2017. We are also
finalizing various requirements for the SNF VBP Program, including a
potentially preventable readmission measure, performance standards, and
a scoring methodology, among other policies. In addition, we are
adopting and implementing four new quality and resource use measures
for the SNF QRP and new SNF review and correction procedures for
performance data that are to be publicly reported as we continue to
implement this program and meet the requirements of the IMPACT Act.
C. Summary of Cost and Benefits
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Provision description Total transfers
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FY 2017 SNF PPS payment rate update.. The overall economic impact of
this final rule would be an
estimated increase of $920
million in aggregate payments to
SNFs during FY 2017.
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II. Background on SNF PPS
A. Statutory Basis and Scope
As amended by section 4432 of the Balanced Budget Act of 1997 (BBA,
Pub. L. 105-33, enacted on August 5, 1997), section 1888(e) of the Act
provides for the implementation of a PPS for SNFs. This methodology
uses prospective, case-mix adjusted per diem payment rates applicable
to all covered SNF services defined in section 1888(e)(2)(A) of the
Act. The SNF PPS is effective for cost reporting periods beginning on
or after July 1, 1998, and covers all costs of furnishing covered SNF
services (routine, ancillary, and capital-related costs) other than
costs associated with approved educational activities and bad debts.
Under section 1888(e)(2)(A)(i) of the Act, covered SNF services include
post-hospital extended care services for which benefits are provided
under Part A, as well as those items and services (other than a small
number of excluded services, such as physician services) for which
payment may otherwise be made under Part B and which are furnished to
Medicare beneficiaries who are residents in a SNF during a covered Part
A stay. A comprehensive discussion of these provisions appears in the
May 12, 1998 interim final rule (63 FR 26252). In addition, a detailed
discussion of the legislative history of the SNF PPS is available
online at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Legislative_History_07302013.pdf.
Section 215(a) of PAMA added section 1888(g) to the Act requiring
the Secretary to specify an all-cause all-condition hospital
readmission measure and a resource use measure, an all-condition risk-
adjusted potentially preventable hospital readmission measure, for the
SNF setting. Additionally, section 215(b) of PAMA added section 1888(h)
to the Act requiring the Secretary to implement a VBP program for SNFs.
Finally, section 2(a) of the IMPACT Act added section 1899B to the Act
that, among other things, requires SNFs to report standardized data for
measures in specified quality and resource use domains. In addition,
the IMPACT Act added section 1888(e)(6) to the Act, which requires the
Secretary to implement a quality reporting program for SNFs, which
includes a requirement that SNFs report certain data to receive their
full payment under the SNF PPS.
B. Initial Transition for the SNF PPS
Under sections 1888(e)(1)(A) and 1888(e)(11) of the Act, the SNF
PPS included an initial, three-phase transition that blended a
facility-specific rate (reflecting the individual facility's historical
cost experience) with the federal case-mix adjusted rate. The
transition extended through the facility's first 3 cost reporting
periods under the PPS, up to and including the one that began in FY
2001. Thus, the SNF PPS is no longer operating under the transition, as
all facilities have been paid at the full federal rate effective with
cost reporting periods beginning in FY 2002. As we now base payments
for SNFs entirely on the adjusted federal per diem rates, we no longer
include adjustment factors under the transition related to facility-
specific rates for the upcoming FY.
C. Required Annual Rate Updates
Section 1888(e)(4)(E) of the Act requires the SNF PPS payment rates
to be updated annually. The most recent annual update occurred in a
final rule that set forth updates to the SNF PPS payment rates for FY
2016 (80 FR 46390, August 4, 2015).
Section 1888(e)(4)(H) of the Act specifies that we provide for
publication annually in the Federal Register of the following:
The unadjusted federal per diem rates to be applied to
days of covered SNF services furnished during the upcoming FY.
The case-mix classification system to be applied for these
services during the upcoming FY.
The factors to be applied in making the area wage
adjustment for these services.
Along with other revisions discussed later in this preamble, this
final rule would provide the required annual updates to the per diem
payment rates for SNFs for FY 2017.
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III. Analysis of and Responses to Public Comments on the FY 2017 SNF
PPS Proposed Rule
In response to the publication of the FY 2017 SNF PPS proposed
rule, we received 95 public comments from individuals, providers,
corporations, government agencies, private citizens, trade
associations, and major organizations. The following are brief
summaries of each proposed provision, a summary of the public comments
that we received related to that proposal, and our responses to the
comments.
A. General Comments on the FY 2017 SNF PPS Proposed Rule
In addition to the comments we received on specific proposals
contained within the proposed rule (which we address later in this
final rule), commenters also submitted the following, more general,
observations on the SNF PPS and SNF care generally. A discussion of
these comments, along with our responses, appears below.
Comment: One commenter stated that there is a significant amount of
fraud and abuse in the SNF PPS. The commenter further stated that,
often times, non-licensed professionals will dictate the type of care
beneficiaries receive, specifically referring to the number of therapy
minutes a beneficiary receives. This commenter also stated that if a
health care professional tries to speak about these issues, his or her
job may be in jeopardy.
Response: We appreciate this commenter raising these concerns.
While outside the scope of this rule, we will pass these concerns along
to our colleagues in the Center for Program Integrity, who are
responsible for identifying and addressing instances of fraud, waste
and abuse in the Medicare program. Additionally, information on areas
of potential waste, fraud or abuse may be reported to the Office of the
Inspector General Hotline by calling 1-800-HHS-TIPS (1-800-447-8477).
Comment: A number of commenters raised concerns regarding the cost
of care for the beneficiary. One commenter discussed how the individual
beneficiary cost for living in a nursing home seemed to greatly exceed
the cost of living in the community. A few commenters referenced the
pace and breadth of potential changes to conditions of participation
for long-term care facilities, notably those contained in rulemaking
such as the 2015 proposed rule entitled ``Medicare and Medicaid
Programs: Reform of Requirements for Long-Term Care Facilities'' (80 FR
42168), as well as noted that the cost of implementing these provisions
is not covered by Medicaid or Medicare.
Response: While we appreciate the commenters raising these
concerns, these comments and the provisions of the proposed rule
referenced by commenters are outside the scope of this final rule. That
being said, we will share these comments with the appropriate team
within CMS responsible for these provisions.
Comment: A few commenters raised concerns regarding decisions made
by Medicare Administrative Contractors. One commenter requested that we
instruct these contractors to refrain from denying coverage and payment
for SNF Part B claims in which physician visits occur more frequently
than the minimum standards set by the conditions of participation at
Sec. 483.40. Another commenter requested that we examine potential
instances in which contractors might unnecessarily target speech-
language pathology services by making revisions to Medicare manuals
which might affect coverage of these services.
Response: With regard to our instructing the contractors to refrain
from denying coverage or payment for SNF Part B claims in which
physician visits occur more frequently than the minimum standard set by
the conditions of participation, this comment is outside the scope of
this final rule. However, we will forward these comments to the
appropriate division within CMS for consideration. With regard to
contractors targeting speech-language pathology services, we are not
aware of such targeting. We will continue to educate the contractors to
ensure compliance with all federal guidance and regulations.
B. SNF PPS Rate Setting Methodology and FY 2017 Update
1. Federal Base Rates
Under section 1888(e)(4) of the Act, the SNF PPS uses per diem
federal payment rates based on mean SNF costs in a base year (FY 1995)
updated for inflation to the first effective period of the PPS. We
developed the federal payment rates using allowable costs from
hospital-based and freestanding SNF cost reports for reporting periods
beginning in FY 1995. The data used in developing the federal rates
also incorporated a Part B add-on, which is an estimate of the amounts
that, prior to the SNF PPS, would have been payable under Part B for
covered SNF services furnished to individuals during the course of a
covered Part A stay in a SNF.
In developing the rates for the initial period, we updated costs to
the first effective year of the PPS (the 15-month period beginning July
1, 1998) using a SNF market basket index, and then standardized for
geographic variations in wages and for the costs of facility
differences in case mix. In compiling the database used to compute the
federal payment rates, we excluded those providers that received new
provider exemptions from the routine cost limits, as well as costs
related to payments for exceptions to the routine cost limits. Using
the formula that the BBA prescribed, we set the federal rates at a
level equal to the weighted mean of freestanding costs plus 50 percent
of the difference between the freestanding mean and weighted mean of
all SNF costs (hospital-based and freestanding) combined. We computed
and applied separately the payment rates for facilities located in
urban and rural areas, and adjusted the portion of the federal rate
attributable to wage-related costs by a wage index to reflect
geographic variations in wages.
2. SNF Market Basket Update
a. SNF Market Basket Index
Section 1888(e)(5)(A) of the Act requires us to establish a SNF
market basket index that reflects changes over time in the prices of an
appropriate mix of goods and services included in covered SNF services.
Accordingly, we have developed a SNF market basket index that
encompasses the most commonly used cost categories for SNF routine
services, ancillary services, and capital-related expenses. We use the
SNF market basket index, adjusted in the manner described below, to
update the federal rates on an annual basis. In the SNF PPS final rule
for FY 2014 (78 FR 47939 through 47946), we revised and rebased the
market basket, which included updating the base year from FY 2004 to FY
2010.
For the FY 2017 proposed rule, the FY 2010-based SNF market basket
growth rate was estimated to be 2.6 percent, which was based on the IHS
Global Insight Inc. (IGI) first quarter 2016 forecast, with historical
data through fourth quarter 2015. However, as discussed in the FY 2017
SNF PPS proposed rule (81 FR 24234), we proposed that if more recent
data become available (for example, a more recent estimate of the FY
2010 based SNF market basket and/or MFP adjustment), we would use such
data, if appropriate, to determine the FY 2017 SNF market basket
percentage change, labor-related share relative importance, forecast
error adjustment, and MFP adjustment in this final rule. Since that
time, we have received an updated FY
[[Page 51973]]
2017 market basket percentage increase, which is based on the second
quarter 2016 IGI forecast of the FY 2010-based SNF market basket. The
revised market basket growth rate is 2.7 percent. In section III.B.2.e.
of this final rule, we discuss the specific application of this
adjustment to the forthcoming annual update of the SNF PPS payment
rates.
b. Use of the SNF Market Basket Percentage
Section 1888(e)(5)(B) of the Act defines the SNF market basket
percentage as the percentage change in the SNF market basket index from
the midpoint of the previous FY to the midpoint of the current FY. For
the federal rates set forth in this final rule, we use the percentage
change in the SNF market basket index to compute the update factor for
FY 2017. This is based on the IGI second quarter 2016 forecast (with
historical data through the first quarter 2016) of the FY 2017
percentage increase in the FY 2010-based SNF market basket index for
routine, ancillary, and capital-related expenses, which is used to
compute the update factor in this final rule. As discussed in sections
III.B.2.c. and III.B.2.d. of this final rule, this market basket
percentage change is reduced by the applicable forecast error
correction (as described in Sec. 413.337(d)(2)) and by the MFP
adjustment as required by section 1888(e)(5)(B)(ii) of the Act.
Finally, as discussed in section II.B. of this final rule, we no longer
compute update factors to adjust a facility-specific portion of the SNF
PPS rates, because the initial three-phase transition period from
facility-specific to full federal rates that started with cost
reporting periods beginning in July 1998 has expired.
c. Forecast Error Adjustment
As discussed in the June 10, 2003 supplemental proposed rule (68 FR
34768) and finalized in the August 4, 2003, final rule (68 FR 46057
through 46059), Sec. 413.337(d)(2) provides for an adjustment to
account for market basket forecast error. The initial adjustment for
market basket forecast error applied to the update of the FY 2003 rate
for FY 2004, and took into account the cumulative forecast error for
the period from FY 2000 through FY 2002, resulting in an increase of
3.26 percent to the FY 2004 update. Subsequent adjustments in
succeeding FYs take into account the forecast error from the most
recently available FY for which there are final data, and apply the
difference between the forecasted and actual change in the market
basket when the difference exceeds a specified threshold. We originally
used a 0.25 percentage point threshold for this purpose; however, for
the reasons specified in the FY 2008 SNF PPS final rule (72 FR 43425,
August 3, 2007), we adopted a 0.5 percentage point threshold effective
for FY 2008 and subsequent FYs. As we stated in the final rule for FY
2004 that first issued the market basket forecast error adjustment (68
FR 46058, August 4, 2003), the adjustment will reflect both upward and
downward adjustments, as appropriate.
For FY 2015 (the most recently available FY for which there is
final data), the estimated increase in the market basket index was 2.5
percentage points, while the actual increase for FY 2015 was 2.3
percentage points, resulting in the actual increase being 0.2
percentage point lower than the estimated increase. Accordingly, as the
difference between the estimated and actual amount of change in the
market basket index does not exceed the 0.5 percentage point threshold,
the FY 2017 market basket percentage change of 2.7 percent will be not
adjusted to account for the forecast error. Table 1 shows the
forecasted and actual market basket amounts for FY 2015.
Table 1--Difference Between the Forecasted and Actual Market Basket Increases for FY 2015
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Forecasted FY Actual FY 2015 FY 2015
Index 2015 increase * increase ** difference
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SNF.......................................................... 2.5 2.3 0.2
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* Published in Federal Register; based on second quarter 2014 IGI forecast (2010-based index).
** Based on second quarter 2016 IGI forecast, with historical data through the first quarter 2016 (2010-based
index).
d. Multifactor Productivity Adjustment
Section 3401(b) of the Affordable Care Act requires that, in FY
2012 (and in subsequent FYs), the market basket percentage under the
SNF payment system as described in section 1888(e)(5)(B)(i) of the Act
is to be reduced annually by the productivity adjustment described in
section 1886(b)(3)(B)(xi)(II) of the Act. Section 1886(b)(3)(B)(xi)(II)
of the Act, added by section 3401(a) of the Affordable Care Act, sets
forth the definition of this productivity adjustment. The statute
defines the productivity adjustment to be equal to the 10-year moving
average of changes in annual economy-wide private nonfarm business
multi-factor productivity (as projected by the Secretary for the 10-
year period ending with the applicable FY, year, cost-reporting period,
or other annual period) (the MFP adjustment). The Bureau of Labor
Statistics (BLS) is the agency that publishes the official measure of
private nonfarm business MFP. We refer readers to the BLS Web site at
http://www.bls.gov/mfp for the BLS historical published MFP data.
MFP is derived by subtracting the contribution of labor and capital
inputs growth from output growth. The projections of the components of
MFP are currently produced by IGI, a nationally recognized economic
forecasting firm with which CMS contracts to forecast the components of
the market baskets and MFP. To generate a forecast of MFP, IGI
replicates the MFP measure calculated by the BLS, using a series of
proxy variables derived from IGI's U.S. macroeconomic models. For a
discussion of the MFP projection methodology, we refer readers to the
FY 2012 SNF PPS final rule (76 FR 48527 through 48529) and the FY 2016
SNF PPS final rule (80 FR 46395). A complete description of the MFP
projection methodology is available on our Web site at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketResearch.html.
(i) Incorporating the MFP Adjustment Into the Market Basket Update
Per section 1888(e)(5)(A) of the Act, the Secretary shall establish
a SNF market basket index that reflects changes over time in the prices
of an appropriate mix of goods and services included in covered SNF
services. Section 1888(e)(5)(B)(ii) of the Act, added by section
3401(b) of the Affordable Care Act, requires that for FY 2012 and each
subsequent FY, after determining the market basket percentage described
in section 1888(e)(5)(B)(i) of the Act, the Secretary shall reduce such
percentage by the
[[Page 51974]]
productivity adjustment described in section 1886(b)(3)(B)(xi)(II)
(which we refer to as the MFP adjustment). Section 1888(e)(5)(B)(ii) of
the Act further states that the reduction of the market basket
percentage by the MFP adjustment may result in the market basket
percentage being less than zero for a FY, and may result in payment
rates under section 1888(e) of the Act for a FY being less than such
payment rates for the preceding FY. Thus, if the application of the MFP
adjustment to the market basket percentage calculated under section
1888(e)(5)(B)(i) of the Act results in an MFP-adjusted market basket
percentage that is less than zero, then the annual update to the
unadjusted federal per diem rates under section 1888(e)(4)(E)(ii) of
the Act would be negative, and such rates would decrease relative to
the prior FY.
For the FY 2017 update, the MFP adjustment is calculated as the 10-
year moving average of changes in MFP for the period ending September
30, 2017. In the FY 2017 SNF PPS proposed rule, this adjustment was
calculated to be 0.5 percent. However, as discussed in the FY 2017 SNF
PPS proposed rule (81 FR 24234), we proposed that if more recent data
become available (for example, a more recent estimate of the FY 2010-
based SNF market basket and/or MFP adjustment), we would use such data,
if appropriate, to determine, among other things, the FY 2017 SNF
market basket percentage change and the MFP adjustment in this final
rule. Therefore, based on IGI's most recent second quarter 2016
forecast (with historical data through first quarter 2016), the MFP
adjustment for FY 2017 is 0.3 percent. Consistent with section
1888(e)(5)(B)(i) of the Act and Sec. 413.337(d)(2) of the regulations,
the market basket percentage for FY 2017 for the SNF PPS is based on
IGI's second quarter 2016 forecast of the SNF market basket update,
which is estimated to be 2.7 percent, as adjusted by any applicable
forecast error adjustment (as discussed above, in this final rule, we
are not applying a forecast error adjustment to the SNF market basket
update). In accordance with section 1888(e)(5)(B)(ii) of the Act (as
added by section 3401(b) of the Affordable Care Act) and Sec.
413.337(d)(3), this market basket percentage is then reduced by the MFP
adjustment (the 10-year moving average of changes in MFP for the period
ending September 30, 2017) of 0.3 percent, which is calculated as
described above and based on IGI's second quarter 2016 forecast. The
resulting MFP-adjusted SNF market basket update is equal to 2.4
percent, or 2.7 percent less 0.3 percentage point.
e. Market Basket Update Factor for FY 2017
Sections 1888(e)(4)(E)(ii)(IV) and 1888(e)(5)(i) of the Act require
that the update factor used to establish the FY 2017 unadjusted federal
rates be at a level equal to the market basket index percentage change.
Accordingly, we determined the total growth from the average market
basket level for the period of October 1, 2015 through September 30,
2016 to the average market basket level for the period of October 1,
2016 through September 30, 2017. This process yields a percentage
change in the market basket of 2.7 percent.
As further explained in section III.B.2.c. of this final rule, as
applicable, we adjust the market basket percentage change by the
forecast error from the most recently available FY for which there is
final data and apply this adjustment whenever the difference between
the forecasted and actual percentage change in the market basket
exceeds a 0.5 percentage point threshold. Since the difference between
the forecasted FY 2015 SNF market basket percentage change and the
actual FY 2015 SNF market basket percentage change (FY 2015 is the most
recently available FY for which there is historical data) did not
exceed the 0.5 percentage point threshold, the FY 2017 market basket
percentage change of 2.7 percent will not be adjusted by the forecast
error correction.
For FY 2017, section 1888(e)(5)(B)(ii) of the Act requires us to
reduce the market basket percentage change by the MFP adjustment (the
10-year moving average of changes in MFP for the period ending
September 30, 2017) of 0.3 percent, as described in section III.B.2.d.
of this final rule. The resulting net SNF market basket update would
equal 2.4 percent, or 2.7 percent less the 0.3 percentage point MFP
adjustment. A discussion of the general comments that we received on
the market basket update factor for FY 2017, and our responses to those
comments, appears below.
Comment: We received a number of comments in relation to applying
the FY 2017 market basket update factor in the determination of the FY
2017 unadjusted federal per diem rates, with some commenters supporting
its application in determining the FY 2017 unadjusted per diem rates,
while others opposed its application. In their March 2016 report
(available at http://medpac.gov/documents/reports/chapter-7-skilled-nursing-facility-services-(march-2016-report).pdf?sfvrsn=0) and in
their comment on the FY 2017 SNF PPS proposed rule, MedPAC recommended
that we eliminate the market basket update for SNFs altogether and
implement revisions to the SNF PPS.
Response: We appreciate all of the comments received on the
proposed market basket update for FY 2017. In response to those
comments opposing the application of the FY 2017 market basket update
factor in determining the FY 2017 unadjusted federal per diem rates,
specifically MedPAC's proposal to eliminate the market basket update
for SNFs, under section 1888(e)(4)(E)(ii)(IV) and (e)(5)(B) of the Act,
we are required to update the unadjusted Federal per diem rates each
fiscal year by the SNF market basket percentage change, as reduced by
the MFP adjustment.
Comment: Several commenters recommended that the SNF market basket
be reweighted more frequently. They stated that due to the rapidly
changing long term care environment, SNFs have and will continue to
make significant modifications to their operations, including the need
to respond to alternative payment models, managed care, and emerging
quality requirements. One specific recommendation was to update the SNF
market basket cost weights in accordance with the hospital market
basket update schedule in order to increase the accuracy of the SNF
market basket--particularly if the SNF wage index continues to be
directly linked to the hospital wage index.
Response: We appreciate the commenter's suggestion for a more
frequent rebasing of the SNF market basket. In the past, we have
rebased the SNF market basket roughly every 5 to 7 years. In accordance
with section 404 of Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA, Pub. L. 108-173), we determined that
the frequency for rebasing the hospital market basket would be every 4
years. The SNF market basket was last rebased and revised 3 years ago
in the FY 2014 SNF PPS final rule (reflecting 2010 base year
expenditures), and was effective beginning in FY 2014. We will continue
to review the most recent SNF Medicare cost report data and resulting
market basket cost weights for any notable changes, and determine if we
need to rebase the SNF market basket more frequently than roughly every
5 to 7 years. Should we determine that the SNF market basket would be
improved by updating the base year, such an update would be proposed in
[[Page 51975]]
rulemaking and be subject to public comment.
Comment: One commenter requested that we engage in an ongoing
dialogue with the commenter's association on their market basket
research. The goal of such discussions would be to inform us and
support any analogous CMS reform efforts.
Response: We appreciate the commenter's review of the market basket
and continued dialogue regarding their research. Additionally, the
commenter is encouraged to submit any research to [email protected].
Comment: One commenter identified a potential error in our
calculation of the proposed FY 2017 unadjusted federal per diem rates.
Specifically, the commenter stated that the FY 2017 unadjusted federal
per diem rates published in the FY 2017 SNF PPS proposed rule (81 FR
24234) did not appear to reflect the full, proposed FY 2017 market
basket update factor of 2.1 percent.
Response: We appreciate this comment and, after review of the
calculations used to determine the FY 2017 unadjusted federal per diem
rates, we have determined that there was an error in our calculation of
the proposed FY 2017 unadjusted federal per diem rates. Specifically,
when performing the calculation of the FY 2017 unadjusted federal per
diem rates, we begin with the FY 2016 unadjusted federal per diem rates
which are updated by the FY 2017 MFP-adjusted market basket update
factor in accordance with section 1888(e)(4)(E)(ii)(IV) and (e)(5)(B)
of the Act. However, in performing the calculation, we inadvertently
made an error in transcribing the FY 2016 unadjusted federal per diem
rates (though we applied the correct FY 2017 proposed market basket
update factor of 2.1 percent). Specifically, for the FY 2017 SNF PPS
proposed rule, we inadvertently used the following rates as the FY 2016
unadjusted urban federal per diem rates in the calculation of the
proposed FY 2017 urban unadjusted federal per diem rates: $171.12
(nursing case-mix), $128.90 (therapy case-mix), $16.97 (therapy non-
case-mix), and $87.33 (non-case-mix). We inadvertently used the
following rates as the FY 2016 unadjusted rural federal per diem rates
in the calculation of the proposed FY 2017 unadjusted rural federal per
diem rates: $163.48 (nursing case-mix), $148.62 (therapy case-mix),
$18.14 (therapy non-case-mix), and $88.95 (non-case-mix). The correct
FY 2016 urban and rural unadjusted federal per diem rates which should
have been used in this calculation, and which have been used in the
calculation of the final FY 2017 urban and rural unadjusted federal per
diem rates provided in Tables 2 and 3 below, are those in Tables 2 and
3 of the FY 2016 SNF PPS final rule (80 FR 46397).
Additionally, as further discussed in section III.B.4., we also
discovered an error in the calculation of the proposed FY 2017 wage
index budget neutrality factor, which also impacted the calculation of
the proposed FY 2017 unadjusted federal per diem rates set forth in the
proposed rule (81 FR 24234) (as well as the impact analysis provided in
Table 19 of the FY 2017 SNF PPS proposed rule (81 FR 24278), as further
discussed in section VI.A.4. of this final rule).
We appreciate the commenter bringing this error to our attention.
The corrected final FY 2017 SNF PPS unadjusted federal per diem rates
are set forth below in Tables 2 and 3. We further note that, as
described previously in this section, the FY 2017 market basket update
factor and MFP adjustment were both updated in advance of the final
rule. As such, the FY 2017 unadjusted federal per diem rates provided
in Tables 2 and 3 reflect the updated FY 2017 market basket increase
factor and MFP adjustment, as well as the corrected FY 2016 unadjusted
federal per diem rates and corrected wage index budget neutrality
factor which serve as the foundation for calculating the FY 2017
unadjusted federal per diem rates.
Accordingly, for the reasons specified in this final rule and in
the FY 2017 SNF PPS proposed rule (81 FR 24230), we are applying the FY
2017 market basket factor, as adjusted by the MFP adjustment as
described above, in our determination of the FY 2017 unadjusted federal
per diem rates. We used the SNF market basket, adjusted as described
previously, to adjust each per diem component of the federal rates
forward to reflect the change in the average prices for FY 2017 from
average prices for FY 2016. We further adjusted the rates by a wage
index budget neutrality factor, described later in this section. Tables
2 and 3 reflect the updated components of the unadjusted federal rates
for FY 2017, prior to adjustment for case-mix. As discussed previously
in this section, the unadjusted federal per diem rates provided below
reflect the updated FY 2017 market basket update factor, as adjusted by
the updated MFP adjustment, and the corrections to the FY 2016
unadjusted federal per diem rates and the FY 2017 wage index budget
neutrality factor described previously.
Table 2--FY 2017 Unadjusted Federal Rate per Diem Urban
----------------------------------------------------------------------------------------------------------------
Nursing--case- Therapy--case- Therapy-- non-
Rate component mix mix case-mix Non-case-mix
----------------------------------------------------------------------------------------------------------------
Per Diem Amount............................. $175.28 $132.03 $17.39 $89.46
----------------------------------------------------------------------------------------------------------------
Table 3--FY 2017 Unadjusted Federal Rate per Diem Rural
----------------------------------------------------------------------------------------------------------------
Nursing--case- Therapy--case- Therapy-- non-
Rate component mix mix case-mix Non-case-mix
----------------------------------------------------------------------------------------------------------------
Per Diem Amount............................. $167.45 $152.24 $18.58 $91.11
----------------------------------------------------------------------------------------------------------------
3. Case-Mix Adjustment
Under section 1888(e)(4)(G)(i) of the Act, the federal rate also
incorporates an adjustment to account for facility case-mix, using a
classification system that accounts for the relative resource
utilization of different patient types. The statute specifies that the
adjustment is to reflect both a resident classification system that the
Secretary establishes to account for the relative resource use of
different patient types, as well as resident assessment data and other
data that the Secretary considers appropriate. In the interim final
rule with comment period that initially implemented the SNF PPS (63 FR
26252, May 12, 1998), we developed the RUG-III case-mix classification
system, which tied the amount of payment to resident resource
[[Page 51976]]
use in combination with resident characteristic information. Staff time
measurement (STM) studies conducted in 1990, 1995, and 1997 provided
information on resource use (time spent by staff members on residents)
and resident characteristics that enabled us not only to establish RUG-
III, but also to create case-mix indexes (CMIs). The original RUG-III
grouper logic was based on clinical data collected in 1990, 1995, and
1997. As discussed in the SNF PPS proposed rule for FY 2010 (74 FR
22208), we subsequently conducted a multi-year data collection and
analysis under the Staff Time and Resource Intensity Verification
(STRIVE) project to update the case-mix classification system for FY
2011. The resulting Resource Utilization Groups, Version 4 (RUG-IV)
case-mix classification system reflected the data collected in 2006-
2007 during the STRIVE project, and was finalized in the FY 2010 SNF
PPS final rule (74 FR 40288) to take effect in FY 2011 concurrently
with an updated new resident assessment instrument, version 3.0 of the
Minimum Data Set (MDS 3.0), which collects the clinical data used for
case-mix classification under RUG-IV.
We note that case-mix classification is based, in part, on the
beneficiary's need for skilled nursing care and therapy services. The
case-mix classification system uses clinical data from the MDS to
assign a case-mix group to each patient that is then used to calculate
a per diem payment under the SNF PPS. As discussed in section IV.A. of
the FY 2017 SNF PPS proposed rule (81 FR 24241 through 24242), the
clinical orientation of the case-mix classification system supports the
SNF PPS's use of an administrative presumption that considers a
beneficiary's initial case-mix classification to assist in making
certain SNF level of care determinations. Further, because the MDS is
used as a basis for payment, as well as a clinical assessment, we have
provided extensive training on proper coding and the time frames for
MDS completion in our Resident Assessment Instrument (RAI) Manual. For
an MDS to be considered valid for use in determining payment, the MDS
assessment must be completed in compliance with the instructions in the
RAI Manual in effect at the time the assessment is completed. For
payment and quality monitoring purposes, the RAI Manual consists of
both the Manual instructions and the interpretive guidance and policy
clarifications posted on the appropriate MDS Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.
In addition, we note that section 511 of the MMA, amended section
1888(e)(12) of the Act, to provide for a temporary increase of 128
percent in the PPS per diem payment for any SNF residents with Acquired
Immune Deficiency Syndrome (AIDS), effective with services furnished on
or after October 1, 2004. This special add-on for SNF residents with
AIDS was to remain in effect until the Secretary certifies that there
is an appropriate adjustment in the case mix to compensate for the
increased costs associated with such residents. The add-on for SNF
residents with AIDS is also discussed in Program Transmittal #160
(Change Request #3291), issued on April 30, 2004, which is available
online at www.cms.gov/transmittals/downloads/r160cp.pdf. In the SNF PPS
final rule for FY 2010 (74 FR 40288), we did not address this
certification in that final rule's implementation of the case-mix
refinements for RUG-IV, thus allowing the add-on payment required by
section 511 of the MMA to remain in effect. For the limited number of
SNF residents that qualify for this add-on, there is a significant
increase in payments. For example, using FY 2014 data (which still used
ICD-9-CM coding), we identified fewer than 4,800 SNF residents with a
diagnosis code of 042 (Human Immunodeficiency Virus (HIV) Infection).
As explained in the FY 2016 SNF PPS final rule (80 FR 46397 through
46398), on October 1, 2015 (consistent with section 212 of PAMA), we
converted to using ICD-10-CM code B20 to identify those residents for
whom it is appropriate to apply the AIDS add-on established by section
511 of the MMA. For FY 2017, an urban facility with a resident with
AIDS in RUG-IV group ``HC2'' would have a case-mix adjusted per diem
payment of $438.13 (see Table 4) before the application of the MMA
adjustment. After an increase of 128 percent, this urban facility would
receive a case-mix adjusted per diem payment of approximately $998.94.
Under section 1888(e)(4)(H) of the Act, each update of the payment
rates must include the case-mix classification methodology applicable
for the upcoming FY. The payment rates set forth in this final rule
reflect the use of the RUG-IV case-mix classification system from
October 1, 2016, through September 30, 2017. We list the case-mix
adjusted RUG-IV payment rates, provided separately for urban and rural
SNFs, in Tables 4 and 5 with corresponding case-mix values. We use the
revised OMB delineations adopted in the FY 2015 SNF PPS final rule (79
FR 45632, 45634) to identify a facility's urban or rural status for the
purpose of determining which set of rate tables would apply to the
facility. Tables 4 and 5 do not reflect the add-on for SNF residents
with AIDS enacted by section 511 of the MMA, which we apply only after
making all other adjustments (such as wage index and case-mix). We
would note that the case mix adjusted rates provided below are based on
the FY 2017 unadjusted federal per diem rates provided in Tables 2 and
3 of this section, which reflect the updated FY 2017 SNF market basket
update factor and updated MFP adjustment, as well as corrections to the
errors associated with the unadjusted federal per diem rates published
in the FY 2017 SNF PPS proposed rule (81 FR 24234) described previously
in this section.
Table 4--RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes--Urban
--------------------------------------------------------------------------------------------------------------------------------------------------------
Nursing Therapy Non-case-mix Non-case-mix
RUG-IV Category Nursing index Therapy index component component therapy comp component Total rate
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUX..................................... 2.67 1.87 $468.00 $246.90 .............. $89.46 $804.36
RUL..................................... 2.57 1.87 450.47 246.90 .............. 89.46 786.83
RVX..................................... 2.61 1.28 457.48 169.00 .............. 89.46 715.94
RVL..................................... 2.19 1.28 383.86 169.00 .............. 89.46 642.32
RHX..................................... 2.55 0.85 446.96 112.23 .............. 89.46 648.65
RHL..................................... 2.15 0.85 376.85 112.23 .............. 89.46 578.54
RMX..................................... 2.47 0.55 432.94 72.62 .............. 89.46 595.02
RML..................................... 2.19 0.55 383.86 72.62 .............. 89.46 545.94
RLX..................................... 2.26 0.28 396.13 36.97 .............. 89.46 522.56
RUC..................................... 1.56 1.87 273.44 246.90 .............. 89.46 609.80
RUB..................................... 1.56 1.87 273.44 246.90 .............. 89.46 609.80
[[Page 51977]]
RUA..................................... 0.99 1.87 173.53 246.90 .............. 89.46 509.89
RVC..................................... 1.51 1.28 264.67 169.00 .............. 89.46 523.13
RVB..................................... 1.11 1.28 194.56 169.00 .............. 89.46 453.02
RVA..................................... 1.10 1.28 192.81 169.00 .............. 89.46 451.27
RHC..................................... 1.45 0.85 254.16 112.23 .............. 89.46 455.85
RHB..................................... 1.19 0.85 208.58 112.23 .............. 89.46 410.27
RHA..................................... 0.91 0.85 159.50 112.23 .............. 89.46 361.19
RMC..................................... 1.36 0.55 238.38 72.62 .............. 89.46 400.46
RMB..................................... 1.22 0.55 213.84 72.62 .............. 89.46 375.92
RMA..................................... 0.84 0.55 147.24 72.62 .............. 89.46 309.32
RLB..................................... 1.50 0.28 262.92 36.97 .............. 89.46 389.35
RLA..................................... 0.71 0.28 124.45 36.97 .............. 89.46 250.88
ES3..................................... 3.58 .............. 627.50 .............. $17.39 89.46 734.35
ES2..................................... 2.67 .............. 468.00 .............. 17.39 89.46 574.85
ES1..................................... 2.32 .............. 406.65 .............. 17.39 89.46 513.50
HE2..................................... 2.22 .............. 389.12 .............. 17.39 89.46 495.97
HE1..................................... 1.74 .............. 304.99 .............. 17.39 89.46 411.84
HD2..................................... 2.04 .............. 357.57 .............. 17.39 89.46 464.42
HD1..................................... 1.60 .............. 280.45 .............. 17.39 89.46 387.30
HC2..................................... 1.89 .............. 331.28 .............. 17.39 89.46 438.13
HC1..................................... 1.48 .............. 259.41 .............. 17.39 89.46 366.26
HB2..................................... 1.86 .............. 326.02 .............. 17.39 89.46 432.87
HB1..................................... 1.46 .............. 255.91 .............. 17.39 89.46 362.76
LE2..................................... 1.96 .............. 343.55 .............. 17.39 89.46 450.40
LE1..................................... 1.54 .............. 269.93 .............. 17.39 89.46 376.78
LD2..................................... 1.86 .............. 326.02 .............. 17.39 89.46 432.87
LD1..................................... 1.46 .............. 255.91 .............. 17.39 89.46 362.76
LC2..................................... 1.56 .............. 273.44 .............. 17.39 89.46 380.29
LC1..................................... 1.22 .............. 213.84 .............. 17.39 89.46 320.69
LB2..................................... 1.45 .............. 254.16 .............. 17.39 89.46 361.01
LB1..................................... 1.14 .............. 199.82 .............. 17.39 89.46 306.67
CE2..................................... 1.68 .............. 294.47 .............. 17.39 89.46 401.32
CE1..................................... 1.50 .............. 262.92 .............. 17.39 89.46 369.77
CD2..................................... 1.56 .............. 273.44 .............. 17.39 89.46 380.29
CD1..................................... 1.38 .............. 241.89 .............. 17.39 89.46 348.74
CC2..................................... 1.29 .............. 226.11 .............. 17.39 89.46 332.96
CC1..................................... 1.15 .............. 201.57 .............. 17.39 89.46 308.42
CB2..................................... 1.15 .............. 201.57 .............. 17.39 89.46 308.42
CB1..................................... 1.02 .............. 178.79 .............. 17.39 89.46 285.64
CA2..................................... 0.88 .............. 154.25 .............. 17.39 89.46 261.10
CA1..................................... 0.78 .............. 136.72 .............. 17.39 89.46 243.57
BB2..................................... 0.97 .............. 170.02 .............. 17.39 89.46 276.87
BB1..................................... 0.90 .............. 157.75 .............. 17.39 89.46 264.60
BA2..................................... 0.70 .............. 122.70 .............. 17.39 89.46 229.55
BA1..................................... 0.64 .............. 112.18 .............. 17.39 89.46 219.03
PE2..................................... 1.50 .............. 262.92 .............. 17.39 89.46 369.77
PE1..................................... 1.40 .............. 245.39 .............. 17.39 89.46 352.24
PD2..................................... 1.38 .............. 241.89 .............. 17.39 89.46 348.74
PD1..................................... 1.28 .............. 224.36 .............. 17.39 89.46 331.21
PC2..................................... 1.10 .............. 192.81 .............. 17.39 89.46 299.66
PC1..................................... 1.02 .............. 178.79 .............. 17.39 89.46 285.64
PB2..................................... 0.84 .............. 147.24 .............. 17.39 89.46 254.09
PB1..................................... 0.78 .............. 136.72 .............. 17.39 89.46 243.57
PA2..................................... 0.59 .............. 103.42 .............. 17.39 89.46 210.27
PA1..................................... 0.54 .............. 94.65 .............. 17.39 89.46 201.50
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 5--RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes--Rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
Nursing Therapy Non-case-mix Non-case-mix
RUG-IV Category Nursing index Therapy index component component therapy comp component Total rate
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUX..................................... 2.67 1.87 $447.09 $284.69 .............. $91.11 $822.89
RUL..................................... 2.57 1.87 430.35 284.69 .............. 91.11 806.15
RVX..................................... 2.61 1.28 437.04 194.87 .............. 91.11 723.02
RVL..................................... 2.19 1.28 366.72 194.87 .............. 91.11 652.70
RHX..................................... 2.55 0.85 427.00 129.40 .............. 91.11 647.51
RHL..................................... 2.15 0.85 360.02 129.40 .............. 91.11 580.53
RMX..................................... 2.47 0.55 413.60 83.73 .............. 91.11 588.44
RML..................................... 2.19 0.55 366.72 83.73 .............. 91.11 541.56
RLX..................................... 2.26 0.28 378.44 42.63 .............. 91.11 512.18
[[Page 51978]]
RUC..................................... 1.56 1.87 261.22 284.69 .............. 91.11 637.02
RUB..................................... 1.56 1.87 261.22 284.69 .............. 91.11 637.02
RUA..................................... 0.99 1.87 165.78 284.69 .............. 91.11 541.58
RVC..................................... 1.51 1.28 252.85 194.87 .............. 91.11 538.83
RVB..................................... 1.11 1.28 185.87 194.87 .............. 91.11 471.85
RVA..................................... 1.10 1.28 184.20 194.87 .............. 91.11 470.18
RHC..................................... 1.45 0.85 242.80 129.40 .............. 91.11 463.31
RHB..................................... 1.19 0.85 199.27 129.40 .............. 91.11 419.78
RHA..................................... 0.91 0.85 152.38 129.40 .............. 91.11 372.89
RMC..................................... 1.36 0.55 227.73 83.73 .............. 91.11 402.57
RMB..................................... 1.22 0.55 204.29 83.73 .............. 91.11 379.13
RMA..................................... 0.84 0.55 140.66 83.73 .............. 91.11 315.50
RLB..................................... 1.50 0.28 251.18 42.63 .............. 91.11 384.92
RLA..................................... 0.71 0.28 118.89 42.63 .............. 91.11 252.63
ES3..................................... 3.58 .............. 599.47 .............. $18.58 91.11 709.16
ES2..................................... 2.67 .............. 447.09 .............. 18.58 91.11 556.78
ES1..................................... 2.32 .............. 388.48 .............. 18.58 91.11 498.17
HE2..................................... 2.22 .............. 371.74 .............. 18.58 91.11 481.43
HE1..................................... 1.74 .............. 291.36 .............. 18.58 91.11 401.05
HD2..................................... 2.04 .............. 341.60 .............. 18.58 91.11 451.29
HD1..................................... 1.60 .............. 267.92 .............. 18.58 91.11 377.61
HC2..................................... 1.89 .............. 316.48 .............. 18.58 91.11 426.17
HC1..................................... 1.48 .............. 247.83 .............. 18.58 91.11 357.52
HB2..................................... 1.86 .............. 311.46 .............. 18.58 91.11 421.15
HB1..................................... 1.46 .............. 244.48 .............. 18.58 91.11 354.17
LE2..................................... 1.96 .............. 328.20 .............. 18.58 91.11 437.89
LE1..................................... 1.54 .............. 257.87 .............. 18.58 91.11 367.56
LD2..................................... 1.86 .............. 311.46 .............. 18.58 91.11 421.15
LD1..................................... 1.46 .............. 244.48 .............. 18.58 91.11 354.17
LC2..................................... 1.56 .............. 261.22 .............. 18.58 91.11 370.91
LC1..................................... 1.22 .............. 204.29 .............. 18.58 91.11 313.98
LB2..................................... 1.45 .............. 242.80 .............. 18.58 91.11 352.49
LB1..................................... 1.14 .............. 190.89 .............. 18.58 91.11 300.58
CE2..................................... 1.68 .............. 281.32 .............. 18.58 91.11 391.01
CE1..................................... 1.50 .............. 251.18 .............. 18.58 91.11 360.87
CD2..................................... 1.56 .............. 261.22 .............. 18.58 91.11 370.91
CD1..................................... 1.38 .............. 231.08 .............. 18.58 91.11 340.77
CC2..................................... 1.29 .............. 216.01 .............. 18.58 91.11 325.70
CC1..................................... 1.15 .............. 192.57 .............. 18.58 91.11 302.26
CB2..................................... 1.15 .............. 192.57 .............. 18.58 91.11 302.26
CB1..................................... 1.02 .............. 170.80 .............. 18.58 91.11 280.49
CA2..................................... 0.88 .............. 147.36 .............. 18.58 91.11 257.05
CA1..................................... 0.78 .............. 130.61 .............. 18.58 91.11 240.30
BB2..................................... 0.97 .............. 162.43 .............. 18.58 91.11 272.12
BB1..................................... 0.90 .............. 150.71 .............. 18.58 91.11 260.40
BA2..................................... 0.70 .............. 117.22 .............. 18.58 91.11 226.91
BA1..................................... 0.64 .............. 107.17 .............. 18.58 91.11 216.86
PE2..................................... 1.50 .............. 251.18 .............. 18.58 91.11 360.87
PE1..................................... 1.40 .............. 234.43 .............. 18.58 91.11 344.12
PD2..................................... 1.38 .............. 231.08 .............. 18.58 91.11 340.77
PD1..................................... 1.28 .............. 214.34 .............. 18.58 91.11 324.03
PC2..................................... 1.10 .............. 184.20 .............. 18.58 91.11 293.89
PC1..................................... 1.02 .............. 170.80 .............. 18.58 91.11 280.49
PB2..................................... 0.84 .............. 140.66 .............. 18.58 91.11 250.35
PB1..................................... 0.78 .............. 130.61 .............. 18.58 91.11 240.30
PA2..................................... 0.59 .............. 98.80 .............. 18.58 91.11 208.49
PA1..................................... 0.54 .............. 90.42 .............. 18.58 91.11 200.11
--------------------------------------------------------------------------------------------------------------------------------------------------------
4. Wage Index Adjustment
Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the
federal rates to account for differences in area wage levels, using a
wage index that the Secretary determines appropriate. Since the
inception of the SNF PPS, we have used hospital inpatient wage data in
developing a wage index to be applied to SNFs. We proposed to continue
this practice for FY 2017, as we continue to believe that in the
absence of SNF-specific wage data, using the hospital inpatient wage
index data is appropriate and reasonable for the SNF PPS. As explained
in the update notice for FY 2005 (69 FR 45786), the SNF PPS does not
use the hospital area wage index's occupational mix adjustment, as this
adjustment serves specifically to define the occupational categories
more clearly in a hospital setting; moreover, the collection of the
occupational wage data also excludes any wage data related to SNFs.
Therefore, we believe that using the updated wage data exclusive of the
occupational mix adjustment continues to be appropriate for SNF
payments. For FY 2017, the updated wage data are for
[[Page 51979]]
hospital cost reporting periods beginning on or after October 1, 2012
and before October 1, 2013 (FY 2013 cost report data).
We note that section 315 of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (BIPA, Pub. L. 106-554,
enacted on December 21, 2000) authorized us to establish a geographic
reclassification procedure that is specific to SNFs, but only after
collecting the data necessary to establish a SNF wage index that is
based on wage data from nursing homes. However, to date, this has
proven to be unfeasible due to the volatility of existing SNF wage data
and the significant amount of resources that would be required to
improve the quality of that data.
In addition, we proposed to continue to use the same methodology
discussed in the SNF PPS final rule for FY 2008 (72 FR 43423) to
address those geographic areas in which there are no hospitals, and
thus, no hospital wage index data on which to base the calculation of
the FY 2017 SNF PPS wage index. For rural geographic areas that do not
have hospitals, and therefore, lack hospital wage data on which to base
an area wage adjustment, we would use the average wage index from all
contiguous Core-Based Statistical Areas (CBSAs) as a reasonable proxy.
For FY 2017, there are no rural geographic areas that do not have
hospitals, and thus, this methodology would not be applied. For rural
Puerto Rico, we would not apply this methodology due to the distinct
economic circumstances that exist there (for example, due to the close
proximity to one another of almost all of Puerto Rico's various urban
and non-urban areas, this methodology would produce a wage index for
rural Puerto Rico that is higher than that in half of its urban areas);
instead, we would continue to use the most recent wage index previously
available for that area. For urban areas without specific hospital wage
index data, we would use the average wage indexes of all of the urban
areas within the state to serve as a reasonable proxy for the wage
index of that urban CBSA. For FY 2017, the only urban area without wage
index data available is CBSA 25980, Hinesville-Fort Stewart, GA. The
wage index applicable to FY 2017 is set forth in Tables A and B
available on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html.
Once calculated, we would apply the wage index adjustment to the
labor-related portion of the federal rate. Each year, we calculate a
revised labor-related share, based on the relative importance of labor-
related cost categories (that is, those cost categories that are labor-
intensive and vary with the local labor market) in the input price
index. In the SNF PPS final rule for FY 2014 (78 FR 47944 through
47946), we finalized a proposal to revise the labor-related share to
reflect the relative importance of the FY 2010-based SNF market basket
cost weights for the following cost categories: Wages and salaries;
employee benefits; the labor-related portion of nonmedical professional
fees; administrative and facilities support services; all other: Labor-
related services; and a proportion of capital-related expenses.
We calculate the labor-related relative importance from the SNF
market basket, and it approximates the labor-related portion of the
total costs, after taking into account historical and projected price
changes between the base year and FY 2017. The price proxies that move
the different cost categories in the market basket do not necessarily
change at the same rate, and the relative importance captures these
changes. Accordingly, the relative importance figure more closely
reflects the cost share weights for FY 2017 than the base year weights
from the SNF market basket.
We calculate the labor-related relative importance for FY 2017 in
four steps. First, we compute the FY 2017 price index level for the
total market basket and each cost category of the market basket.
Second, we calculate a ratio for each cost category by dividing the FY
2017 price index level for that cost category by the total market
basket price index level. Third, we determine the FY 2017 relative
importance for each cost category by multiplying this ratio by the base
year (FY 2010) weight. Finally, we add the FY 2017 relative importance
for each of the labor-related cost categories (wages and salaries,
employee benefits, the labor-related portion of non-medical
professional fees, administrative and facilities support services, all
other: Labor-related services, and a portion of capital-related
expenses) to produce the FY 2017 labor-related relative importance.
Table 6 summarizes the updated labor-related share for FY 2017,
compared to the labor-related share that was used for the FY 2016 SNF
PPS final rule. In the FY 2017 SNF PPS proposed rule, the labor-related
share for FY 2017 was proposed to be 68.9 percent. However, as
discussed in the FY 2017 SNF PPS proposed rule (81 FR 24234), we
proposed that if more recent data become available, we would use such
data, if appropriate, to determine, among other things, the FY 2017 SNF
labor related share. Therefore, based on IGI's most recent second
quarter 2016 forecast (with historical data through first quarter
2016), the labor-related share for FY 2017 is 68.8 percent.
We invited public comments on these proposals. A discussion of the
comments we received on these proposals, as well as a discussion of the
general comments we received on the wage index adjustment, and our
responses to those comments, appears below.
Comment: One commenter is concerned with the significant drop in
the wage index for Great Falls, Montana (CBSA 24500). The commenter
mentioned that Montana is a frontier state as defined in the Affordable
Care Act and that the Affordable Care Act, specifically section 10324
of the Affordable Care Act, establishes a wage index floor of 1.0 for
frontier state hospitals. The commenter recommends that CMS use its
authority to apply the ACA-mandated frontier floor for hospitals to
SNFs.
Response: We appreciate the commenter's concern regarding the
application of a floor on area wage indexes for SNFs in frontier
states. Section 10324 of the Affordable Care Act requires that
hospitals in frontier states cannot be assigned a wage index of less
than 1.0000. We do not believe it would be prudent at this time to
adopt such a policy under the SNF PPS. As we stated in the FY 2016 SNF
PPS final rule (80 FR 46401), MedPAC has recommended eliminating the
rural floor policy (which actually sets a floor for urban hospitals)
from the calculation of the IPPS wage index (see, for example, Chapter
3 of MedPAC's March 2013 Report to Congress on Medicare Payment Policy,
available at http://medpac.gov/documents/reports/mar13_entirereport.pdf, which notes on page 65 that in 2007, MedPAC had
``. . . recommended eliminating these special wage index adjustments
and adopting a new wage index system to avoid geographic inequities
that can occur due to current wage index policies (Medicare Payment
Advisory Commission 2007b.'') We stated in the FY 2016 SNF PPS final
rule that if we adopted the rural floor at that time under the SNF PPS,
we believed that the SNF PPS wage index could become vulnerable to
problems similar to those that MedPAC identified in its March 2013
Report to Congress. Similarly, we have concerns regarding adopting a
frontier state floor at this time under the SNF PPS as we are concerned
that the frontier state floor could produce vulnerabilities for the SNF
PPS wage index similar to those discussed by
[[Page 51980]]
MedPAC in its report. As stated above, under section 1888(e)(4)(G)(ii)
of the Act and Sec. 413.337(a)(1)(ii) of the regulations, we adjust
the SNF PPS rates to account for differences in area wage levels. We
believe that applying a floor to those facilities located in frontier
states would make the wage index for those areas less reflective of the
area wage levels.
Comment: Several commenters recommend that we continue exploring
potential approaches for collecting SNF-specific wage data to establish
a SNF-specific wage index. These commenters stated that the hospital
wage index does not provide a reasonable proxy for SNF wages and
occupational mix and should be replaced by use of SNF-specific data as
soon as is practicable. One commenter recommended that we consider
collecting base-hourly wage data as part of the Payroll-Based Journal
(PBJ) initiative, which may be used in developing a SNF-specific wage
index.
Response: We appreciate the commenters raising these concerns
regarding the use of the hospital wage index data under the SNF PPS,
and the commenter's recommendation to continue exploring potential
approaches for collecting SNF-specific wage data to establish a SNF-
specific wage index. However, we note that, consistent with our
previous responses to these recurring comments (most recently published
in the FY 2016 SNF PPS final rule (80 FR 46401)), developing such a
wage index would require a resource-intensive audit process similar to
that used for IPPS hospital data, to improve the quality of the SNF
cost report data, in order for it to be used as part of this analysis.
We would further note that, as this audit process is quite extensive in
the case of approximately 3,300 hospitals, it would be significantly
more so in the case of approximately 15,000 SNFs. Therefore, while we
continue to review all available data and contemplate the potential
methodological approaches for a SNF-specific wage index in the future,
we continue to believe that in the absence of the appropriate SNF-
specific wage data, using the pre-reclassified hospital inpatient wage
data (without the occupational mix adjustment) is appropriate and
reasonable for the SNF PPS. With regard to the PBJ recommendation, we
will pass this comment to our colleagues managing that initiative for
further consideration.
Comment: A few commenters suggested that we modify the use of
hospital wage data used to construct the SNF PPS wage index,
specifically calling for us to remove certain labor categories and data
that are specific to hospitals only. These commenters also suggested
that this modified methodology could further be tailored to SNFs by
weighting it by occupational mix data for SNFs published by the Bureau
of Labor Statistics (BLS).
Response: We appreciate these commenters' suggestion that we modify
the current hospital wage data used to construct the SNF PPS wage index
to reflect the SNF environment more accurately. While we consider
whether or not such an approach may constitute an interim step in the
process of developing a SNF-specific wage index, we would note that
other provider types also use the hospital wage index as the basis for
their associated wage index. As such, we believe that such a
recommendation should be part of a broader discussion of wage index
reform across Medicare payment systems.
Comment: A few commenters raised concerns around evolving minimum
wage standards across the country and recommended that we consider ways
to incorporate increasing minimum wage standards into the SNF PPS wage
index. One commenter recommended that we should modify the wage index
adjustment in the future to identify ``living wages'' across the
country and that wage index policies should ensure that facilities pay
their staff such a living wage. This commenter also recommended that we
reward facilities that invest in their workforce.
Response: With regard to rising minimum wage standards, we would
note that such increases would likely be reflected in future data used
to create the hospital wage index, to the extent these changes to state
minimum wage standards are reflected in increased wages to hospital
staff. Therefore, such standards would already be incorporated into the
calculation of the SNF PPS wage index to the extent that these
standards impact on facility wages. With regard to the comment that we
should modify the wage index adjustment to identify and support
facilities that pay a living wage to their staff, the purpose of the
wage index adjustment is to reflect the actual wages being paid to
staff, not to influence the wages being paid to staff. Therefore, we do
not believe that we should make modifications to the wage index to
reflect an ideal standard of wages that does not currently exist.
Accordingly, after considering the comments received and for the
reasons discussed previously in this section and in the FY 2017 SNF PPS
proposed rule (81 FR 24237 through 24241), we are finalizing the FY
2017 wage index adjustment and related policies as proposed in the FY
2017 SNF PPS proposed rule. For FY 2017, the updated wage data are for
hospital cost reporting periods beginning on or after October 1, 2012
and before October 1, 2013 (FY 2013 cost report data). Table 6
summarizes the updated labor-related share for FY 2017, compared to the
labor-related share that was used in the FY 2016 SNF PPS final rule.
Table 6--Labor-Related Relative Importance, FY 2016 and FY 2017
------------------------------------------------------------------------
Relative Relative
importance, labor- importance, labor-
related, FY 2016 related, FY 2017
15:2 forecast \1\ 16:2 forecast \2\
------------------------------------------------------------------------
Wages and salaries................ 48.8 48.8
Employee benefits................. 11.3 11.1
Nonmedical Professional fees: 3.5 3.4
Labor-related....................
Administrative and facilities 0.5 0.5
support services.................
All Other: Labor-related services. 2.3 2.3
Capital-related (.391)............ 2.7 2.7
-------------------------------------
Total......................... 69.1 68.8
------------------------------------------------------------------------
\1\ Published in the Federal Register; based on second quarter 2015 IGI
forecast.
\2\ Based on second quarter 2016 IGI forecast, with historical data
through first quarter 2016.
[[Page 51981]]
Tables 7 and 8 show the RUG-IV case-mix adjusted federal rates by
labor-related and non-labor-related components.
Table 7--RUG-IV Case-Mix Adjusted Federal Rates for Urban SNFs By Labor and Non-Labor Component
----------------------------------------------------------------------------------------------------------------
Non-labor
RUG-IV category Total rate Labor portion portion
----------------------------------------------------------------------------------------------------------------
RUX............................................................. 804.36 $553.40 $250.96
RUL............................................................. 786.83 541.34 245.49
RVX............................................................. 715.94 492.57 223.37
RVL............................................................. 642.32 441.92 200.40
RHX............................................................. 648.65 446.27 202.38
RHL............................................................. 578.54 398.04 180.50
RMX............................................................. 595.02 409.37 185.65
RML............................................................. 545.94 375.61 170.33
RLX............................................................. 522.56 359.52 163.04
RUC............................................................. 609.80 419.54 190.26
RUB............................................................. 609.80 419.54 190.26
RUA............................................................. 509.89 350.80 159.09
RVC............................................................. 523.13 359.91 163.22
RVB............................................................. 453.02 311.68 141.34
RVA............................................................. 451.27 310.47 140.80
RHC............................................................. 455.85 313.62 142.23
RHB............................................................. 410.27 282.27 128.00
RHA............................................................. 361.19 248.50 112.69
RMC............................................................. 400.46 275.52 124.94
RMB............................................................. 375.92 258.63 117.29
RMA............................................................. 309.32 212.81 96.51
RLB............................................................. 389.35 267.87 121.48
RLA............................................................. 250.88 172.61 78.27
ES3............................................................. 734.35 505.23 229.12
ES2............................................................. 574.85 395.50 179.35
ES1............................................................. 513.50 353.29 160.21
HE2............................................................. 495.97 341.23 154.74
HE1............................................................. 411.84 283.35 128.49
HD2............................................................. 464.42 319.52 144.90
HD1............................................................. 387.30 266.46 120.84
HC2............................................................. 438.13 301.43 136.70
HC1............................................................. 366.26 251.99 114.27
HB2............................................................. 432.87 297.81 135.06
HB1............................................................. 362.76 249.58 113.18
LE2............................................................. 450.40 309.88 140.52
LE1............................................................. 376.78 259.22 117.56
LD2............................................................. 432.87 297.81 135.06
LD1............................................................. 362.76 249.58 113.18
LC2............................................................. 380.29 261.64 118.65
LC1............................................................. 320.69 220.63 100.06
LB2............................................................. 361.01 248.37 112.64
LB1............................................................. 306.67 210.99 95.68
CE2............................................................. 401.32 276.11 125.21
CE1............................................................. 369.77 254.40 115.37
CD2............................................................. 380.29 261.64 118.65
CD1............................................................. 348.74 239.93 108.81
CC2............................................................. 332.96 229.08 103.88
CC1............................................................. 308.42 212.19 96.23
CB2............................................................. 308.42 212.19 96.23
CB1............................................................. 285.64 196.52 89.12
CA2............................................................. 261.10 179.64 81.46
CA1............................................................. 243.57 167.58 75.99
BB2............................................................. 276.87 190.49 86.38
BB1............................................................. 264.60 182.04 82.56
BA2............................................................. 229.55 157.93 71.62
BA1............................................................. 219.03 150.69 68.34
PE2............................................................. 369.77 254.40 115.37
PE1............................................................. 352.24 242.34 109.90
PD2............................................................. 348.74 239.93 108.81
PD1............................................................. 331.21 227.87 103.34
PC2............................................................. 299.66 206.17 93.49
PC1............................................................. 285.64 196.52 89.12
PB2............................................................. 254.09 174.81 79.28
PB1............................................................. 243.57 167.58 75.99
PA2............................................................. 210.27 144.67 65.60
PA1............................................................. 201.50 138.63 62.87
----------------------------------------------------------------------------------------------------------------
[[Page 51982]]
Table 8--RUG-IV Case-Mix Adjusted Federal Rates for Rural SNFs by Labor and Non-Labor Component
----------------------------------------------------------------------------------------------------------------
Non-labor
RUG-IV Category Total rate Labor portion portion
----------------------------------------------------------------------------------------------------------------
RUX............................................................. 822.89 $566.15 $256.74
RUL............................................................. 806.15 554.63 251.52
RVX............................................................. 723.02 497.44 225.58
RVL............................................................. 652.70 449.06 203.64
RHX............................................................. 647.51 445.49 202.02
RHL............................................................. 580.53 399.40 181.13
RMX............................................................. 588.44 404.85 183.59
RML............................................................. 541.56 372.59 168.97
RLX............................................................. 512.18 352.38 159.80
RUC............................................................. 637.02 438.27 198.75
RUB............................................................. 637.02 438.27 198.75
RUA............................................................. 541.58 372.61 168.97
RVC............................................................. 538.83 370.72 168.11
RVB............................................................. 471.85 324.63 147.22
RVA............................................................. 470.18 323.48 146.70
RHC............................................................. 463.31 318.76 144.55
RHB............................................................. 419.78 288.81 130.97
RHA............................................................. 372.89 256.55 116.34
RMC............................................................. 402.57 276.97 125.60
RMB............................................................. 379.13 260.84 118.29
RMA............................................................. 315.50 217.06 98.44
RLB............................................................. 384.92 264.82 120.10
RLA............................................................. 252.63 173.81 78.82
ES3............................................................. 709.16 487.90 221.26
ES2............................................................. 556.78 383.06 173.72
ES1............................................................. 498.17 342.74 155.43
HE2............................................................. 481.43 331.22 150.21
HE1............................................................. 401.05 275.92 125.13
HD2............................................................. 451.29 310.49 140.80
HD1............................................................. 377.61 259.80 117.81
HC2............................................................. 426.17 293.20 132.97
HC1............................................................. 357.52 245.97 111.55
HB2............................................................. 421.15 289.75 131.40
HB1............................................................. 354.17 243.67 110.50
LE2............................................................. 437.89 301.27 136.62
LE1............................................................. 367.56 252.88 114.68
LD2............................................................. 421.15 289.75 131.40
LD1............................................................. 354.17 243.67 110.50
LC2............................................................. 370.91 255.19 115.72
LC1............................................................. 313.98 216.02 97.96
LB2............................................................. 352.49 242.51 109.98
LB1............................................................. 300.58 206.80 93.78
CE2............................................................. 391.01 269.01 122.00
CE1............................................................. 360.87 248.28 112.59
CD2............................................................. 370.91 255.19 115.72
CD1............................................................. 340.77 234.45 106.32
CC2............................................................. 325.70 224.08 101.62
CC1............................................................. 302.26 207.95 94.31
CB2............................................................. 302.26 207.95 94.31
CB1............................................................. 280.49 192.98 87.51
CA2............................................................. 257.05 176.85 80.20
CA1............................................................. 240.30 165.33 74.97
BB2............................................................. 272.12 187.22 84.90
BB1............................................................. 260.40 179.16 81.24
BA2............................................................. 226.91 156.11 70.80
BA1............................................................. 216.86 149.20 67.66
PE2............................................................. 360.87 248.28 112.59
PE1............................................................. 344.12 236.75 107.37
PD2............................................................. 340.77 234.45 106.32
PD1............................................................. 324.03 222.93 101.10
PC2............................................................. 293.89 202.20 91.69
PC1............................................................. 280.49 192.98 87.51
PB2............................................................. 250.35 172.24 78.11
PB1............................................................. 240.30 165.33 74.97
PA2............................................................. 208.49 143.44 65.05
PA1............................................................. 200.11 137.68 62.43
----------------------------------------------------------------------------------------------------------------
[[Page 51983]]
Section 1888(e)(4)(G)(ii) of the Act also requires that we apply
this wage index in a manner that does not result in aggregate payments
under the SNF PPS that are greater or less than would otherwise be made
if the wage adjustment had not been made. For FY 2017 (federal rates
effective October 1, 2016), we will apply an adjustment to fulfill the
budget neutrality requirement. We meet this requirement by multiplying
each of the components of the unadjusted federal rates by a budget
neutrality factor equal to the ratio of the weighted average wage
adjustment factor for FY 2016 to the weighted average wage adjustment
factor for FY 2017. For this calculation, we use the same FY 2015
claims utilization data for both the numerator and denominator of this
ratio. We define the wage adjustment factor used in this calculation as
the labor share of the rate component multiplied by the wage index plus
the non-labor share of the rate component. The budget neutrality factor
stated in the FY 2017 SNF PPS proposed rule was 1.0000. However, we
discovered that in calculating the FY 2017 proposed wage index budget
neutrality factor, we inadvertently failed to update the wage index
data used in the calculation with the most recently available FY 2017
data. This resulted in a budget neutrality factor of 1.000, whereas,
using the most recently available wage index data at the time of the
proposed rule, the proposed factor should have been 0.9997. Moreover,
because the wage index data used were incorrect and because the wage
index is the primary source of variation in the impacts calculated in
the regulatory impact analysis, the error which caused the incorrect
calculation of the wage index budget neutrality factor in the proposed
rule also affected the wage index impacts in Table 19 of the FY 2017
SNF PPS proposed rule (Projected Impact to the SNF PPS for FY 2017) (81
FR 24278). These impacts are discussed further in section V.A.4. of
this final rule. We have recalculated the wage index budget neutrality
factor for FY 2017 utilizing updated wage index data, and the final
budget neutrality factor for FY 2017 is 1.0000.
In the SNF PPS final rule for FY 2006 (70 FR 45026, August 4,
2005), we adopted the changes discussed in the OMB Bulletin No. 03-04
(June 6, 2003), available online at www.whitehouse.gov/omb/bulletins/b03-04.html, which announced revised definitions for MSAs and the
creation of micropolitan statistical areas and combined statistical
areas.
In adopting the CBSA geographic designations, we provided for a 1-
year transition in FY 2006 with a blended wage index for all providers.
For FY 2006, the wage index for each provider consisted of a blend of
50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY
2006 CBSA-based wage index (both using FY 2002 hospital data). We
referred to the blended wage index as the FY 2006 SNF PPS transition
wage index. As discussed in the SNF PPS final rule for FY 2006 (70 FR
45041), since the expiration of this 1-year transition on September 30,
2006, we have used the full CBSA-based wage index values.
Generally, OMB issues major revisions to statistical areas every 10
years, based on the results of the decennial census. In the FY 2015 SNF
PPS final rule (79 FR 45644 through 45646), we finalized changes to the
SNF PPS wage index based on the newest OMB delineations, as described
in OMB Bulletin No. 13-01, beginning in FY 2015, including a 1-year
transition with a blended wage index for FY 2015. OMB Bulletin No. 13-
01 established revised delineations for Metropolitan Statistical Areas,
Micropolitan Statistical Areas, and Combined Statistical Areas in the
United States and Puerto Rico based on the 2010 Census, and provided
guidance on the use of the delineations of these statistical areas
using standards published in the June 28, 2010 Federal Register (75 FR
37246 through 37252). In addition, OMB occasionally issues minor
updates and revisions to statistical areas in the years between the
decennial censuses. On July 15, 2015, OMB issued OMB Bulletin No. 15-
01, which provides minor updates to and supersedes OMB Bulletin No. 13-
01 that was issued on February 28, 2013. The attachment to OMB Bulletin
No. 15-01 provides detailed information on the update to statistical
areas since February 28, 2013. The updates provided in OMB Bulletin No.
15-01 are based on the application of the 2010 Standards for
Delineating Metropolitan and Micropolitan Statistical Areas to Census
Bureau population estimates for July 1, 2012 and July 1, 2013. A copy
of this bulletin may be obtained on the Web site at https://www.whitehouse.gov/sites/default/files/omb/bulletins/2015/15-01.pdf. As
we previously stated in the FY 2008 SNF PPS proposed and final rules
(72 FR 25538 through 25539, and 72 FR 43423), we again wish to clarify
that this and all subsequent SNF PPS rules and notices are considered
to incorporate any such updates and revisions set forth in the most
recent OMB bulletin that applies to the hospital wage data used to
determine the current SNF PPS wage index. As noted previously in this
section, the wage index applicable to FY 2017 is set forth in Tables A
and B available on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html.
5. Adjusted Rate Computation Example
Using the hypothetical SNF XYZ described below, Table 9 shows the
adjustments made to the federal per diem rates to compute the
provider's actual per diem PPS payment. We derive the Labor and Non-
labor columns from Table 7. The wage index used in this example is
based on the final wage index, which may be found in Table A as
referenced previously in this section. As illustrated in Table 9, SNF
XYZ's total PPS payment would equal $46,861.86.
Chart 9--Adjusted Rate Computation Example
SNF XYZ: Located in Frederick, MD (Urban CBSA 43524)
Wage Index: 0.9797
[See Wage Index in Table A] \1\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Adjusted Percent Medicare
RUG-IV group Labor Wage index labor Non-labor rate adjustment days Payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
RVX............................................. $492.57 0.9797 $482.57 $223.37 $705.94 $705.94 14 $9,883.16
ES2............................................. 395.50 0.9797 387.47 179.35 566.82 566.82 30 17,004.60
RHA............................................. 248.50 0.9797 243.46 112.69 356.15 356.15 16 5,698.40
CC2 *........................................... 229.08 0.9797 224.43 103.88 328.31 748.55 10 7,485.50
BA2............................................. 157.93 0.9797 154.72 71.62 226.34 226.34 30 6,790.20
[[Page 51984]]
........... ........... ........... ........... ........... ........... 100 46,861.86
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Reflects a 128 percent adjustment from section 511 of the MMA.
\1\ Available on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html.
C. Additional Aspects of the SNF PPS
1. SNF Level of Care--Administrative Presumption
The establishment of the SNF PPS did not change Medicare's
fundamental requirements for SNF coverage. However, because the case-
mix classification is based, in part, on the beneficiary's need for
skilled nursing care and therapy, we have attempted, where possible, to
coordinate claims review procedures with the existing resident
assessment process and case-mix classification system discussed in
section III.B.3. of this final rule. This approach includes an
administrative presumption that utilizes a beneficiary's initial
classification in one of the upper 52 RUGs of the 66-group RUG-IV case-
mix classification system to assist in making certain SNF level of care
determinations.
In accordance with section 1888(e)(4)(H)(ii) of the Act and the
regulations at Sec. 413.345, we include in each update of the federal
payment rates in the Federal Register the designation of those specific
RUGs under the classification system that represent the required SNF
level of care, as provided in Sec. 409.30. As set forth in the FY 2011
SNF PPS update notice (75 FR 42910), this designation reflects an
administrative presumption under the 66-group RUG-IV system that
beneficiaries who are correctly assigned to one of the upper 52 RUG-IV
groups on the initial 5-day, Medicare-required assessment are
automatically classified as meeting the SNF level of care definition up
to and including the assessment reference date (ARD) on the 5-day
Medicare-required assessment.
A beneficiary assigned to any of the lower 14 RUG-IV groups is not
automatically classified as either meeting or not meeting the
definition, but instead receives an individual level of care
determination using the existing administrative criteria. This
presumption recognizes the strong likelihood that beneficiaries
assigned to one of the upper 52 RUG-IV groups during the immediate
post-hospital period require a covered level of care, which would be
less likely for those beneficiaries assigned to one of the lower 14
RUG-IV groups.
In the July 30, 1999 final rule (64 FR 41670), we indicated that we
would announce any changes to the guidelines for Medicare level of care
determinations related to modifications in the case-mix classification
structure. In this final rule, we continue to designate the upper 52
RUG-IV groups for purposes of this administrative presumption,
consisting of all groups encompassed by the following RUG-IV
categories:
Rehabilitation plus Extensive Services.
Ultra High Rehabilitation.
Very High Rehabilitation.
High Rehabilitation.
Medium Rehabilitation.
Low Rehabilitation.
Extensive Services.
Special Care High.
Special Care Low.
Clinically Complex.
However, we note that this administrative presumption policy does
not supersede the SNF's responsibility to ensure that its decisions
relating to level of care are appropriate and timely, including a
review to confirm that the services prompting the beneficiary's
assignment to one of the upper 52 RUG-IV groups (which, in turn, serves
to trigger the administrative presumption) are themselves medically
necessary. As we explained in the FY 2000 SNF PPS final rule (64 FR
41667), the administrative presumption:
. . . is itself rebuttable in those individual cases in which
the services actually received by the resident do not meet the basic
statutory criterion of being reasonable and necessary to diagnose or
treat a beneficiary's condition (according to section 1862(a)(1) of
the Act). Accordingly, the presumption would not apply, for example,
in those situations in which a resident's assignment to one of the
upper . . . groups is itself based on the receipt of services that
are subsequently determined to be not reasonable and necessary.
Moreover, we want to stress the importance of careful monitoring
for changes in each patient's condition to determine the continuing
need for Part A SNF benefits after the ARD of the 5-day assessment.
2. Consolidated Billing
Sections 1842(b)(6)(E) and 1862(a)(18) of the Act (as added by
section 4432(b) of the BBA) require a SNF to submit consolidated
Medicare bills to its Medicare Administrative Contractor for almost all
of the services that its residents receive during the course of a
covered Part A stay. In addition, section 1862(a)(18) of the Act places
the responsibility with the SNF for billing Medicare for physical
therapy, occupational therapy, and speech-language pathology services
that the resident receives during a noncovered stay. Section
1888(e)(2)(A) of the Act excludes a small list of services from the
consolidated billing provision (primarily those services furnished by
physicians and certain other types of practitioners), which remain
separately billable under Part B when furnished to a SNF's Part A
resident. These excluded service categories are discussed in greater
detail in section V.B.2. of the May 12, 1998 interim final rule (63 FR
26295 through 26297).
A detailed discussion of the legislative history of the
consolidated billing provision is available on the SNF PPS Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Legislative_History_07302013.pdf. In particular, section 103
of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999 (BBRA) (Pub. L. 106-113, enacted on November 29, 1999) amended
section 1888(e)(2)(A) of the Act by further excluding a number of
individual high-cost, low probability services, identified by
Healthcare Common Procedure Coding System (HCPCS) codes, within several
broader categories (chemotherapy items, chemotherapy administration
services, radioisotope services, and customized prosthetic devices)
that otherwise remained subject to the provision. We discuss this BBRA
amendment in
[[Page 51985]]
greater detail in the SNF PPS proposed and final rules for FY 2001 (65
FR 19231 through 19232, April 10, 2000, and 65 FR 46790 through 46795,
July 31, 2000), as well as in Program Memorandum AB-00-18 (Change
Request #1070), issued March 2000, which is available online at
www.cms.gov/transmittals/downloads/ab001860.pdf.
As explained in the FY 2001 proposed rule (65 FR 19232), the
amendments enacted in section 103 of the BBRA not only identified for
exclusion from this provision a number of particular service codes
within four specified categories (that is, chemotherapy items,
chemotherapy administration services, radioisotope services, and
customized prosthetic devices), but also gave the Secretary the
authority to designate additional, individual services for exclusion
within each of the specified service categories. In the proposed rule
for FY 2001, we also noted that the BBRA Conference report (H.R. Rep.
No. 106-479 at 854 (1999) (Conf. Rep.)) characterizes the individual
services that this legislation targets for exclusion as high-cost, low
probability events that could have devastating financial impacts
because their costs far exceed the payment SNFs receive under the PPS.
According to the conferees, section 103(a) of the BBRA is an attempt to
exclude from the PPS certain services and costly items that are
provided infrequently in SNFs. By contrast, we noted that the Congress
declined to designate for exclusion any of the remaining services
within those four categories (thus, leaving all of those services
subject to SNF consolidated billing), because they are relatively
inexpensive and are furnished routinely in SNFs.
As we further explained in the final rule for FY 2001 (65 FR
46790), and according to our longstanding policy, any additional
service codes that we might designate for exclusion under our
discretionary authority must meet the same statutory criteria used in
identifying the original codes excluded from consolidated billing under
section 103(a) of the BBRA: They must fall within one of the four
service categories specified in the BBRA; and they also must meet the
same standards of high cost and low probability in the SNF setting, as
discussed in the BBRA Conference report. Accordingly, we characterized
this statutory authority to identify additional service codes for
exclusion as essentially affording the flexibility to revise the list
of excluded codes in response to changes of major significance that may
occur over time (for example, the development of new medical
technologies or other advances in the state of medical practice) (65 FR
46791). In the FY 2017 SNF PPS proposed rule (81 FR 24242), we
specifically invited public comments identifying HCPCS codes in any of
these four service categories (chemotherapy items, chemotherapy
administration services, radioisotope services, and customized
prosthetic devices) representing recent medical advances that might
meet our criteria for exclusion from SNF consolidated billing. We
stated that we may consider excluding a particular service if it meets
our criteria for exclusion as specified above. We also asked that
commenters identify in their comments the specific HCPCS code that is
associated with the service in question, as well as their rationale for
requesting that the identified HCPCS code(s) be excluded.
Commenters submitted the following comments related to the proposed
rule's discussion of the consolidated billing aspects of the SNF PPS. A
discussion of these comments, along with our responses, appears below.
Comment: One commenter suggested excluding all high-cost oral
chemotherapy drugs from consolidated billing, and proposed a threshold
of $50 or more per tablet to define ``high-cost'' for this purpose.
Another commenter specifically recommended for exclusion the oral
chemotherapy drug Revlimid[supreg] (lenalidomide). Still another
suggested that we conduct an analysis with a view toward excluding a
broader range of expensive drugs beyond the category of chemotherapy
alone, citing anecdotal evidence that leaving such drugs within the SNF
PPS bundle may create a disincentive for admitting those patients who
require them.
Response: When the Congress carved out certain exceptionally
intensive chemotherapy drugs from the SNF PPS bundle in section 103 of
the BBRA, it characterized those drugs as ``high-cost'' and ``low
probability.'' This legislation did not categorically exclude all high-
cost oral chemotherapy drugs from SNF consolidated billing. The
accompanying Conference Report explained that this provision
. . . is an attempt to exclude from the PPS certain services and
costly items that are provided infrequently in SNFs. For example, in
the case of chemotherapy drugs, [this provision has] excluded
specific chemotherapy drugs from the PPS because these drugs are not
typically administered in a SNF, or are exceptionally expensive, or
are given as infusions, thus requiring special staff expertise to
administer. Some chemotherapy drugs, which are relatively
inexpensive and are administered routinely in SNFs, were excluded
from this provision'' (H. Conf. Rep. No. 106-479 at 854) (emphasis
added).
Accordingly, we decline to exclude all high-cost oral chemotherapy
drugs as a class from consolidated billing, because any such drugs that
are capable of being ``administered routinely in SNFs'' are not
reasonably characterized as ``requiring special staff expertise to
administer.'' We note that in the SNF PPS final rules for FYs 2009 (73
FR 46436, August 8, 2008) and 2010 (74 FR 40353, August 11, 2009), we
declined to exclude certain oral medications suggested by commenters
for the same reason. In addition, the BBRA Conference Report language
(H. Conf. Rep. No. 106-479 at 854) further indicates that the term
``high-cost'' in this context would not serve to encompass a routinely-
used chemotherapy drug merely because its cost somewhat exceeds the
typical range of drug costs encountered in this setting; rather, this
provision is directed specifically at those uncommon chemotherapy drugs
that are so exceptionally expensive as to ``. . . have devastating
financial impacts because their costs far exceed the payment [SNFs]
receive under the prospective payment system'' (emphasis added). With
specific reference to Revlimid[supreg], we note that we already
received a similar exclusion recommendation during the public comment
period on the FY 2015 SNF PPS proposed rule, and we discussed our
decision not to exclude this particular drug in that year's final rule
(79 FR 45641 through 45642, August 5, 2014). Finally, in response to
the suggestion that we exclude a broader range of expensive drugs
beyond the category of chemotherapy alone, as we have noted repeatedly
in previous rulemaking--most recently, in the FY 2016 SNF PPS final
rule (80 FR 46406, August 4, 2015)--the statutory authority to
designate additional services for exclusion applies solely to the four
service categories (chemotherapy items, chemotherapy administration
services, radioisotope services, and customized prosthetic devices)
that are specified in the law. Accordingly, expanding the existing
exclusion authority to encompass additional categories (such as non-
chemotherapy drugs) is not provided for in current law.
Comment: Several commenters noted the importance of continuing to
exclude prosthetic devices from consolidated billing. They suggested
that the following four HCPCS codes should be added to the list of
codes excluded from consolidated billing: L5010--Partial foot, molded
socket, ankle height, with toe filler; L5020--Partial foot, molded
socket, tibial tubercle height, with toe
[[Page 51986]]
filler; L5969--Addition, endoskeletal ankle-foot or ankle system, power
assist, includes any type motor(s); and L5987--All lower extremity
prosthesis, shank foot system with vertical loading pylon. Some also
advocated excluding custom orthotics from consolidated billing as well.
They stated that the custom orthotic and prosthetic professions are
closely aligned, with a sizable percentage of patients who require
prosthetic care also requiring custom orthotics to address orthopedic
impairments of the arms, legs, spine, and neck. They further suggested
that the same factors that justify exempting prosthetic devices also
apply to custom orthotics, as custom orthotics are typically a high-
cost, low frequency service for patients in SNFs.
Response: The recommendation to exclude certain particular
prosthetics essentially reiterates a comment made during last year's
SNF PPS rulemaking cycle, which recommended for exclusion certain
prosthetic device codes that were already in existence--but not
excluded--upon the original 1999 enactment of the customized prosthetic
device exclusion in the BBRA. In response, we reiterated in the FY 2016
SNF PPS final rule our longstanding position that if a particular
prosthetic code was already in existence as of the BBRA enactment date
but was not designated in the BBRA for exclusion, this meant that it
was intended to remain within the SNF PPS bundle, subject to a GAO
review that was conducted the following year (80 FR 46407, August 4,
2015). This would apply to three of the prosthetic codes (L5010, L5020,
and L5987) cited in the current comments. Regarding the fourth
prosthetic code (L5969), we also noted in last year's final rule (80 FR
46407) that code L5969 actually appears already on the exclusion list
under Major Category III.D. (``Customized Prosthetic Devices''), where
this particular L code has, in fact, been listed ever since its initial
assignment in January 2014.
With reference to orthotics, in the FY 2016 SNF PPS final rule (80
FR 46407, August 4, 2015), we explained that while the law does specify
customized prosthetic devices as one of the exclusion categories, this
is a separate and distinct category from orthotics and does not
encompass orthotics. Moreover, as already noted in this and previous
final rules, the statutory authority to designate additional services
for exclusion applies solely to the four service categories
(chemotherapy items, chemotherapy administration services, radioisotope
services, and customized prosthetic devices) that are specified in the
law. Accordingly, expanding the existing exclusion authority to
encompass additional categories (such as orthotics) is not provided for
in current law.
3. Payment for SNF-Level Swing-Bed Services
Section 1883 of the Act permits certain small, rural hospitals to
enter into a Medicare swing-bed agreement, under which the hospital can
use its beds to provide either acute- or SNF-level care, as needed. For
critical access hospitals (CAHs), Part A pays on a reasonable cost
basis for SNF-level services furnished under a swing-bed agreement.
However, in accordance with section 1888(e)(7) of the Act, these
services furnished by non-CAH rural hospitals are paid under the SNF
PPS, effective with cost reporting periods beginning on or after July
1, 2002. As explained in the FY 2002 final rule (66 FR 39562), this
effective date is consistent with the statutory provision to integrate
swing-bed rural hospitals into the SNF PPS by the end of the transition
period, June 30, 2002.
Accordingly, all non-CAH swing-bed rural hospitals have now come
under the SNF PPS. Therefore, all rates and wage indexes outlined in
earlier sections of this proposed rule for the SNF PPS also apply to
all non-CAH swing-bed rural hospitals. A complete discussion of
assessment schedules, the MDS, and the transmission software (RAVEN-SB
for Swing Beds) appears in the FY 2002 final rule (66 FR 39562) and in
the FY 2010 final rule (74 FR 40288). As finalized in the FY 2010 SNF
PPS final rule (74 FR 40356 through 40357), effective October 1, 2010,
non-CAH swing-bed rural hospitals are required to complete an MDS 3.0
swing-bed assessment which is limited to the required demographic,
payment, and quality items. The latest changes in the MDS for swing-bed
rural hospitals appear on the SNF PPS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html.
D. Other Issues
1. Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)
a. Background
Section 215 of the Protecting Access to Medicare Act of 2014 (PAMA)
authorizes the SNF VBP Program by adding sections 1888(g) and (h) to
the Act. These sections provide structure for the development of the
SNF VBP Program, including, among other things, the requirement of only
two measures--an all-cause, all-condition hospital readmission measure,
which is to be replaced as soon as practicable by an all-condition
risk-adjusted potentially preventable hospital readmission measure--and
confidential and public reporting requirements for the SNF VBP Program.
We began development of the SNF VBP Program in the FY 2016 SNF PPS
final rule with, among other things, the adoption of an all-cause, all-
condition hospital readmission measure, as required under section
1888(g)(1) of the Act. We will continue the process in this final rule
with our adoption of an all-condition risk-adjusted potentially
preventable hospital readmission measure for SNFs, which the Secretary
is required to specify no later than October 1, 2016 under section
1888(g)(2) of the Act. The Act requires that the SNF VBP apply to
payments for services furnished on or after October 1, 2018. The SNF
VBP Program applies to freestanding SNFs, SNFs affiliated with acute
care facilities, and all non-CAH swing-bed rural hospitals. We believe
the implementation of the SNF VBP Program is an important step toward
transforming how care is paid for, moving increasingly toward rewarding
better value, outcomes, and innovations instead of merely volume.
For additional background information on the SNF VBP Program,
including an overview of the SNF VBP Report to Congress and a summary
of the Program's statutory requirements, we refer readers to the FY
2016 SNF PPS final rule (80 FR 46409 through 46410).
We received a number of general comments on the Program.
Comment: Some commenters urged us to broaden the SNF VBP Program to
include other post-acute care outcome measures, such as measures of
care transitions, resource use over care episodes, and beneficiary
functional change. Commenters noted that these measures are required of
all PAC providers, though implementation dates vary.
Response: We thank commenters for this feedback. However, as we
stated in the FY 2016 SNF PPS final rule (80 FR 46410), we do not
believe we have the authority to adopt measures covering additional
clinical topics beyond those specified in sections 1888(g)(1) and (2)
of the Act at this time.
Comment: Commenters urged us to monitor the Program's impact on
facilities' delivery of care quality and on beneficiaries' quality of
life in nursing homes.
Response: We thank the commenters for this suggestion. We intend to
monitor the Program's effects on
[[Page 51987]]
beneficiaries, care quality, and other factors carefully.
Comment: One commenter offered several general suggestions for the
Program based on New York's experience with the Nursing Home VBP
Demonstration (https://innovation.cms.gov/initiatives/Nursing-Home-Value-Based-Purchasing/) including incomparability of specialty and
general facilities, narrowly-structured measures for participating
facilities, regional adjustments, measure and calculation information
provided to facilities to assist with quality improvement, a focus on
preventable hospitalizations, and incentive payments large enough and
close enough to the performance period to maximize behavioral changes.
Response: We thank the commenter for these suggestions. We proposed
to adopt a performance period that is as close as we feasibly can set
it to the payment year in order to establish a clear link between
quality measurement and value-based payment. We note also that the
methodology for determining the size of the pool available to fund the
value-based incentive payments that we will disburse under the Program
is specified in the statute. We intend to provide SNFs with information
to assist with quality improvement efforts, and will work with
stakeholders to ensure that all SNFs are able to improve the quality of
care that they provide to Medicare beneficiaries. However, we do not
agree with the commenter that we should perform regional adjustments to
the measures adopted under the Program. Our experience with achievement
thresholds and benchmarks based on national data in the Hospital Value-
Based Purchasing Program has given us confidence that regional
adjustments are not necessary to ensure that achievement thresholds and
benchmarks for this program are balanced, appropriate standards of high
quality. Some groups of facilities may perform better or worse than
other facilities on certain measures, but we do not believe it would be
appropriate to raise or lower the performance standards or measured
performance for a facility based on regional differences in quality
measurement, because such adjustments would seem to indicate that some
areas of the country should be held to higher or lower standards of
care quality. We intend to monitor SNFs' performance on the measures
adopted under the Program carefully and may consider further
adjustments to the measures or to the scoring methodology in the
future.
Comment: Commenter also suggested that we factor managed care
expansions into our measure calculations, noting that many states are
rapidly expanding into managed care for Medicare and Medicaid
beneficiaries and that managed care delivery could affect quality
measurements. Commenter also recommended that we consider major care
innovations that are being developed and tested across state lines to
ensure that the interventions with the greatest potential for quality
improvement may proliferate among SNFs.
Response: We thank the commenter for the suggestion. However, the
SNF VBP Program is limited by statute to payments made under Medicare's
SNF PPS, not payments to managed-care organizations, and we therefore
believe the Program is appropriately focused on Medicare quality data
at this time. We may consider incorporating quality information related
to care provided by managed-care organizations in the Program in the
future. However, we do not have the authority to make value-based
incentive payments to SNFs based on their performance with patients
enrolled in managed care plans. We will monitor clinical research on
the effects of managed care in comparison to care delivered under fee-
for-service systems, however.
We will consider major care innovations as they arise in clinical
literature and in care delivery and will work with SNFs and
stakeholders in order to encourage their proliferation.
We thank the commenters for this feedback.
b. Measures
i. SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510)
Per the requirement at section 1888(g)(1) of the Act, in the FY
2016 SNF PPS final rule (80 FR 46419), we finalized our proposal to
specify the SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF
#2510) as the SNF all-cause, all-condition hospital readmission measure
for the SNF VBP Program. The SNFRM assesses the risk-standardized rate
of all-cause, all-condition, unplanned inpatient hospital readmissions
of Medicare fee-for-service (FFS) SNF patients within 30 days of
discharge from an admission to an inpatient prospective payment system
(IPPS) hospital, CAH, or psychiatric hospital. The measure is claims-
based, requiring no additional data collection or submission burden for
SNFs. For additional details on the SNFRM, including our responses to
public comments, we refer readers to the FY 2016 SNF PPS final rule (80
FR 46411 through 46419).
We received one comment on the SNFRM.
Comment: One commenter urged us to provide more timely feedback to
SNFs on their performance on the SNFRM in order to better enable
performance improvement.
Response: We intend to provide as much feedback on the SNFRM as is
operationally possible to SNFs, and to do so as quickly as possible. As
required by section 1888(g)(5) of the Act and as discussed further
below, we will provide quarterly confidential feedback reports to SNFs
beginning October 1, 2016, and will continue providing as much
information to SNFs on their performance on the SNFRM as possible using
those reports.
ii. Skilled Nursing Facility 30-Day Potentially Preventable Readmission
Measure (SNFPPR)
We proposed to specify the SNF 30-Day Potentially Preventable
Readmission Measure (SNFPPR) as the SNF all-condition risk-adjusted
potentially preventable hospital readmission measure to meet the
requirements of section 1888(g)(2) of the Act. This proposed measure
assesses the facility-level risk-standardized rate of unplanned,
potentially preventable hospital readmissions for SNF patients within
30 days of discharge from a prior admission to an IPPS hospital, CAH,
or psychiatric hospital. Hospital readmissions include readmissions to
a short-stay acute-care hospital or CAH, with a diagnosis considered to
be unplanned and potentially preventable. This proposed measure is
claims-based, requiring no additional data collection or submission
burden for SNFs.
Hospital readmissions among the Medicare population, including
beneficiaries that utilize post-acute care, are common, costly, and
often preventable.1 2 The Medicare Payment Advisory
Commission (MedPAC) and a study by Jencks et al. estimated that 17 to
20 percent of Medicare beneficiaries discharged from the hospital were
readmitted within 30 days. MedPAC found that more than 75 percent of
30-day and 15-day readmissions and 84 percent of 7-day readmissions
were considered potentially preventable.\3\ In
[[Page 51988]]
addition, MedPAC calculated that annual Medicare spending on
potentially preventable readmissions would be $12B for 30-day, $8B for
15-day, and $5B for 7-day readmissions.\4\ For hospital readmissions
from SNFs, MedPAC deemed 76 percent of readmissions as potentially
avoidable--associated with $12B in Medicare expenditures.\5\ Mor et al.
analyzed 2006 Medicare claims and SNF assessment data (Minimum Data
Set), and reported a 23.5 percent readmission rate from SNFs,
associated with $4.3B in expenditures.\6\
---------------------------------------------------------------------------
\1\ Friedman, B., and Basu, J.: The rate and cost of hospital
readmissions for preventable conditions. Med. Care Res. Rev.
61(2):225-240, 2004. doi:10.1177/1077558704263799.
\2\ Jencks, S.F., Williams, M.V., and Coleman, E.A.:
Rehospitalizations among patients in the Medicare Fee-for-Service
Program. N. Engl. J. Med. 360(14):1418-1428, 2009. doi:10.1016/
j.jvs.2009.05.045.
\3\ MedPAC: Payment policy for inpatient readmissions, in Report
to the Congress: Promoting Greater Efficiency in Medicare.
Washington, DC, pp. 103-120, 2007. Available from http://www.medpac.gov/documents/reports/Jun07_EntireReport.pdf.
\4\ Ibid.
\5\ Ibid.
\6\ Mor, V., Intrator, O., Feng, Z., et al.: The revolving door
of rehospitalization from SNFs. Health Aff. 29(1):57-64, 2010.
doi:10.1377/hlthaff.2009.0629.
---------------------------------------------------------------------------
We have addressed the high rates of hospital readmissions in the
acute care setting, as well as in PAC by developing the SNF 30-Day All-
Cause Readmission Measure (NQF #2510), as well as similar measures for
other PAC providers (NQF #2502 for IRFs and NQF #2512 for LTCHs).\7\
These measures are endorsed by the National Quality Forum (NQF), and
the NQF-endorsed measure (NQF #2510) was adopted for the SNF VBP
program in the FY 2016 SNF PPS final rule (80 FR 46411 through 46419).
These NQF-endorsed measures assess all-cause unplanned readmissions.
---------------------------------------------------------------------------
\7\ National Quality Forum: All-Cause Admissions and
Readmissions Measures. pp. 1-319, April 2015. Available from http://www.qualityforum.org/Publications/2015/04/All-Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx.
---------------------------------------------------------------------------
Several general methods and algorithms have been developed to
assess potentially avoidable or preventable hospitalizations and
readmissions for the Medicare population. These include the Agency for
Healthcare Research and Quality's (AHRQ) Prevention Quality Indicators,
approaches developed by MedPAC, and proprietary approaches, such as the
3M\TM\ algorithm for Potentially Preventable Readmissions
(PPR).8 9 10 Recent work led by Kramer et al. for MedPAC
identified 13 conditions for which readmissions were deemed as
potentially preventable among SNF and IRF populations 11 12;
however, these conditions did not differ by PAC setting or readmission
window (that is, readmissions during the PAC stay or post-PAC
discharge). Although much of the existing literature addresses hospital
readmissions more broadly and potentially avoidable hospitalizations
for specific settings like skilled nursing facilities, these findings
are relevant to the development of potentially preventable readmission
measures for PAC.13 14 15
---------------------------------------------------------------------------
\8\ Goldfield, N.I., McCullough, E.C., Hughes, J.S., et al.:
Identifying potentially preventable readmissions. Health Care Finan.
Rev. 30(1):75-91, 2008. Available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195042/.
\9\ Agency for Healthcare Research and Quality: Prevention
Quality Indicators Overview. 2008.
\10\ MedPAC: Online Appendix C: Medicare Ambulatory Care
Indicators for the Elderly. pp. 1-12, prepared for Chapter 4, 2011.
Available from http://www.medpac.gov/documents/reports/Mar11_Ch04_APPENDIX.pdf?sfvrsn=0.
\11\ Kramer, A., Lin, M., Fish, R., et al.: Development of
Inpatient Rehabilitation Facility Quality Measures: Potentially
Avoidable Readmissions, Community Discharge, and Functional
Improvement. pp. 1-42, 2015. Available from http://www.medpac.gov/documents/contractor-reports/development-of-inpatient-rehabilitation-facility-quality-measures-potentially-avoidable-readmissions-community-discharge-and-functional-improvement.pdf?sfvrsn=0.
\12\ Kramer, A., Lin, M., Fish, R., et al.: Development of
Potentially Avoidable Readmission and Functional Outcome SNF Quality
Measures. pp. 1-75, 2014. Available from http://www.medpac.gov/documents/contractor-reports/mar14_snfqualitymeasures_contractor.pdf?sfvrsn=0.
\13\ Allaudeen, N., Vidyarthi, A., Maselli, J., et al.:
Redefining readmission risk factors for general medicine patients.
J. Hosp. Med. 6(2):54-60, 2011. doi:10.1002/jhm.805.
\14\ Gao, J., Moran, E., Li, Y.-F., et al.: Predicting
potentially avoidable hospitalizations. Med. Care 52(2):164-171,
2014. doi:10.1097/MLR.0000000000000041.
\15\ Walsh, E.G., Wiener, J.M., Haber, S., et al.: Potentially
avoidable hospitalizations of dually eligible Medicare and Medicaid
beneficiaries from nursing facility and home[hyphen]and
community[hyphen]based services waiver programs. J. Am. Geriatr.
Soc. 60(5):821-829, 2012. doi:10.1111/j.1532-5415.2012.03920.
---------------------------------------------------------------------------
Based on the evidence discussed above and to meet PAMA
requirements, we proposed to specify this measure, entitled, SNF 30-Day
Potentially Preventable Readmission Measure (SNFPPR), for the SNF VBP
Program. The SNFPPR measure was developed by CMS to harmonize with the
NQF-endorsed SNF 30-Day All-Cause Readmission Measure (NQF #2510) \16\
adopted in the FY 2016 SNF final rule (80 FR 46411 through 46419) and
the Hospital-Wide Risk-Adjusted All-Cause Unplanned Readmission Measure
(NQF #1789) (Hospital-Wide Readmission or HWR measure \17\), finalized
for the Hospital IQR Program in the FY 2013 IPPS/LTCH PPS final rule
(77 FR 53521 through 53528). Although these existing measures focus on
all-cause unplanned readmissions and the SNFPPR measure assesses
potentially preventable hospital readmissions, the SNFPPR will use the
same statistical approach, the same time window as NQF measure #2510
(that is, 30 days post-hospital discharge), and a similar set of
patient characteristics for risk adjustment. As appropriate, the
potentially preventable hospital readmission measure for SNFs is being
harmonized with similar measures being finalized for LTCHs, IRFs, and
HHAs to meet the requirements of the Improving Medicare Post-Acute Care
Transformation Act of 2014 (IMPACT Act) (Pub. L. 113-185).
---------------------------------------------------------------------------
\16\ National Quality Forum: All-Cause Admissions and
Readmissions Measures. pp. 1-319, April 2015. National Quality
Forum: All-Cause Admissions and Readmissions Measures. pp. 1-319,
April 2015. Available from http://www.qualityforum.org/Publications/2015/04/All-Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx.
\17\ Available by searching for ``1789'' at http://www.qualityforum.org/QPS/QPSTool.aspx.
---------------------------------------------------------------------------
The SNFPPR measure estimates the risk-standardized rate of
unplanned, potentially preventable hospital readmissions for Medicare
FFS beneficiaries that occur within 30 days of discharge from the prior
proximal hospitalization. This is a departure from readmission measures
in other PAC settings, such as the two measures being adopted in the
Inpatient Rehabilitation Facility (IRF) Quality Reporting Program, one
of which assesses readmissions that take place during the IRF stay and
the other that assesses readmissions within 30 days following discharge
from the IRF. The SNFPPR measure is distinct because section 1888(h)(2)
of the Act requires that only a single quality measure be implemented
in the SNF VBP program at one time. A purely within-stay measure (that
is, a measure that assesses readmission rates only when those
readmissions occurred during a SNF stay) would perversely incentivize
the premature discharge of residents from SNFs to avoid penalty.
Conversely, limiting the measure to readmissions that occur within 30-
days post-discharge from the SNF would not capture readmissions that
occur during the SNF stay. In order to qualify for this measure, the
SNF admission must take place within 1 day of discharge from a prior
proximal hospital stay. The prior proximal hospital stay is defined as
an inpatient admission to an acute care hospital (including IPPS, CAH,
or a psychiatric hospital). Because the measure denominator is based on
SNF admissions, a single Medicare beneficiary could be included in the
measure multiple times within a given year. Readmissions counted in
this measure are identified by examining Medicare FFS claims data for
readmissions to either acute care hospitals (IPPS or CAH) that occur
within 30 days of discharge from the prior proximal hospitalization,
regardless of whether the readmission occurs during the SNF stay or
takes
[[Page 51989]]
place after the patient is discharged from the SNF. Because patients
differ in complexity and morbidity, the measure is risk-adjusted for
case-mix. Our approach for defining potentially preventable
readmissions is described below.
Potentially Preventable Readmission Measure Definition: We
conducted a comprehensive environmental scan, analyzed claims data, and
obtained input from a technical expert panel (TEP) to develop a working
conceptual definition and list of conditions for which hospital
readmissions may be considered potentially preventable. The Ambulatory
Care Sensitive Conditions (ACSC)/Prevention Quality Indicators (PQI),
developed by AHRQ, served as the starting point in this work. For the
purposes of the SNFPPR measure, the definition of potentially
preventable readmissions differs based on whether the resident is
admitted to the SNF (referred to as ``within-stay'') or in the post-SNF
discharge period; however, there is considerable overlap of the
definitions. For patients readmitted to a hospital during within the
SNF stay, potentially preventable readmissions (PPR) should be
avoidable with sufficient medical monitoring and appropriate treatment.
The within-stay list of PPR conditions includes the following, which
are categorized by 4 clinical rationale groupings: (1) Inadequate
management of chronic conditions; (2) Inadequate management of
infections; (3) Inadequate management of other unplanned events; and
(4) Inadequate injury prevention. For individuals in the post-SNF
discharge period, a potentially preventable readmission refers to a
readmission in which the probability of occurrence could be minimized
with adequately planned, explained, and implemented post discharge
instructions, including the establishment of appropriate follow-up
ambulatory care. Our list of PPR conditions in the post-SNF discharge
period includes the following, categorized by 3 clinical rationale
groupings: (1) Inadequate management of chronic conditions; (2)
Inadequate management of infections; and (3) Inadequate management of
other unplanned events. Additional details regarding the definitions of
potentially preventable readmissions are available in our Measure
Specification (available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html).
This SNFPPR measure focuses on readmissions that are potentially
preventable and also unplanned. Similar to the SNF 30-Day All-Cause
Readmission Measure (SNFRM) (NQF #2510), this measure uses the CMS
Planned Readmission Algorithm to define planned readmissions. In
addition to the CMS Planned Readmission Algorithm, this measure
incorporates procedures that are considered planned in post-acute care
settings, as identified in consultation with TEPs. Full details on the
planned readmissions criteria used, including the additional procedures
considered planned for post-acute care, can be found in the Measure
Specifications (available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html).
This measure assesses potentially preventable readmission rates
while accounting for patient or resident demographics, principal
diagnosis in the prior hospital stay, comorbidities, and other patient
factors. The model also estimates a facility-specific effect, common to
patients or residents treated in each facility. This measure is
calculated for each SNF based on the ratio of the predicted number of
risk-adjusted, unplanned, potentially preventable hospital readmissions
that occurred within 30 days of discharge from the prior proximal
hospitalization, including the estimated facility effect, to the
estimated predicted number of risk-adjusted, unplanned hospital
readmissions for the same individuals receiving care at the average
SNF. A ratio above 1.0 indicates a higher than expected readmission
rate (worse), while a ratio below 1.0 indicates a lower than expected
readmission rate (better). This ratio is referred to as the
standardized risk ratio or SRR. The SRR is then multiplied by the
overall national raw rate of potentially preventable readmissions for
all SNF stays. The resulting rate is the risk-standardized readmission
rate (RSRR) of potentially preventable readmissions. The full
methodology is detailed in the Measure Specifications (available at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html).
Eligible SNF stays in the measure are assessed until: (1) The 30-
day period ends; or (2) the patient is readmitted to an acute care
hospital (IPPS or CAH). If the readmission is classified as unplanned
and potentially preventable, it is counted as a readmission in the
measure calculation. If the readmission is planned or not preventable,
the readmission is not counted in the measure rate.
Readmission rates are risk-adjusted for case-mix characteristics.
The risk adjustment modeling estimates the effects of patient/resident
characteristics, comorbidities, and select health care variables on the
probability of readmission. More specifically, the risk-adjustment
model for SNFs accounts for sociodemographic characteristics (age, sex,
original reason for entitlement), principal diagnosis during the prior
proximal hospital stay, body system specific surgical indicators,
comorbidities, length of stay during the resident's prior proximal
hospital stay, intensive care utilization, end-stage renal disease
status, and number of prior acute care hospitalizations in the
preceding 365 days. This measure is calculated using one full calendar
year of data. The full measure specifications and results of the
reliability testing can be found in the Measure Specifications
(available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html).
Our measure development contractor convened a TEP, which provided
input on the technical specifications of this measure, including the
development of an approach to define potentially preventable hospital
readmissions for a number of PAC settings, including SNFs. Details from
the TEP meetings, including TEP members' ratings of conditions proposed
as being potentially preventable, are available in the TEP Summary
Report available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html. We also solicited stakeholder feedback on the development
of this measure through a public comment period held from November 2
through December 1, 2015. A summary of the public comments we received
is also available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
In addition to our TEP and public comment feedback, we also
considered input from the Measures Application Partnership (MAP) on the
SNFPPR. The MAP is composed of multi-stakeholder groups convened by the
NQF. The MAP provides input on the measures we are considering for
implementation in certain quality reporting and pay-for-performance
programs. In general, the MAP has noted the need for care
[[Page 51990]]
transition measures in PAC/LTC performance measurement programs and
stated that setting-specific admission and readmission measures would
address this need.\18\ The SNFPPR measure that we proposed, and that we
are adopting for the SNF VBP Program in this final rule, was included
in the List of Measures under Consideration (MUC List) for December 1,
2015.\19\
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\18\ National Quality Forum: Measure Applications Partnership
Pre-Rulemaking Report: 2013 Recommendations of Measures Under
Consideration by HHS. pp. 1-394, February 2013. Available from
https://www.qualityforum.org/Publications/2013/02/MAP_Pre-Rulemaking_Report_-_February_2013.aspx.
\19\ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/2015-Measures-Under-Consideration-List.pdf.
---------------------------------------------------------------------------
The MAP encouraged continued development of the measure in the SNF
VBP Program to meet the mandate of PAMA. Specifically, the MAP stressed
the need to promote shared accountability and ensure effective care
transitions. More information about the MAP's recommendations for this
measure is available at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx. At the time, the risk-adjustment model was still under
development. Following completion of that development work, we were
able to test for measure validity and reliability as available in the
measure specifications document provided above. Testing results are
within range for similar outcome measures finalized in public reporting
and value-based purchasing programs, including the SNFRM finalized for
this program.
We invited public comment on our proposal to adopt this measure,
the SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR).
The comments we received on this topic, with their responses, appear
below.
Comment: One commenter called on us to establish a standardized
process by which we could evaluate new measures for the Program, or
alternatively a standard process to evaluate whether or not we should
remove or retire a measure. The commenter suggested that we adopt the
same methods under use in the Hospital IQR and Hospital VBP Programs.
Response: We do not believe that a standardized process is
necessary for the SNF VBP Program because unlike the Hospital IQR and
Hospital VBP Programs, we are statutorily limited in the SNF VBP
Program to including only two measures (one at a time). Since we have
not yet implemented the SNFPPR, we do not believe establishing a
standardized process for replacing it is warranted at this time.
Comment: Some commenters supported our proposal to adopt the
SNFPPR, including the measure's intent, and recognized that the measure
will provide incentives for SNFs to coordinate care post-discharge.
Some commenters specifically stated their support for the infectious
conditions defined as potentially preventable, stating that many of
these conditions are preventable using appropriate infection prevention
interventions.
Response: We agree that the measure will provide strong incentives
for care coordination and will appropriately capture preventable
readmissions, including infection-related readmissions.
Comment: One commenter stated that SNFs should not be penalized for
readmissions when the conditions that prompted them are unrelated to
the reasons the patient was admitted to the SNF. The commenter also
called on us to account for differences in each SNF's mix of low-income
patients when calculating readmissions.
Response: We note that the SNF VBP Program's statute requires that
the measures required under sections 1888(g)(1) and (2) of the Act must
be ``all-condition hospital readmission'' measures, which we believe
necessitates attributing readmissions to SNFs even in the case the
commenter specifies.
We believe that the proposed risk adjustment methodology
appropriately adjusts for SNFs' patient mix when calculating
readmissions, particularly because the measure's risk adjustments were
developed to harmonize with the Hospital Wide Readmission (HWR) measure
(NQF #1789), and the SNFRM. We describe the risk adjustment variables
in more detail in the draft SNF PPR technical report, which is
available on our Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNFPPR-Technical-Report.pdf. We respond to commenter's point about
sociodemographic or socioeconomic adjustments below in a subsequent
response.
Comment: One commenter stated that we should develop additional
criteria for SNFs that have implemented programs and policies to
mitigate unplanned events. The commenter suggested that SNFs with
standard fall precautions should not be penalized if a well-managed,
low-risk dementia patient falls and sustains a fracture.
Response: We believe that SNFs with programs and policies that
reduce the incidence of unplanned events may generally experience fewer
readmissions over time. However, a potentially preventable readmission
still presents the potential for harm to the patient and generates
costs for the Medicare program. We wish to clarify that this is a
measure of potentially preventable readmissions and that not all
readmissions are preventable. The PPR rate is not expected to be 0. The
focus of this measure is to identify excess PPR rates for the purposes
of quality improvement. We believe the Program will encourage SNFs to
take appropriate, effective steps to minimize this outcome for SNF
patients.
Comment: One commenter suggested that we adopt a minimum
denominator size for the SNFPPR measure of 25 stays, though they
preferred 30, stating that 30 stays would produce more reliable results
for low-volume SNFs. The commenter noted that observed variability
increases substantially between 30 and 20 stays, and requested that we
provide data on the variation in SNFPPR rates for SNFs with small
denominator sizes.
Response: We wish to clarify that we did not propose a minimum
denominator size for the SNFPPR measure. We acknowledge that increasing
the denominator size for this measure may increase its reliability.
However, doing so would exclude a substantial number of SNFs from the
measure calculation and thus the SNF VBP Program However, as stated in
the SNF PPR technical report available on our Web site (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNFPPR-Technical-Report.pdf), we found 1 year of data to be sufficient to calculate this
measure in a statistically reliable manner.
Comment: One commenter supported the proposed risk adjustment
methodology for the SNFPPR, noting that the adjustments will provide a
valid assessment of a facility's care quality in preventing unplanned,
preventable hospital readmissions.
Response: We thank the commenter for their comment.
Comment: One commenter expressed concern about our proposal to use
claims-based data for quality measurement. The commenter believes that
claims-based data are not accurate compared to other types of quality
measure data, and the commenter cautioned that having performance data
is not the same as having highly reliable and accurate data. The
commenter suggested that claims data may be better
[[Page 51991]]
used as a supplement to traditional HAI surveillance after validation.
Response: With respect to the use of claims data to calculate this
measure, multiple studies have been conducted to examine the validity
of using Medicare hospital claims for several NQF-endorsed quality
measures used in public reporting and value-based purchasing
programs.20 21 22 These studies supported the use of claims
data as a valid means for risk adjustment and assessing similar
outcomes. Additionally, although assessment and other data sources may
be valuable for risk adjustment, we are not aware of another data
source aside from Medicare claims data that could be used to reliably
assess the outcome of potentially preventable hospital readmissions
during this readmission window.
---------------------------------------------------------------------------
\20\ Bratzler DW, Normand SL, Wang Y, et al. An administrative
claims model for profiling hospital 30-day mortality rates for
pneumonia patients. PLoS One 2011;6(4):e17401.
\21\ Keenan PS, Normand SL, Lin Z, et al. An administrative
claims measure suitable for profiling hospital performance on the
basis of 30-day all-cause readmission rates among patients with
heart failure. Circulation 2008;1(1):29-37.
\22\ Krumholz HM, Wang Y, Mattera JA, et al. An administrative
claims model suitable for profiling hospital performance based on
30-day mortality rates among patients with heart failure.
Circulation 2006;113:1693-1701.
---------------------------------------------------------------------------
Comment: One commenter expressed concerns about the use of
readmissions measures for SNFs, stating that the sickest individuals
are the most likely to be readmitted. The commenter also noted that the
sickest individuals are the most likely to die, so facilities with
excessive mortality rates may have lower readmission rates. Some
commenters were concerned that facilities may be incentivized to delay
needed care in order to improve their readmission scores and suggested
that we include ER visits in the measure.
Response: We believe that the risk adjustment approach used in
calculating the SNFPPR measure appropriately adjusts for patient case-
mix even among patients that may be at end-of-life. We intend to
conduct ongoing evaluation and monitoring to ensure that the measure
does not result in unintended consequences for patients, such as
increased mortality rates.
With respect to emergency room visits, we note while such visits
can certainly be negative outcomes for patients, they are not
readmissions within the definitions we have adopted for measures of
readmissions. We agree with commenters that mortality is also an
important clinical outcome, but in other settings where we assess both
readmission and mortality rates, the two types of measures seem to
correlate,\23\ which suggests that we do not see reductions in
readmission rates as a consequence of increasing mortality rates.
---------------------------------------------------------------------------
\23\ See Medicare Hospital Quality Chartbook 2010, p. 12,
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/HospitalChartBook.pdf.
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Comment: One commenter suggested that we allow additional time
between when we specify a quality measure for the Program and when we
begin using the measures for payment purposes. The commenter stated
that more lead time would better enable providers to understand new
measures and address quality improvement issues.
Response: While we understand the commenter's concern, we must
implement the Program in accordance with the deadlines specified in
statute, and quality measure development is a lengthy process requiring
significant time and testing to ensure that measures are clinically and
statistically valid. We were required under section 1888(g)(1) of the
Act to specify a skilled nursing facility all-cause, all-condition
hospital readmission measure not later than October 1, 2015. Similarly,
under section 1888(g)(2) of the Act, we are required to specify a
measure of all-condition risk-adjusted potentially preventable hospital
readmissions for skilled nursing facilities not later than October 1,
2016. Additionally, under section 1888(h)(1)(B) of the Act, we are
required to begin making value-based incentive payments to SNFs on
October 1, 2018 (the beginning of FY 2019). However, we intend to work
with SNFs and other stakeholders to raise awareness and understanding
of program requirements. For example, the confidential feedback reports
required by PAMA are one mechanism through which we can educate SNFs
about the measures and their performance on the measures prior to
implementation.
Comment: One commenter was concerned that SNFs would not
necessarily be able to verify the accuracy of the risk adjustment
model, as they are unlikely to have access to complete information on
sociodemographic characteristics, principal diagnosis during the
proximal hospital stay, body system specific surgical indicators,
comorbidities, length of stay during the proximal hospital stay,
intensive care utilization, ESRD status, and the number of hospital
stays during the prior year. The commenter suggested that we provide
SNFs with verifiable prior hospitalization information used to
calculate the risk adjustment.
Response: We thank the commenter for their concern over providers'
ability to verify the accuracy of the data used for risk adjustment and
to calculate this measure. We will take this comment under
consideration as we determine which data elements would enable SNFs to
verify their data and risk-standardized PPR rate. We refer readers to
the review and correction subsection of this final rule for additional
information.
Comment: One commenter recommended that we describe readmissions as
``potentially preventable,'' not ``preventable,'' stating that the
literature on readmissions shows that they occur even when ideal care
that conforms to all clinical guidelines is provided. The commenter
noted that ambulatory care sensitive conditions and Patient Quality
Indicators developed by AHRQ were intended to assess the availability
of and access to ambulatory care services in a community, but have not
been focused on individual hospitals and other providers. The commenter
did not object to this focus, but requested that we modify our language
and measure construction to account for the measure's use in tracking
individual providers rather than the community. The commenter stated
that our goal should not be zero readmissions, as SNFPPR rates of zero
can only be achieved by denying hospital services to individuals.
Response: The readmissions to be measured in the SNFPPR are defined
as those believed to be ``potentially preventable,'' as we understand
that some SNF patients might be readmitted to the hospital even if they
receive excellent care from the SNF. Both the SNFPPR and the SNFRM
calculate facility-level risk-standardized readmission rates in order
to provide quality of care information about individual providers
rather than community-level characteristics. Given that the SNFPPR is
capturing ``potentially preventable'' readmissions, the goal is not to
reach zero readmissions, but is to identify excess rates of
readmissions that could potentially have been avoided in order to
assess the quality of care being furnished by individual SNFs.
Comment: Several commenters urged us to consider adjusting the
SNFPPR for socioeconomic and/or sociodemographic factors. The commenter
also urged us to conduct additional testing on the categories and codes
used to identify PPRs.
Response: The categories and specific conditions used to identify
potentially preventable readmissions were
[[Page 51992]]
developed based on existing evidence and were vetted by a TEP, which
included clinicians and post-acute care experts. We also conducted a
comprehensive environmental scan to identify conditions for which
readmissions may be considered potentially preventable. Results of this
environmental scan and details of the TEP input received were made
available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
Readmissions may be considered potentially preventable even if they
may not appear to be clinically related to the patient's original
reason for SNF admission. There is substantial evidence that the
conditions included in the definition are preventable with sufficient
medical monitoring and appropriate patient treatment during the SNF
stay or adequately planned, explained, and implemented post-discharge
instructions, including effective care coordination ensuring
appropriate follow-up care after SNF discharge. Furthermore, this
measure is based on Medicare claims data and it may not always be
feasible to determine whether a subsequent readmission is or is not
clinically related to the reason why the patient was admitted to the
SNF.
With respect to socioeconomic or sociodemographic adjustment, we
note that the NQF is currently undertaking a 2-year trial period in
which new measures and measures undergoing maintenance review will be
assessed to determine if risk-adjusting for sociodemographic factors is
appropriate. This trial entails temporarily allowing inclusion of
sociodemographic factors in the risk-adjustment approach for some
performance measures. At the conclusion of the trial, NQF will issue
recommendations on future permanent inclusion of sociodemographic
factors. During the trial, measure developers are encouraged to submit
information such as analyses and interpretations as well as performance
scores with and without sociodemographic factors in the risk adjustment
model. Several measures developed by CMS have been brought to NQF since
the beginning of the trial. We, consistent with NQF's guidance to
measure developers, have tested sociodemographic factors in the
measures' risk models and made recommendations about whether or not to
include these factors in the endorsed measure. We intend to continue
engaging in the NQF process as we consider the appropriateness of
adjusting for sociodemographic factors in our outcome measures.
Furthermore, the Office of the Assistant Secretary for Planning and
Evaluation (ASPE) is conducting research to examine the impact of
sociodemographic status on quality measures, resource use, and other
measures under the Medicare program as directed by the IMPACT Act. We
will closely examine the findings of the ASPE reports and related
recommendations and consider how they apply to our quality programs at
such time as they are available.
Comment: One commenter expressed concern that the SNFPPR proposed
for the Program differs from the SNF QRP's readmission measure. The
commenter noted that the VBP Program's measure assesses both post-
discharge PPRs as well as those occurring during a SNF stay and
includes an additional category of PPR of inadequate prevention of
injury. The commenter urged us to consider a single measure for both
programs.
Response: We made a policy decision to use two different measures
for the SNF VBP and QRP Programs. Our rationale for this decision was
that the readmission window associated with each measure assesses
different aspects of SNF care. The readmission window for the SNFPPR
measure was developed to align with the SNFRM which was previously
adopted for the SNF VBP Program, and both of which are required by the
SNF VBP Program's statute. Both the SNFRM and SNFPPR measure
specifications, including the readmission window, were designed to
harmonize with CMS's Hospital Wide All-Cause Unplanned Readmission
(HWR) measure used in the Hospital IQR Program. The advantage of this
window is that it assesses readmissions both during the SNF stay and
post-SNF discharge for most SNF patients, depending on the SNF length
of stay (LOS). For these measures, the focus is on transitions to the
SNF from the prior proximal hospital stay, and we believe the alignment
to be appropriate since the SNF VBP Program's statute specifically
directs us to adopt measures of hospital readmissions.
The readmission window used for the SNF measure proposed for the
SNF QRP to meet the IMPACT Act requirements was developed to align with
other post-acute care readmission measures. The focus of this post-PAC
discharge readmission window is on assessing potentially preventable
hospital readmissions during the 30 days after discharge. We believe
that assessing PPRs during each of these readmission windows provides
valuable information for their respective programs.
Comment: One commenter was concerned about the measure's ability to
pinpoint the SNF's care for a short-stay resident who is expected to
move on to the community setting, and commenter noted that SNFs often
do not have easy access to information needed to improve on the
measure. The commenter called on CMS to provide claims data to SNFs so
that facilities can verify the measure, determine whether or not they
are receiving necessary patient information, and conduct quality
improvement efforts.
Response: We appreciate the commenters' feedback. We are cognizant
of providers' desire for more information on quality performance, and
we are considering ways to provide the best information to SNFs. As
required by statute and as discussed further below, we will provide
quarterly confidential feedback reports to SNFs detailing their
performance on measures specified for the Program, and we are
interested in SNFs' feedback on the reports and on their contents once
we provide them. We will take that feedback into account as we refine
the quarterly reports to be most useful to SNFs for quality improvement
efforts.
Comment: Commenter noted that the SNF QRP version of the SNFPPR
counts unplanned readmissions to LTCHs and asked us to clarify why the
SNF VBP version of the measure does not include readmissions to LTCHs.
Response: The SNFPPR was developed to harmonize with the SNFRM,
previously adopted for the SNF VBP Program, and both measures do not
count planned readmissions to LTCHs. However, the potentially
preventable hospital readmission measure proposed for the SNF QRP to
meet the requirements of the IMPACT Act does count readmissions to
LTCHs in order to align with the other IMPACT Act measures. We intend
to conduct analyses to determine the impact that including readmissions
to LTCHs would have on the QRP measure performance; however, we expect
that this will represent a relatively small number of readmissions and
will have a minimal impact.
Comment: Commenter was concerned that SNFs would not necessarily be
able to verify the accuracy of the risk adjustment model, as they are
unlikely to have access to complete information on sociodemographic
characteristics, principal diagnosis during the proximal hospital stay,
body system specific surgical indicators, comorbidities, length of stay
during the proximal hospital stay, intensive care utilization,
[[Page 51993]]
ESRD status, and the number of hospital stays during the prior year.
The commenter suggested that we provide SNFs with verifiable prior
hospitalization information used to calculate the risk adjustment.
Response: We thank the commenter for their concern over providers'
ability to verify the accuracy of the data used to calculate this
measure. We will take this comment under consideration as we determine
which data elements would enable SNFs to verify their data and risk-
standardized PPR rate.
Comment: Commenter supported our proposal to adopt claims-based
measures rather than measures based on self-reported data, stating that
the latter are susceptible to gaming. The commenter also applauded our
choice to count within-stay and post-discharge hospital readmissions in
the measure. However, the commenter stated that we should extend the
measured time period to 90 days, suggesting that the proposed 30-day
time period is too short to capture poor care provided by a SNF.
Another commenter supported the adoption of the SNFPPR and suggested
that both the proposed and previously adopted measure (SNFRM)
readmission measures could be improved by extending the readmission
window. The commenter noted that about one-third of SNF stays are
longer than the proposed 30-day window, and suggested that the current
proposal could create incentives for SNFs to delay care until after the
30th day to avoid being penalized on the measure.
Response: We appreciate the commenter's support for the proposed
measure, including the support for using claims data as the source for
the measure's calculation. We are not aware of another data source
aside from Medicare claims data that could be used to reliably assess
the outcome of potentially preventable hospital readmissions for this
specific readmission window.
The 30-day readmission window used in both the SNFRM (NQF #2510)
and the proposed SNFPPR was developed to harmonize with measures used
in the hospital setting, including the NQF-endorsed Hospital-Wide Risk-
Adjusted All-Cause Unplanned Readmission Measure (NQF #1789). This
readmission window was also vetted by technical expert panels. We
appreciate the suggestion to consider a 90-day readmission window;
however, we believe it would be difficult to ensure that potentially
preventable hospital readmissions occurring up to 90 days after prior
hospital discharge are attributable to the SNF care received. As we
noted previously in this section, the advantage of this window is that
it assesses readmissions both during the SNF stay and post-SNF
discharge for most SNF patients, depending on the SNF length of stay.
For these measures, the focus is on transitions to the SNF from the
prior proximal hospital stay, and we believe the alignment to be
appropriate since the SNF VBP Program's statute specifically directs us
to adopt measures of hospital readmissions.
We intend to conduct ongoing evaluation and monitoring to assess
for potential unintended consequences associated with the
implementation of this measure. We will report results of our
monitoring for potential unintended consequences--including the
potential of SNFs to push needed care just past the 30-day window--in
future SNF PPS rules.
Comment: Commenter expressed concern about our proposal to include
the number of hospitalizations during the previous year as a factor in
risk-adjustment. The commenter stated that this factor could result in
adjusting a facility's rate for potentially preventable readmissions
that occurred during the previous year. The commenter stated that a
facility that did poorly preventing preventable readmissions during the
prior year would receive a lower readmission target rate as a result.
Response: We agree with the comment that risk adjusting for the
count of a beneficiary's prior year hospitalizations may include
potentially preventable readmissions. However, we do not believe that
the impact of risk adjusting for this will be driven by potentially
preventable readmissions since this captures all hospital admissions as
well as hospital readmissions. We have chosen to adjust for this factor
at the patient-level because it is an indicator of several case-mix
factors that we believe are important for risk adjustment. For example,
a higher number of prior hospital stays may be indicative of a more
complex or compromised clinical state. The number of prior hospital
stays may also be related to otherwise unmeasured patient
characteristics such as access, and patient compliance during the post-
discharge period. Furthermore, we do not believe that including this as
a risk adjuster will have a major impact on SNFs' performance on the
measure.
Comment: Some commenters suggested that we adopt a measure that
assesses the rate of readmissions of SNF beneficiaries to a hospital
within 30 days of their discharge from the SNF to a lower level of care
or the community.
Response: We agree that a 30-day post-discharge from SNF measure
would also be valuable for assessing potentially preventable hospital
readmissions; however, given the Program is limited to one measure at a
time, we believe that the readmission window selected for the SNFPRR
provides specific advantages for the reasons described in this section.
We note that we are adopting the Potentially Preventable 30-Day Post-
Discharge Readmission Measure for the SNF QRP. That measure assesses
the rate of readmissions within 30 days of a SNF discharge.
Comment: Commenters stated that the SNFPPR needs additional risk
adjustment in order to avoid establishing incentives for facilities to
avoid admitting challenging patients. Commenters specifically called
for risk adjustment for socioeconomic status, functional status,
medical complexity, and cognitive impairment. Commenters specifically
stated that functional and cognitive status are among the strongest
predictors of future health care utilization.
Response: We developed a comprehensive claims-based risk-adjustment
model that takes into account demographic and eligibility
characteristics; principal diagnoses; types of surgery or procedure
from the prior short-term hospital stay; comorbidities; length of stay
and ICU/CCU utilization from the immediately prior short-term hospital
stay; and number of admissions in the year preceding the SNF admission.
We direct readers to the final measure specifications posted on the CMS
Web site (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html),
which includes results of the final risk adjustment model. This
comprehensive risk-adjustment model is similar to those developed for
other NQF-endorsed readmission measures. Results of our testing are
within range for similar outcome measures finalized in public reporting
and value-based purchasing programs, including the SNFRM.
We agree with the comment that functional and cognitive status are
potentially important predictors of readmission outcomes. We intend to
evaluate the feasibility of including functional and cognitive status
in the future, including using standardized assessment data required by
the IMPACT Act when they become available. We refer readers to our
reply above on the topic of socioeconomic or sociodemographic
adjustment.
[[Page 51994]]
Comment: One commenter questioned why we exclude SNF stays where
the patient had one or more intervening PAC admissions between the
prior proximal hospital discharge and SNF admission or after the SNF
discharge, within the 30-day risk window. The commenter also questioned
why we exclude SNF admissions where the patient had multiple SNF
admissions after the prior proximal hospitalization, within the 30-day
risk window. The commenter believed that our stated rationale for this
exclusion could apply to any PAC setting and therefore disagreed with
the exclusion.
Response: This measure was developed to align with the SNFRM
previously adopted for the SNF VBP Program. Both measures exclude
patients who have intervening IRF or LTCH admissions before their first
SNF admission. In analyses conducted for the SNFRM (NQF #2510), we
found that these patients started their SNF admission later in the 30-
day readmission window and received services different from those
received by patients admitted directly from the hospital to the SNF. As
a result, we determined patients with intervening stays present a
different risk for readmission than patients admitted directly to the
SNF. SNF patients with intervening IRF/LTCH stays had the lowest rates
of all-cause readmission (8.6 percent) as compared with those with no
intervening IRF/LTCH stay. Additionally, we found that those with
intervening IRF/LTCH admissions had longer hospital lengths of stay and
more prior proximal hospitalizations involving surgical procedures
compared to those without an intervening stay.
This issue also impacts a relatively small number of SNF stays;
previous analyses showed that 6 percent of SNF stays had an intervening
PAC stay (IRF, LTCH, or another SNF) or go home from their prior
proximal hospitalization and are later admitted to a SNF within the 30-
day readmission window. Combined, these analyses provide justification
for excluding SNF admissions with intervening IRF or LTCH admissions,
or with multiple SNF stays, by showing these exclusions will not have a
substantial effect on the SNFPPR. Additionally, concerns about
attribution, given the mix of providers these patients have received
services from during the risk period, states for the appropriateness of
excluding these patients. Lastly, patients with multiple PAC stays do
not cluster in a small group of facilities, so no facilities are
disproportionately impacted by these exclusions. We will continue to
monitor, among other unintended consequences of introducing this
measure, whether patients are being shifted to other PAC providers or
being sent home before arriving at SNFs.
Comment: One commenter stated that we should not exclude SNF stays
with a gap of greater than one day between discharge from the prior
proximal hospitalization and admission to a SNF. The commenter stated
that this exclusion criterion does not consider medically complex
patients treated in IRFs and subsequently readmitted for issues that
may be treated as comorbidities. The commenter stated that admissions
to IRFs should be considered as proximal hospitalizations since IRFs
are licensed as hospitals.
Response: This measure was developed to harmonize with our other
hospital readmission measures, the SNFRM, and other potentially
preventable readmission measures which do not consider post-acute care
settings, like IRFs, as proximal hospitalizations. Although IRFs are
licensed as hospitals, we include them in the PAC continuum of care
and, as such, we have proposed potentially preventable hospital
readmission measures for the IRF QRP.
Comment: Commenter stated that we should not finalize the SNFPPR
because the measure specifications were not published for the Technical
Expert Panel or the MAP to review prior to the proposed rule's display.
The commenter also noted that the risk adjustment model is new, and
stated that the measure should not be rushed to meet an artificial
deadline.
Response: In order to be as transparent as possible with the
public, we made the specifications we had completed available to the
TEP and the MAP. We then continued developing the measure in order to
meet the deadline under section 1888(g)(2) of the Act to specify the
measure by October 1, 2016. We also wish to note that although we were
not required to make the specifications available to the MAP prior to
proposing to adopt it for the SNF VBP, we did make the final
specifications available to the MAP for comments and feedback. The
risk-adjustment model developed for the SNFPPR measure was also made
available at the time of the proposed rule.
Comment: Commenter stated that we should not finalize the SNFPPR
because the MAP only recommended the measure as ``encourage further
development,'' and did not vote to ``support'' or ``support with
conditions.'' The commenter suggested that we should submit the measure
for NQF endorsement. The commenter also noted that the SNF VBP statute
specifies that the measure should be adopted ``as soon as
practicable,'' and stated their belief that measures that will affect
beneficiary access and quality as well as providers should undergo
consensus review.
Response: Although the measure is not currently NQF-endorsed, we
did conduct additional testing subsequent to the December 2015 MAP
meeting where this measure was discussed. Based on that testing, we
were able to complete the risk adjustment model and evaluate
facilities' PPR rates, and we made the results of our analyses
available at the time of the proposed rule. We found that testing
results were similar to the SNFRM (NQF #2510) and allowed us to
conclude that the measure is sufficiently developed, valid and reliable
for adoption in the SNF VBP Program.
Comment: One commenter also stated that we should await NQF
endorsement of the SNFPPR before we adopt it for use in the SNF VBP
Program and at a minimum, should wait until at least 2 years after the
SNFRM has been used in the Program.
Response: We intend to submit the SNFPPR to NQF for consideration
of endorsement. With regard to the waiting at least 2 years before we
adopt the SNFPPR for use in the SNF VBP, we will take this comment
under consideration.
Comment: Commenter stated that we should use an ``actual
readmission rate'' to calculate SRRs rather than predicted
readmissions, or we should show how predicted and actual readmissions
result in significantly different rankings in order to justify their
use in the methodology. The commenter understood the statistical
rationale for using the risk-adjusted estimate instead of actual
readmission rate in the SRR, but did not believe that this approach
provides superior or more accurate information than the actual
readmission rate, and will instead be more confusing. The commenter
called on us to use a simpler method.
Response: The statistical approach for this measure, including the
use of the predicted to expected PPR rate, is used in several other
quality measures, including the NQF-endorsed all-cause unplanned
readmission measures for post-acute care and the hospital-wide all-
cause readmission measure (NQF #1789) and other hospital readmission
measures used in the Hospital Inpatient Quality Reporting (IQR)
Program. Our decision to use this approach was influenced by work we
became aware of by an independent committee appointed by the Committee
of Presidents of Statistical Societies. In its White Paper
[[Page 51995]]
report, the committee approved CMS's approach as a valid modeling
approach with preferred statistical characteristics.\24\ We believe
that this approach makes providers with small numbers of eligible
patient stays less vulnerable to reported rates driven by the influence
of random variation in performance, and, thus, will maximize the value
of assessing SNFs' performance in SNF VBP. We would also like to note
that facilities will be given their observed or actual readmission
rates in their reports.
---------------------------------------------------------------------------
\24\ The COPSS-CMS White Paper Committee. Statistical Issues in
Assessing Hospital Performance. January 2012. Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/Statistical-Issues-in-Assessing-Hospital-Performance.pdf.
---------------------------------------------------------------------------
Comment: Commenter stated that the SNFPPR should not exclude
individuals who died during the SNF stay, noting that individuals who
died could still have been hospitalized for a PPR prior to dying.
Commenter stated that excluding these patients will overestimate
readmission rates in SNFs with high rates of within-SNF stay mortality
and could create incentives to let patients die in SNFs rather than
sending them to the hospital.
Response: We wish to clarify that the SNFPPR measure does not
exclude patients who die during the 30-day window. If an individual
died and was hospitalized for a PPR prior to dying, this readmission
would in fact be included in the numerator for the facility. For
additional information on the SNFPPR's calculation and methodology, we
refer readers to the final specification that we will post on the SNF
VBP Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html.
Comment: Commenter called on us to harmonize the SNFPPR with other
PAC PPR measures, noting that the SNFPPR is the only one of several
measures that counts readmissions during a patient's stay and after
discharge, depending on the SNF length of stay. The commenter stated
that the MAP recommended that the measure track ``within stay''
readmissions in order to align with other measures and avoid
duplication of efforts, and noted that readmissions will be counted in
both the SNFPPR and the Potentially Preventable 30-Day Post-Discharge
Readmission Measure for the SNF QRP measure. The commenter acknowledged
our concern that not counting post-discharge hospitalizations may
create incentives for SNFs to discharge patients prematurely, but
stated that we have not presented any evidence that this will, in fact,
occur and that we have numerous other programs available to monitor any
such behavior by SNFs. This commenter stated that, if nothing else, we
should reduce the readmission window to seven days post-discharge,
suggesting that readmissions after seven days are more reflective of
quality and access to ambulatory care.
Response: Our decision to develop the SNFPPR using this specific
readmission window was intended to balance the relative advantages
associated with assessing the outcome both during the SNF stay and
potentially post-discharge with any possible incentives to discharge
patients who represent the highest risk for readmission in order to
avoid penalty. Given that this measure is the sole determinant of a
value-based purchasing program for SNFs, we were limited to selecting
one readmission window for the measure and believe that counting
readmissions that may occur post-discharge but within the 30-day window
would be most valuable, even though other quality programs outside the
VBP may be available to monitor premature discharges in SNFs.
The 30-day window reflects a transitional time period wherein the
acute care hospital and skilled nursing facility are responsible for
coordinating the care of a patient moving from one setting to another
and is consistent with readmission measures used in other value-based
purchasing programs, such as the ESRD Quality Incentive Program and the
Hospital Readmission Reduction Program, as well as readmission measures
used in a number of quality reporting programs that apply to post-acute
care providers. Furthermore, our analysis of readmission rates showed
no patterns indicating that using a shorter or longer period would
produce very different comparative results, though the overall rates
would change. In addition, the NQF Standing Committee generally agreed
that 30 days post-hospital discharge is an accepted standard for
measuring readmissions. Longer windows may be subject to greater
``noise'' in the readmission rate. The measure as specified has the
potential for this unintended consequence of delaying hospital care
beyond the 30-day readmission window, but this is a danger that would
be associated with any selected day threshold. In addition, we will
continue to analyze whether there are changes in the number of days to
hospital readmission over time in order to assess whether a change to
the readmissions window is needed for this measure in the future.
After consideration of the public comments that we received, we are
finalizing our proposal to adopt the SNF 30-Day Potentially Preventable
Readmission Measure (SNFPPR) for the SNF VBP Program.
Section 1888(h)(2)(B) of the Act requires the Secretary to apply
the all-condition risk-adjusted potentially preventable hospital
readmission measure specified under paragraph (g)(2) instead of the
measure specified under paragraph (g)(1) as soon as practicable. We
will apply the measure specified under paragraph (g)(1) beginning in
performance year CY 2017 for payment year FY 2019, and we will apply it
until such a time as the measure specified under paragraph (g)(2)
replaces the measure specified under paragraph (g)(1). We intend to
propose the timing for the change to the paragraph (g)(2) measure in
future rulemaking. We sought comment on when we should propose this
change for the SNF VBP Program. The comments we received on this topic,
with their responses, appear below.
Comment: One commenter stated that the SNFPPR should replace the
SNFRM as soon as possible because the SNFPPR holds providers
accountable for conditions that can be managed in the SNF. The
commenter suggested that we could replace the SNFRM for scoring
beginning in October 2019, after the first Program year. Still other
commenters suggested that we transition the measure once it receives
unconditional endorsement from NQF, or that we allow at least a full
year for SNFs to receive and understand their SNFPPR data before we
implement the measure. Another commenter suggested that we defer
transitioning the Program from the SNFRM to the SNFPPR, citing the
MAP's vote to recommend the measure to ``encourage further
development'' and the commenter's belief that the measure should be
subjected to additional public comments prior to its adoption.
Response: We thank commenters for these suggestions. We will
consider these comments when we develop a future proposal to replace
the SNFRM with the SNFPPR.
As noted previously in this section, we also intend to submit the
SNFPPR to the NQF for consideration of endorsement as soon as possible.
c. Performance Standards
i. Background
Sections 1888(h)(3)(A) of the Act requires the Secretary to
establish performance standards for the SNF VBP Program. Under
paragraph (3)(B) of section 1888(h) of the Act, the
[[Page 51996]]
performance standards must include levels of achievement and
improvement, and under paragraph (3)(C) of such section, must be
established and announced not later than 60 days prior to the beginning
of the performance period for the FY involved.
In the FY 2016 SNF PPS final rule (80 FR 46419 through 46422), we
summarized public comments we received on possible approaches to
calculating performance standards under the SNF VBP Program. We
specifically sought comment on the approaches that we have adopted for
other Medicare VBP programs such as the Hospital VBP Program (Hospital
VBP Program), the Hospital-Acquired Conditions Reduction Program (HAC
Reduction Program), the Hospital Readmissions Reduction Program (HRRP),
and the End-Stage Renal Disease Quality Incentive Program (ESRD QIP).
We also sought comment on the best possible approach to measuring
improvement, particularly given the SNF VBP Program's limitation to one
measure for each program year.
ii. Proposed Performance Standards Calculation Methodology
We believe that an essential goal of the SNF VBP program is to
provide incentives for all SNFs to improve the quality of care that
they furnish to their residents. In determining what level of SNF
performance would be appropriate to select as the performance standard
for the quality measures specified under the SNF VBP program, we
focused on selecting levels that would challenge SNFs to improve
continuously or to maintain high levels of performance. To achieve this
aim, we analyzed SNFRM data and examined how different achievement
performance standards would impact SNFs' scores under the proposed
scoring methodology described further below. As more data becomes
available, we will continue to assess the appropriateness of these
performance standards for the SNF VBP program and, if necessary,
propose to refine these standards' definitions and calculation
methodologies to better incentivize the provision of high-quality care.
(a) Proposed Achievement Performance Standard and Benchmark
Beginning with the FY 2019 SNF VBP program, we proposed to define
the achievement performance standard (which we will refer to as the
``achievement threshold'') for quality measures specified under the SNF
VBP program as the 25th percentile of national SNF performance on the
quality measure during the applicable baseline period. We believe this
achievement threshold definition represents an achievable standard of
excellence and will reward SNFs appropriately for their performance on
the quality measures specified for the SNF VBP program. We further
believe this achievement threshold definition will provide strong
incentives for SNFs to improve their performance on the measures
specified for the SNF VBP Program continuously and will result in a
wide range of SNF measure scores that can be used in public reporting.
We further proposed to define the ``benchmark'' for quality
measures specified under the SNF VBP program as the mean of the top
decile of SNF performance on the quality measure during the applicable
baseline period. We believe this definition represents demonstrably
high but achievable standards of excellence; in other words, the
benchmark will reflect observed scores for the group of highest-
performing SNFs on a given measure. This proposed benchmark policy
aligns with that used by the Hospital VBP Program. As stated in the FY
2016 SNF PPS final rule (80 FR 46419 through 46420), we believe the
Hospital VBP Program's performance standards methodology is a well-
understood methodology under which health care providers and suppliers
can be rewarded both for providing high-quality care and for improving
their performance over time. We therefore believe it is appropriate to
align with the Hospital VBP Program in setting benchmarks for the SNF
VBP Program.
We also proposed that SNFs would receive points along an
achievement range, which is the scale between the achievement threshold
and the benchmark. Under this proposal, SNFs would receive achievement
points if they meet or exceed the achievement threshold for the
specified measure, and could increase their achievement score based on
higher levels of performance. (We described the proposed scoring
methodology, including how we proposed to award points for both
achievement and improvement, in the scoring methodology section of the
proposed rule). This proposed achievement range policy aligns with that
used by the Hospital VBP Program. We refer readers to the FY 2016 SNF
PPS final rule (80 FR 46419 through 46420) for a discussion of the
rationale behind aligning SNF VBP Program policies with the Hospital
VBP Program. As stated in that rule, we believe that the Hospital VBP
Program's performance standards methodology is well-understood and
would allow us to reward SNFs both for providing high-quality care and
for improving their performance over time. We stated our intent to
publish the final performance standards using complete data from CY
2015 in the FY 2017 SNF PPS final rule, and we have updated the
numerical values in Table.
The comments we received on this topic, with their responses,
appear below.
Comment: Commenters supported our proposed performance standards
calculations, including our proposal to define the achievement
threshold as the 25th percentile of national SNF performance during the
baseline period. Commenters also supported our proposal to define the
benchmark as the mean of the top decile of all SNFs' performance on
proposed measures. Some commenters requested that we establish and
announce the achievement threshold and benchmark earlier in the year in
order to give SNFs additional time to develop quality improvement
strategies.
Response: We thank the commenters for their support. However, we do
not believe we can establish and announce the achievement threshold and
the benchmark earlier in the year given the time needed to compile
claims data and compute the readmissions measures.
We also sought comment on whether we should consider adopting
either the 50th or 15th percentiles of national SNFs' performance on
the quality measure during the applicable baseline period. We sought
comment on data or other analysis that we should consider regarding the
impact on SNFs' financial viability and service delivery to
beneficiaries at either the higher or lower alternative standard. For
example, while the 50th percentile would represent a more challenging
threshold for care quality improvement, that standard would align with
the Hospital VBP Program and would likely result in higher value-based
incentive payments to top-performing SNFs than other definitions,
though the actual distribution of value-based incentive payments would
depend on all SNFs' performance and on the statutory rules governing
their distribution. Such a standard would likely result in lower value-
based incentive payments to lower-performing SNFs, which could create
substantial payment disparities among participating SNFs. Conversely,
the 15th percentile would likely result in higher value-based incentive
payments for lower-performing SNFs than other thresholds, with the
corresponding result of lower value-based incentive-payments for top-
performing SNFs compared to other thresholds. The comments we received
[[Page 51997]]
on this topic, with their responses, appear below.
Comment: Commenter stated that we should not increase the proposed
achievement threshold to 50 percent, noting that meeting such a
standard may be difficult for small, rural, or frontier facilities with
limited resources and low volume. The commenter also suggested that we
should test the two-pronged process for performance standards for
reliability and validity prior to payment and public reporting. Other
commenters stated that the 2 percent withhold has a significant enough
impact on providers that they need to take time to understand how to
minimize payment penalties.
Response: As discussed further below, we are finalizing the
definition of the achievement threshold as the 25th percentile of SNFs'
performance during the applicable baseline period. We intend to monitor
the effects of the performance standards' definition on SNFs'
performance and on the provision of care to Medicare beneficiaries.
We are required by statute to implement the 2 percent withhold from
Medicare payments for SNFs. We intend to monitor the Program's effects
on the impact of care by SNFs. However, as explained more fully above,
we do not believe we can allow SNFs more time than we have proposed in
order to understand how to minimize payment penalties.
Comment: One commenter recommended that we adopt the 50th
percentile for the achievement threshold, stating that we should
maintain consistency across settings when calculating achievement
scores.
Response: While we agree with the commenter in general that
consistency across settings in our value-based purchasing programs is
important, we also recognize that we must implement these programs
differently where statutory language differs or where the different
care setting necessitates a policy change from other programs. We
remain concerned that adopting the 50th percentile for the definition
of the achievement threshold would result in about half of SNFs
receiving no points for achievement under the Program, which would mean
that we are effectively unable to reward their performance,
particularly in cases where they do not qualify for improvement points.
Our intention with the SNF VBP Program is to provide strong incentives
for SNFs to improve their performance on the Program's measures
continuously, and we do not believe that effectively excluding about
half of SNFs from receiving achievement points will further that
objective. We balanced that intention with our desire to ensure that we
award points under the Program for quality performance, and do not
award substantial points for what we have measured as poor-quality
care. Upon further consideration of the comments, we believe the 25th
percentile appropriately balances those goals.
Comment: Commenter expressed concerns about the alternative levels
of the achievement threshold presented in the rule, suggesting that the
25th percentile represents the best chance to balance incentive
payments between low and high performers. The commenter urged us to
test these alternatives prior to implementation and public reporting.
Response: We thank the commenter for their support, and as
discussed further above, we share the commenter's concerns about the
alternatives to the 25th percentile for the achievement threshold.
Accordingly, we are finalizing the definition of the achievement
threshold as the 25th percentile of SNFs' performance on the Program's
measures during the applicable baseline period.
Comment: One commenter was concerned about the proposed definition
for the benchmark under the Program, explaining their preference for
additional testing of the benchmark prior to its public reporting and
use in calculating incentive payments. The commenter was concerned
about unintended consequences for nursing homes and medically-complex
or otherwise high-risk patients.
Response: We intend to monitor the Program's effects on SNFs'
provision of high-quality care to Medicare beneficiaries. However, as
we stated in the proposed rule (81 FR 24246), we believe that the
proposed definition of the benchmark represents a demonstrably high but
achievable standard of excellence for all SNFs, including those SNFs
that treat high-risk patients. We note further that the measures
specified under the Program are risk adjusted for medically-complex or
otherwise high-risk patients, and we believe that adjustment will
mitigate the commenter's concerns about unintended consequences. We
intend to monitor the effects of the measures' risk adjustment policy
to ensure that SNFs serving those patients are scored appropriately and
are not penalized for treating medically-complex or high-risk patients.
(b) Improvement Performance Standard
Beginning with the FY 2019 SNF VBP program, we proposed to define
the improvement performance standard (which we will refer to as the
``improvement threshold'') for quality measures specified under the SNF
VBP program as each specific SNF's performance on the specified measure
during the applicable baseline period. As discussed further below, we
will measure SNFs' performance during both the proposed performance and
baseline periods, and we will award improvement points by comparing
SNFs' performance to the improvement threshold. We believe this
improvement performance standard ensures that SNFs will be adequately
incentivized to improve continuously their performance on the quality
measures specified under the SNF VBP Program, and we believe it
appropriately balances our view that we should both reward SNFs for
high performance and encourage improved performance over time.
We invited public comment on this proposal. The comments we
received on this topic, with their responses, appear below.
Comment: Some commenters expressed concern about the proposed
improvement points formula, suggesting that the formula should not
require unrealistic levels of improvement from providers that are
already high achievers based on their baseline period scores. Other
commenters noted that we have in other rules explained that measures
should be dropped or changed when performance reaches a uniformly high
level.
Response: SNFs that are already high achievers based on their
baseline period scores will be able to score achievement points under
the proposed scoring methodology. While the commenter is correct that
it may be difficult for a SNF to score a substantial number of
improvement points if that SNF has a high baseline period score, the
proposed methodology allows SNFs to earn ten additional points for
achievement than they are able to earn for improvement. We therefore
believe that SNFs that are already high achievers are well-positioned
to earn high scores under the Program so long as they maintain their
high performance on the specified measures.
We thank commenters for the suggestion that we should adopt a
policy to drop measures or change them when performance reaches a
uniformly high level. In other contexts, we have described this as a
``topped-out'' measures policy. We have not considered adopting such a
policy for the SNF VBP Program to date, but we will consider whether or
not to do so in future rulemaking.
[[Page 51998]]
(c) Publication of Performance Standard Numerical Values
Section 1888(h)(3)(C) of the Act requires the Secretary to
establish and announce the performance standards for a given SNF VBP
program year not later than 60 days prior to the beginning of the
performance period for the FY involved. Based on the proposed
performance period of CY 2017 for the FY 2019 SNF VBP Program, we
believe that we must establish and announce performance standards for
the FY 2019 Program not later than November 1, 2016. We intend to
establish and announce performance standards for the Program in the
annual SNF PPS rule, which is effective on October 1 of each year.
However, finalizing numerical values of these performance standards
is often logistically difficult because it requires the collection and
analysis of large amounts of quality measure data in a short period of
time. For example, the data file for a full year of SNF claims data is
typically completed around May of the following year. To calculate a
numerical value for a performance standard, we must perform multiple
levels of analyses on the data to ensure that all appropriate SNFs and
patients are included in measure calculations; perform the measure
calculations themselves; and then use those calculations to determine
the numerical value for the performance standards. If any individual
step of this process is delayed, it may preclude us from publishing
finalized numerical values for the finalized performance standards in
the applicable SNF PPS final rule, which is typically displayed
publicly by August 1 of each year.
To retain the flexibility needed to ensure that numerical values
published for the finalized performance standards are accurate, we
proposed to publish these numerical values no later than 60 days prior
to the beginning of the performance period but, if necessary, outside
of notice-and-comment rulemaking. As noted, we intend to publish
numerical values for those performance standards in the final rule when
practicable. However, in instances in which we cannot complete the
necessary analyses in time to include them in the SNF PPS final rule,
we proposed to publish the numerical values for the performance
standards on the QualityNet Web site used by SNFs to receive VBP
information as soon as practicable but in no event later than the
statutorily required 60 days prior to the beginning of the performance
period for the fiscal year involved. In this instance, we would notify
SNFs and the public of the publication of the performance standards
using a listserv email and posting on the QualityNet News portion of
the Web site.
We welcomed public comment on this proposal. The comments we
received on this topic, with their responses, appear below.
Comment: One commenter supported our proposed timing and method for
publishing the numerical values of the performance standards and for
payment adjustments. The commenter appreciated the complexity of
calculating hospital readmission rates and understood that we may need
to publish performance standards or payment information outside of
rulemaking. The commenter believed this to be a reasonable trade-off in
order to have the performance period occur as close to the payment
adjustment as possible.
Response: We thank the commenter for their support.
After consideration of the public comments that we received, we are
finalizing our performance standards policies as proposed.
Specifically, we are finalizing our definition of the achievement
performance standard, which we refer to as the ``achievement
threshold,'' for quality measures specified under the SNF VBP Program
as the 25th percentile of national SNF performance on the quality
measure during the applicable baseline period. We are finalizing our
proposal to define the ``benchmark'' for quality measures specified
under the SNF VBP Program as the mean of the top decile of SNF
performance on the applicable quality measure during the applicable
baseline period. We are also finalizing our proposals that SNFs would
receive points along an achievement range, which is the scale between
the achievement threshold and the benchmark.
We are also finalizing our proposal to define the improvement
performance standard (which we refer to as the ``improvement
threshold'') for quality measures specified under the SNF VBP Program
as each specific SNF's performance on the specified measure during the
applicable baseline period.
We are also finalizing our proposal to publish the numerical values
of the achievement threshold and the benchmark no later than 60 days
prior to the beginning of the performance period, but if necessary,
outside of notice-and-comment rulemaking.
The final values for the achievement threshold and the benchmark
for the FY 2019 Program are displayed below in Table 10. For clarity,
and as discussed further above, we have inverted the SNFRM rate so that
a higher rate represents better performance.
Table 10--Final FY 2019 SNF VBP Program Performance Standards *
----------------------------------------------------------------------------------------------------------------
Achievement
Measure ID Measure description threshold Benchmark
----------------------------------------------------------------------------------------------------------------
SNFRM......................................... SNF 30-Day All-Cause Readmission 0.79590 0.83601
Measure (NQF #2510).
----------------------------------------------------------------------------------------------------------------
* Note: Performance standards were calculated as of July 14, 2016 using CY 2015 data.
d. FY 2019 Performance Period and Baseline Period
i. Background
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46422)
for discussion of the considerations that we intend to take into
account when specifying a performance period under the SNF VBP Program.
We also explained our view that the SNF VBP Program necessitates
adoption of a baseline period, similar to those adopted under the
Hospital VBP Program and ESRD QIP, which we would use to establish
performance standards and measure improvement.
We received public comments on this topic, and we refer readers to
the FY 2016 SNF PPS final rule for a summary of those comments and our
responses. We considered those comments when developing our performance
and baseline period proposals for this proposed rule.
ii. Proposed FY 2019 Performance Period
In considering various performance periods that could apply for the
FY 2019 SNF VBP Program, we recognized that we must balance the length
of the performance period used to collect quality measure data and the
amount of data needed to calculate reliable, valid
[[Page 51999]]
measure rates with the need to finalize a performance period through
notice and comment rulemaking. We therefore proposed to adopt CY 2017
(January 1, 2017 through December 31, 2017) as the performance period
for the FY 2019 SNF VBP Program, with a 90-day run out period
immediately thereafter for claims processing, based on the following
considerations.
We strive to link performance furnished by SNFs as closely as
possible to the payment year to ensure clear connections between
quality measurement and value-based payment. We also strive to measure
performance using a sufficiently reliable population of patients that
broadly represent the total care provided by SNFs. As such, we
anticipate that our annual performance period end date must provide
sufficient time for SNFs to submit claims for the patients included in
our measure population. Based on past experience with claims processing
in other quality reporting and value-based purchasing programs, this
time lag between care delivered to patients who are included in
readmission measures and application of a payment consequence linked to
reporting or performance on those measures has historically been close
to 1 year. We also recognize that other factors contribute to the delay
between data collection and payment impacts, including: The processing
time needed to calculate measure rates using multiple sources of claims
needed for statistical modeling; time for determining achievement and
improvement scores; time for providers to review their measure rates
and included patients; and processing time needed to determine whether
a payment adjustment needs to be made to a provider's reimbursement
rate under the applicable PPS based on its performance. Further, our
preference is to adopt at least a 12-month period as the performance
period, consistent with our view that using a full year's performance
period provides sufficient levels of data accuracy and reliability for
scoring SNF performance on the SNFRM and SNFPPR. We also believe that
adopting a 12-month period for the performance period supports the
direction provided of section 1888(g)(3) of the Act that the quality
measures specified under the SNF VBP Program shall be designed to
achieve a high level of reliability and validity. Specifically, we
believe using a full year of claims data better ensures that the
variation found among SNF performance on the measures is due to real
differences between SNFs, and not within-facility variation due to
issues such as seasonality. Additionally, we believe that adopting 12-
month performance and baseline periods enables us to measure SNFs'
performance on the specified measures in sequence, which we believe is
necessary in order to measure SNFs on both achievement and improvement,
as required by section 1888(h)(3)(B) of the Act.
Finally, we also considered the time necessary to calculate SNF-
specific performance on the SNFRM after the conclusion of the
performance period and to develop and provide SNF VBP scoring reports,
including the requirement under section 1888(h)(7) of the Act that we
inform each SNF of the adjustments to the SNF's payments as a result of
the program not later than 60 days prior to the FY involved. Based on
the requirements and concerns discussed above, we believe a 12-month
time period is the only operationally feasible performance period for
the SNF VBP Program.
We invited public comments on this proposal, and we respond to them
in the next section.
iii. Proposed FY 2019 Baseline Period
As we have done in the Hospital VBP Program and the ESRD QIP, we
proposed to adopt a baseline period for use in the SNF VBP Program.
We proposed to adopt calendar year 2015 claims (January 1, 2015
through December 31, 2015) as the baseline period for the FY 2019 SNF
VBP Program and to use that baseline period as the basis for
calculating performance standards. We stated that, as with the
performance period, we will allow for a 90-day claims run out following
the last date of discharge (December 31, 2015) before incorporating the
2015 claims in our database into the measure calculation.
We welcomed public comment on this proposal. The comments we
received on this topic, as well as the comments that we received on the
proposed performance period, with their responses, appear below.
Comment: One commenter supported our baseline and performance
period proposals, stating their appreciation that we proposed a
performance period as close to the payment period as possible.
Response: We thank the commenter for the support and agree. When
developing these policies, we attempted to balance the length of the
performance period with its proximity to the payment period, and we
believe we have appropriately balanced those two factors.
Comment: One commenter was concerned about the delay between
quality measurement and incentive payments or penalties, stating that
providers need a clear link between practice and outcomes.
Response: As explained previously in this section, we believe that
the proposed performance period is as close to the payment period as we
can implement practically given the time necessary for claims
submission and processing, as well as for scoring under the Program.
Comment: One commenter recommended that we expand the performance
period for low-volume SNFs (which the commenter defined as SNFs having
less than 25 stays) to 24 months, and that we exclude from the program
SNFs that have fewer than 25 stays during the 2-year performance
period. The commenter stated that this suggested exemption's effects
would be insignificant on SNFs' scores in the aggregate, pointing to
analysis that a similarly-structured 20-stay exclusion would only
exempt about 7.4 percent of SNFs and just 1 percent of stays. The
commenter noted that increasing the minimum stays count to 25 would
increase the number of exempted SNFs to approximately 9.2 percent of
all SNFs and about 1.6 percent of Medicare SNF stays, but also noted
that expanding the performance period for low-volume SNFs would reduce
the number of exempted SNFs and stays to 4.8 percent and 0.4 percent
respectively. The commenter believed that these relatively low numbers
of exempted SNFs and stays are justifiable since those SNFs are likely
serving isolated areas or providing specialized care.
Response: We are sensitive to the effects the SNF VBP could have on
beneficiaries' access to SNF care, and especially how the program might
affect access to SNF care in rural and low-volume facilities.
However, while we appreciate the commenters' intent to ensure as
broad participation as possible in the Program, we do not believe that
a separate performance period for low-volume SNFs is feasible. Under
section 1888(h)(3)(C) of the Act, we are required to establish and
announce performance standards for a fiscal year not later than 60 days
prior to the beginning of the performance period for that fiscal year.
We do not believe we would comply with that requirement by establishing
a longer performance period for certain SNFs. In addition, because we
would not know which SNFs would have had fewer than 25 stays in their
measure denominator until after the performance period concluded, it
would be impossible for us to have provided the appropriate notice to
those SNFs as required under section 1888(h)(3)(C) of
[[Page 52000]]
the Act. Moreover, unless we established a separate baseline period for
low-volume SNFs, we would be comparing performance and baseline periods
of different durations, which raises questions about the validity of
those performance comparisons over time. Further, we do not believe
that a separate 24-month baseline period is appropriate, as it would
require wholly separate calculations of measured performance using an
additional year's claims data, which is both time-consuming and costly.
Finally, we do not believe that low-volume SNFs are penalized by
participating in the Program. The measures of readmissions adopted
under the Program include an adjustment that reduces variability in
low-volume SNFs' measured performance called ``shrinkage estimation,''
and we believe that this adjustment ensures that the measures are
sufficiently reliable for the Program's purposes. However, we will
continue to test and evaluate the Program's measures and will take this
recommendation under consideration prior to transitioning from the
SNFRM to the proposed SNFPPR measure in the SNF VBP Program.
After consideration of the public comments that we received, we are
finalizing our proposals to adopt CY 2015 as the baseline period for
the FY 2019 SNF VBP Program, and CY 2017 as the performance period for
the same Program year.
e. SNF VBP Performance Scoring
i. Background
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46422
through 46425) for a discussion of other Medicare VBP scoring
methodologies, including the methodologies used by the Hospital VBP
Program and HAC Reduction Program. We also discussed policy
considerations related to the Hospital Readmission Reduction Program
and the ESRD QIP in the performance standards section of that final
rule (80 FR 46420 through 46421). We also discussed the potential
application of an exchange function (80 FR 46424 through 46425) to
translate SNF performance scores into value-based incentive payments
under the SNF VBP Program.
We considered those issues, as well as comments we received on
these issues, when developing our performance scoring policy below.
ii. SNF VBP Program Scoring Methodology
Section 1888(h)(4)(A) of the Act requires the Secretary develop a
methodology for assessing the total performance of each SNF based on
the performance standards established under section 1888(h)(3) of the
Act for the measure applied under section 1888(h)(2) of the Act.
Section 1888(h)(3)(B) of the Act further requires that these
performance standards include levels of achievement and improvement and
that, in calculating a facility's SNF performance score, the Secretary
use the higher of either improvement or achievement.
After carefully reviewing and evaluating a number of scoring
methodologies for the SNF VBP Program, we proposed to adopt a scoring
model for the SNF VBP Program similar conceptually to that used by the
Hospital VBP Program and the ESRD QIP, with certain modifications to
allow us to better differentiate between SNFs' performance on the
quality measures specified under the SNF VBP Program.\25\ We believe
this hybrid appropriately accounts for the SNF VBP Program's statutory
limitation to a single measure, will maintain consistency and alignment
with other VBP programs already in place, and in doing so, will better
enable SNFs to understand the SNF VBP Program. Specifically, we
proposed to implement a 0 to 100-point scale for achievement scoring
and a 0 to 90-point scale for improvement scoring. In addition, as
discussed previously, we proposed to set the achievement threshold for
the SNF VBP Program at the 25th percentile of SNF national performance
on the quality measure during the baseline period rather than the 50th
percentile achievement threshold used in the Hospital VBP Program,
though as noted above, we also sought comment on whether or not we
should consider adopting the 50th percentile or the 15th percentile.
---------------------------------------------------------------------------
\25\ We refer readers to the FY 2013 IPPS final rule for a
discussion of the Hospital VBP Program scoring methodology (76 FR
2466 through 2470).
---------------------------------------------------------------------------
We believe using wider scales of 0 to 100 points and 0 to 90 points
instead of the 0 to 10 and 0 to 9 scales used in the Hospital VBP
Program and ESRD QIP will allow us to calculate more granular
performance scores for individual SNFs and provide greater
differentiation between facilities' performance. We further believe
that setting the achievement threshold for the SNF VBP Program at the
25th percentile of national SNF performance on the quality measure
during the baseline period is preferable to the Hospital VBP Program's
achievement threshold of the 50th percentile of national facility
performance for this Program because it accounts for the statutory
requirement that the SNF VBP Program include only one quality measure
at a time. Unlike the Hospital VBP Program, which contains many
measures across multiple domains, the SNF VBP Program is limited by
statute to a single quality measure at a time. As a result, a hospital
participating in the Hospital VBP Program could perform below the 50th
percentile of national performance on one or more measures without
experiencing a dramatic drop in its Total Performance Score because the
hospital's performance on other measures would contribute to its total
performance score. By contrast, if the SNF VBP Program used an
achievement threshold of the 50th percentile of national SNF
performance, approximately one-half of all SNFs nationwide would
automatically receive 0 achievement points assuming no national
improvement trends between baseline and performance periods. While
these SNFs could still receive improvement points, we believe it is
preferable to set a lower achievement threshold that would award the
majority of SNFs at least some achievement points, thereby enabling us
to differentiate performance among the lower-performing half of SNFs
and enabling SNFs to continually increase their achievement score based
on higher levels of performance. As stated above, as more data becomes
available, we will continue to assess the appropriateness of this
achievement threshold for the SNF VBP program and, if necessary,
propose to refine these standards' definitions and calculation
methodologies to better incentivize the provision of high-quality care.
For these reasons, we proposed to adopt the following scoring
methodology beginning with the FY 2019 SNF VBP Program.
(a) Scoring of SNF Performance on the SNFRM
Because the SNF VBP Program uses only one measure to incentivize
and assess facility performance and improvement, we believe it is
important to ensure that SNFs and the public are able to understand
these measure scores easily. SNFRM rates represent the percentage of
qualifying patients at a facility that were readmitted within the risk
window for the measure. As a result, lower SNFRM rates indicate lower
rates of readmission, and are therefore an indicator of higher quality
care. For example, a SNFRM rate of 0.14159 means that approximately
14.2 percent of qualifying patients discharged from that SNF were
readmitted during the risk window.
[[Page 52001]]
We understand that the use of a ``lower is better'' rate could
cause confusion among SNFs and the public. Therefore, we proposed to
calculate scores under the Program by first inverting SNFRM rates using
the following calculation:
SNFRM Inverted Rate = 1-Facility's SNFRM Rate
This calculation inverts SNFs' SNFRM rates such that higher SNFRM
performance reflects better performance on the SNFRM. As a result, the
same SNFRM rate presented above (0.14159) would result in a SNFRM
inverted rate of 0.85841, which means that approximately 86 percent of
qualifying patients discharged from that SNF were not readmitted during
the risk window. We believe this inversion is important to incentivize
improvement in a clear and understandable manner, and will also
simplify public reporting of SNF performance for use in consumer,
family, and caregiver decision-making. Further, under this proposal,
all SNFRM inverted rates would be rounded to the fifth significant
digit.
(b) Scoring SNFs' Performance Based on Achievement
We proposed that a SNF would earn an achievement score of 0 to 100
points based on where its performance on the specified measure fell
relative to the achievement threshold (which we proposed above to
define for the quality measures specified under the SNF VBP program as
the 25th percentile of SNF performance on the quality measure during
the applicable baseline period) and the benchmark (which we proposed to
define as the mean of the top decile of SNF performance on the measure
during the baseline period). As with the Hospital VBP Program, we
proposed to award points to SNFs based on their performance as follows:
If a SNF's SNFRM inverted rate was equal to or greater
than the benchmark, the SNF would receive 100 points for achievement;
If a SNF's SNFRM inverted rate was less than the
achievement threshold (that is, the lower bound of the achievement
range), the SNF would receive 0 points for achievement.
If a SNF's SNFRM inverted rate was equal to or greater
than the achievement threshold, but less than the benchmark, we would
award between 0 and 100 points to the SNF according to the following
formula:
[GRAPHIC] [TIFF OMITTED] TR05AU16.011
The results of this formula would be rounded to the nearest whole
number.
The SNF achievement score would therefore range between 0 and 100
points, with a higher achievement score indicating higher performance.
(c) Scoring SNF Performance Based on Improvement
We proposed that a SNF would earn an improvement score of 0 to 90
points based on how much its performance on the specified measure
during the performance period improved from its performance on the
measure during the baseline period. Under this proposal, a unique
improvement range would be established for each SNF that defines the
distance between the SNF's baseline period score and the national
benchmark for the measure (which we propose to define as the mean of
the top decile of SNF performance on the measure during the baseline
period). We would then calculate a SNF improvement score for each SNF
depending on its performance period score:
If the SNF's performance period score was equal to or
lower than its improvement threshold, the SNF would receive 0 points
for improvement.
If the SNF's performance period score was equal to or
higher than the benchmark, the SNF would receive 90 points for
improvement.
If the SNF's performance period score was greater than its
improvement threshold, but less than the benchmark, we would award
between 0 and 90 points for improvement according to the following
formula:
[GRAPHIC] [TIFF OMITTED] TR05AU16.012
The results of this formula would be rounded to the nearest whole
number.
(d) Establishing SNF Performance Scores
Consistent with sections 1888(h)(3)(B) and 1888(h)(4)(A) of the
Act, we proposed to use the higher of a SNF's achievement and
improvement scores to serve as the SNF's performance score for a given
year of the SNF VBP Program. The resulting SNF performance score would
be used as the basis for ranking SNF performance on the quality
measures specified under the SNF VBP Program and establishing the
value-based incentive payment percentage for each SNF for a given FY.
(e) Examples of the Proposed FY 2019 SNF VBP Program Scoring
Methodology
In the proposed rule, we provided two examples to illustrate the
proposed scoring methodology for the FY 2019 SNF VBP Program using
hypothetical SNFs A, B, and C. The benchmark calculated for the SNFRM
for all of these hypotheticals is 0.83915 (the mean of the top decile
of SNF performance on the SNFRM in 2014), and the achievement threshold
is 0.79551 (the 25th percentile of national SNF performance on the
SNFRM in 2014). We noted that, as discussed previously, our proposal
for scoring SNF performance on the SNFRM inverts the measure rates so
that a higher rate represents better performance.
Figure AA shows the scoring for SNF A. SNF A's SNFRM rate of
0.15025 means that approximately 15 percent of qualifying patients
discharged from SNF A were readmitted during the 30-day risk window.
Under the proposed SNFRM scoring methodology, SNF A's SNFRM inverted
rate would be calculated as follows:
Facility a SNFRM Inverted Rate = 1-0.15025
[[Page 52002]]
As a result of this calculation, Facility A's SNFRM inverted rate
would be 0.84975 on the SNFRM for the performance period. This result
indicates that approximately 85 percent of SNF A's qualifying patients
were not readmitted during the 30-day risk window. Because SNF A's
SNFRM inverted rate of 0.84975 exceeds the benchmark (that is, the mean
of the top decile of facility performance, or 0.83915), SNF A would
receive 100 points for achievement. Because SNF A has earned the
maximum number of points possible for the SNFRM, its improvement score
would not be calculated.
[GRAPHIC] [TIFF OMITTED] TR05AU16.013
Figure BB shows the scoring for SNF B. As can be seen below, SNF
B's performance on the SNFRM went from 0.21244, for a SNFRM inverted
rate of 0.78756 (below the achievement threshold) in the baseline
period to 0.18322, for a SNFRM inverted rate of 0.81668 (above the
achievement threshold) in the performance period. Applying the
achievement scoring methodology proposed above, SNF B would earn [49]
achievement points for this measure, calculated as follows:
[GRAPHIC] [TIFF OMITTED] TR05AU16.014
However, because SNF B's performance during the performance period
is greater than its performance during the baseline period, but below
the benchmark, we would calculate an improvement score as well.
According to the improvement scale, based on SNF B's improved SNFRM
inverted rate from 0.78756 to 0.81668, SNF B would receive 51
improvement points, calculated as follows:
[[Page 52003]]
[GRAPHIC] [TIFF OMITTED] TR05AU16.044
[GRAPHIC] [TIFF OMITTED] TR05AU16.015
In Figure CC, SNF C's performance on the SNFRM drops from 0.19487,
for a SNFRM inverted rate of 0.80513, in the baseline period to
0.21148, for a SNFRM inverted rate 0.78852, in the performance period
(a decline of 0.01661). Because this SNF's performance during the
performance period is lower than the achievement
[[Page 52004]]
threshold of 0.79551, it receives 0 points based on achievement. It
would also receive 0 points for improvement, because its performance
during the performance period is lower than its performance period
during the baseline period. In this example, SNF C would receive 0
points for its SNF performance score.
[GRAPHIC] [TIFF OMITTED] TR05AU16.016
The comments we received on this topic, with their responses,
appear below.
Comment: One commenter supported the proposed scoring methodology,
characterizing it as a reasonable approach that appropriately rewards
achievement more than improvement.
Response: We thank the commenter for this feedback and agree. We
believe the proposed scoring methodology complies with the Program's
statutory requirement to score SNFs on both achievement and improvement
while reserving the maximum scores for SNFs that are high achievers.
Comment: Some commenters appreciated our proposal to invert SNFs'
performance rates on readmission measures to show that higher
performance is better, particularly given the requirement to rank SNFs
under the program.
Response: We thank the commenters for this feedback.
Comment: Some commenters supported the proposed 0 to 100 scoring
approach, and called on us to monitor performance over time to ensure
that the scores continue to reflect meaningful differences in care.
Other commenters noted the proposed methodology's similarity to the
HVBP program and expressed their support accordingly. Commenters also
supported our proposed improvement scoring methodology, expressing
appreciation that we intend to award fewer improvement points than
achievement points. Commenters agreed that including the improvement
score creates strong incentives for all SNFs to improve over time.
[[Page 52005]]
Response: We thank the commenters for their support.
Comment: One commenter suggested that we consider two additional
factors for scoring adjustments, including the best ways to encourage
palliative care without harming performance scores and how to adjust
for individuals with specialized conditions that present increased
risks of hospitalizations.
Response: We do not believe that the Program will discourage
palliative care because the Program's measures do not hold SNFs
accountable for admissions to hospice or other forms of palliative
care, and we believe that the measures' risk adjustment appropriately
controls for variations related to individuals' clinical status.
However, we will monitor the Program's effects on access to care, and
if necessary, will consider additional adjustments in the future.
After consideration of the public comments that we received, we are
finalizing the scoring methodology for the SNF VBP Program as proposed.
f. SNF Value-Based Incentive Payments
i. Background
Paragraphs (5), (6), (7), and (8) of section 1888(h) of the Act
outline several requirements for value-based incentive payments under
the SNF VBP Program. Section 1888(h)(5)(A) of the Act requires that the
Secretary increase the adjusted Federal per diem rate for skilled
nursing facilities by the value-based incentive payment amount
determined under section 1888(h)(5)(B) of the Act. That amount is to be
determined by the product of the adjusted federal per diem rate and the
value-based incentive payment percentage specified under section
1888(h)(5)(C) of the Act for each SNF for a FY.
Section 1888(h)(5)(C) of the Act requires that the value-based
incentive payment percentage be based on the SNF performance score and
must be appropriately distributed so that the highest-ranked SNFs
receive the highest payments, the lowest-ranked SNFs receive the lowest
payments, and that the payment rate for services furnished by SNFs in
the lowest 40 percent of the rankings be less than would otherwise
apply. Finally, the total amount of value-based incentive payments must
be greater than or equal to 50 percent, but not greater than 70
percent, of the total amount of the reductions to payments for the FY
specified under section 1888(h)(6) of the Act, as estimated by the
Secretary. As discussed further below, we will propose to adopt in
future rulemaking an exchange function to ensure that the total amount
of value-based incentive payments made under the program each year
meets those criteria.
Section 1888(h)(7) of the Act requires the Secretary, not later
than 60 days prior to the fiscal year involved, to inform each SNF of
the adjustments to its Medicare payments for services furnished by the
SNF during the FY. Section 1888(h)(8) of the Act requires that the
value-based incentive payment and payment reduction only apply for the
FY involved, and not be taken into account in making payments to a SNF
in a subsequent year.
We received a number of comments on incentive payments that will be
made under the Program.
Comment: Several commenters recommended that we disburse the
maximum 70 percent of payments withheld from SNFs as value-based
incentive payments, stating that the larger the incentive, the greater
the behavioral change. Commenters believed that making the largest
amount of funds available would have the greatest impact on changing
care practices.
Response: We thank commenters for this feedback. We will address
the topic of value-based incentive payments under the Program in future
rulemaking. We agree with commenters that the Program's incentive
payments should be substantial enough to promote quality improvement
through changing care practices.
Comment: One commenter stated that the SNF VBP Program should be
budget-neutral, and suggested that we should reconsider the 50 to 70
percent payback to facilities under the Program.
Response: Section 1888(h)(5)(C)(ii)(III) of the Act requires that
the total amount of value-based incentive payments available under the
Program for a fiscal year range from between 50 percent and 70 percent
of the total amount of the reductions to the adjusted Federal per diem
rates otherwise applicable to skilled nursing facilities for that
fiscal year, as estimated by the Secretary. As a result, we do not
believe we have the authority to make the SNF VBP Program budget-
neutral, or to vary the total amount that we will disburse in value-
based incentive payments beyond the 50 to 70 percent range specified
under the statute.
ii. Request for Comment on Exchange Function
As we discussed in the FY 2016 SNF PPS final rule (80 FR 46424
through 46425), we use a linear exchange function to translate a
hospital's Total Performance Score under the Hospital VBP Program into
the percentage multiplier to be applied to each Medicare discharge
claim submitted by the hospital during the applicable FY. We intend to
adopt a similar methodology to translate SNF performance scores into
value-based incentive payment percentages under the SNF VBP Program.
When considering that methodology, we sought public comments on the
appropriate form and slope of the exchange function to determine how
best to reward high performance and encourage SNFs to improve the
quality of care provided to Medicare beneficiaries. As illustrated in
Figure DD, we considered the following four mathematical exchange
function options: Straight line (linear); concave curve (cube root
function); convex curve (cube function); and S-shape (logistic
function).
[[Page 52006]]
[GRAPHIC] [TIFF OMITTED] TR05AU16.017
We received numerous public comments on the FY 2016 SNF PPS
proposed rule, and we sought further public comments to inform our
policies on this topic. We requested additional public comments on the
specific form of the exchange function that we should propose in the
future, including any additional forms beyond the four examples that we
have illustrated above, and any considerations we should take into
account when selecting an exchange function form that would best
support quality improvement in SNFs.
Additionally, we will determine the precise slope of the exchange
function after the performance period has concluded, because the
distribution of SNFs' performance scores will form the basis for value-
based incentive payments under the program. However, two additional
considerations will affect the exchange function's slope. As required
in section 1888(h)(5)(C)(ii)(II)(cc) of the Act, SNFs in the lowest 40
percent of the ranking determined under paragraph (4)(B) must receive a
payment that is less than the payment rate for such services that would
otherwise apply. Additionally, as described in this section, section
1888(h)(5)(C)(ii)(III) of the Act requires that the total amount of
value-based incentive payments under the Program be greater than or
equal to 50 percent, but not greater than 70 percent, of the total
amount of reductions to SNFs' payments for the FY, as estimated by the
Secretary. We intend to ensure that both of these requirements, as well
as all other statutory requirements under the Program, are fulfilled
when we specify the exchange function's slope.
We invited public comments on this topic. The comments we received
on this topic, with their responses, appear below.
Comment: Commenter offered several principles for us to consider
when developing our exchange function proposals in the future. The
commenter suggested that top performing SNFs should receive an increase
in their Medicare rates, that we should maximize the number of SNFs
that do not receive a cut in their rates, that we should allow for
continuous improvement, even for SNFs that are already high performers,
and that differences in rehospitalization scores should be tied to
meaningful differences in incentive payments. The commenter recommended
that we adopt the logistic function and recommended against the cube
root function, stating that the former balances incentives for low and
high performers and that the latter creates very little incentive for
performance improvement.
Response: We thank the commenter for this feedback, and we will
take it into account as we develop proposals for the exchange function
in the future.
g. SNF VBP Reporting
i. Confidential Feedback Reports
Section 1888(g)(5) of the Act requires that we provide quarterly
confidential feedback reports to SNFs on their performance on the
measures specified under sections 1888(g)(1) and (2) of the Act.
Section 1888(g)(5) of the Act also requires that we begin providing
those reports on October 1, 2016.
In order to meet the statutory deadline, we are developing the
feedback reports, operational systems, and implementation guidance
related to those reports. We intend to provide these reports to SNFs
via the QIES system CASPER files currently used by SNFs to report
quality performance.
We invited public comments on the appropriateness of the QIES
system, and any considerations we should take into account when
designing and providing
[[Page 52007]]
these feedback reports. The comments we received on this topic, with
their responses, appear below.
Comment: One commenter supported our proposal to use the QIES
system to deliver feedback reports to SNFs. The commenter suggested
that we provide these reports in a spreadsheet-based format to allow
data aggregation within organizations.
Response: We thank the commenter for this feedback.
Comment: One commenter requested that trade organizations and other
organizations that represent the interests of SNFs be provided access
to SNFs' quarterly feedback reports. The commenter believed that these
organizations can assure that SNF VBP data affecting each SNF will be
protected and only shared with representatives for that particular SNF.
The commenter noted that many SNFs are members of larger organizations,
and that allowing further data distribution would enable these
organizations to aggregate these reports rather than manually enter
data voluntarily provided by each SNF. Commenter also requested that we
provide a national data file with SNF VBP performance to these
organizations that can help disseminate performance information to
individual SNFs or their parent organizations.
Response: Section 1888(g)(5) of the Act requires us to provide
confidential feedback reports to SNFs. We do not believe that we have
the authority to share those confidential feedback reports with other
entities.
Comment: One commenter requested that we consider using the QIES
system to provide real-time data updates, or as close to real-time
updates as possible. Commenter noted that we update our MDS data weekly
to capture SNFs' most current measure rates in order to facilitate
quality improvement efforts and suggested that we could do something
similar with Part A claims and the Program's measures.
Response: Although we agree that SNFs would benefit from receiving
the most up-to-date information as possible, it is not operationally
feasible to provide SNFs with real-time data updates at this time.
Unlike MDS data, claims-based measures require significant time to
compute and are based on large pools of data. While we will, as
described above, provide quarterly confidential feedback reports, we do
not believe more frequent updates are possible at this time.
Comment: One commenter suggested several data elements that we
could consider including in SNFs' quarterly reports, including
readmission counts during and after the Part A stay, names of
beneficiaries triggering readmissions, number of readmissions by PPR
diagnosis, predicted and expected rates used to calculate the SSR for
the prior rolling 12-month window, and national rates used to calculate
achievement and improvement scores.
Response: We thank the commenter for this feedback. As we continue
the Program's implementation, we will refine the quarterly reports in
accordance with SNFs' feedback, and will take these suggestions into
consideration.
ii. Proposed Two-Phase SNF VBP Data Review and Correction Process
(a) Background
Section 1888(g)(6) of the Act requires the Secretary to establish
procedures to make public performance information on the measures
specified under paragraphs (1) and (2) of such section. The procedures
must ensure that a SNF has the opportunity to review and submit
corrections to the information that will be made public for the
facility prior to its being made public. This public reporting is also
required by statute to begin no later than October 1, 2017.
Additionally, section 1888(h)(9) of the Act requires the Secretary to
make available to the public information regarding SNFs' performance
under the SNF VBP Program, specifically including each SNF's
performance score and the ranking of SNFs for each fiscal year.
Accordingly, we proposed to adopt a two-phase review and correction
process for (1) SNFs' measure data that will be made public under
section 1888(g)(6) of the Act, which will consist of each SNFs'
performance on the measures specified under sections 1888(g)(1) and (2)
of the Act, and (2) SNFs' performance information that will be made
public under section 1888(h)(9) of the Act.
(b) Phase One: Review and Correction of SNFs' Quality Measure
Information
We view the quarterly confidential feedback reports described
previously in this section, as one possible means to provide SNFs an
opportunity to review and provide corrections to their performance
information. However, collecting SNF measure data and calculating
measure performance scores takes a number of months following the end
of a measurement period. Because it is not feasible to provide SNFs
with an updated measure rate for each quarterly report or engage in
review and corrections on a quarterly basis, we proposed to use one of
the four reports each year to provide SNFs an opportunity to review
their data slated for public reporting. In this specific quarterly
report, we intend to provide SNFs: (1) A count of readmissions; (2) the
number of eligible stays at the SNF; (3) the SNF's risk-standardized
readmissions ratio; and (4) the national SNF measure performance rate.
In addition, we intend to provide the patient-level information used in
calculating the measure rate. However, we sought comment on what
patient-level information would be most useful to SNFs and how we
should make this information available if requested. We intend to
address the topic of what specific information will be provided if
requested in this specific quarterly report in future rulemaking, where
we intend to propose a process for SNFs' requests for patient-level
data. We intend to notify SNFs of this report's release via listserv
email and posting on the QualityNet News portion of the Web site.
Therefore, we proposed to fulfill the statutory requirement that
SNFs have an opportunity to review and correct information that is to
be made public under section 1888(g)(6) of the Act by providing SNFs
with an annual confidential feedback report that we intend to provide
via the QIES system CASPER files. We further proposed that SNFs must,
if they believe the report's contents to be in error, submit a
correction request to [email protected] with the following
information:
SNF's CMS Certification Number (CCN).
SNF Name.
The correction requested and the SNF's basis for
requesting the correction. More specifically, the SNF must identify the
error for which it is requesting correction, and explain its reason for
requesting the correction. The SNF must also submit documentation or
other evidence, if available, supporting the request. Additionally, any
requests made during phase one of the proposed process will be limited
to the quality measure information at issue.
We further proposed that SNFs must make any correction requests
within 30 days of posting the feedback report via the QIES system
CASPER files, not counting the posting date itself. For example, if we
provide reports on October 1, 2017, SNFs must review those reports and
submit any correction requests by October 31, 2017. We will not
consider any requests for correction to quality measure data that are
received after the close of the first phase of the proposed review and
correction process. As discussed further in this section, any
corrections sought during phase two of
[[Page 52008]]
the proposed process will be limited to the SNF performance score
calculation and the ranking.
We will review all timely phase one correction requests that we
receive and will provide responses to SNFs that have requested
corrections as soon as practicable.
(c) Phase Two: Review and Correction of SNF Performance Scores and
Ranking
As required by section 1888(h)(7) of the Act, we intend to inform
each SNF of its payment adjustments as a result of the SNF VBP Program
not later than 60 days prior to the fiscal year involved. For the FY
2019 SNF VBP Program, we intend to notify SNFs of those payment
adjustments via a SNF performance score report not later than 60 days
prior to October 1, 2018. We intend to address the specific contents of
that report in future rulemaking.
In that report, however, we also intend to provide SNFs with their
SNF performance scores and ranking. By doing so, we intend to use the
performance score report's provision to SNFs as the beginning of the
second phase of the proposed review and correction process. By
completing phase one, SNFs will have an opportunity to verify that
their quality measure data are fully accurate and complete and as a
result, phase two will be limited only to corrections to the SNF
performance score's calculation and the SNF's ranking. Any requests to
correct quality measure data that are received during phase two will be
denied.
We intend to set out specific requirements for phase two of the
proposed review and correction process in future rulemaking. To inform
those proposals, we sought comments on what information would be most
useful for us to provide to SNFs to facilitate their review of their
SNF performance scores and ranking. As with the phase one process, we
intend to adopt a 30-day time period for phase two review and
corrections, beginning with the date on which we provide SNF
performance score reports.
We invited public comments on this proposed two-phase review and
correction process. The comments we received on this topic, with their
responses, appear below.
Comment: One commenter only supported the 30-day deadline for
correction requests if sufficient information is included in the
quarterly reports. The commenter noted that SNFs may not be able to
submit documentation or other evidence supporting a correction request
within 30 days if they do not receive the names of the beneficiaries
who were readmitted, when the readmission occurred, and the readmission
diagnosis. Commenter appreciated that we may receive many correction
requests, and suggested that we consider allowing corrections for
missing data only annually, but corrections for when patients'
admissions are listed incorrectly quarterly in order to streamline our
reviews of correction requests. Another commenter requested that we
provide SNF and hospital inpatient Part A claims to SNFs on a quarterly
basis, both to facilitate quality improvement and correction requests.
Commenter suggested that we could provide patient identifiable files to
organizations that have a Business Associate Agreement with the SNF and
allow the organizations to share data with the SNF. Commenter noted
that many facilities do not have the capacity to analyze claims data,
but many large organizations are working with SNFs to provide this
service. Another commenter opposed the ability of SNFs to request data
corrections in phase two of the proposed review and correction process
unless all data in phase two is also included in the quarterly feedback
reports in phase one, and the last quarterly report in phase one
includes the final data used to calculate the rehospitalization score.
Commenter explained that if SNFs will not be able to file correction
requests based on phase two feedback reports, all of the data used to
calculate the rehospitalization score needs to be in the phase one
reports.
Response: We thank the commenters for this feedback. As we discuss
further below in response to other comments, we are finalizing a policy
whereby we will accept corrections on any quarterly report provided
during a calendar year until the following March 31.
However, the feedback reports that we must provide to SNFs under
the requirements at section 1888(g)(5) of the Act are specifically
required to remain confidential. We do not believe that we have the
authority to share those confidential feedback reports with other
organizations than SNFs themselves. We note that SNFs are free to share
their feedback reports with other organizations at their discretion.
We would like to clarify the distinction between the two phases of
the proposed review and correction process. As we discussed in the
proposed rule (81 FR 24255), the first phase is intended to allow SNFs
to review and correct patient-level information that we used to
calculate the measure rates. The second phase is intended to allow SNFs
to review and correct only their performance scores and the ranking,
not their measure rates. Although the two phases are separate, they
will, taken together, provide SNFs with an opportunity to correct both
the measure rates that are used to generate their performance scores
and ranking, as well as their actual performance scores and ranking. We
do not believe that we should conflate the two, or allow corrections to
quality measure data (that is, phase one requests) during the phase two
process, because the two phases are aimed at two separate purposes. We
believe it to be necessary to finalize the claims data that SNFs will
be able to correct in phase one so that those data may form the basis
for performance calculations that SNFs will be able to review in phase
two.
Comment: One commenter recommended that SNFs be provided access to
the information used to calculate their rehospitalization scores and
also information to estimate their adjustment factor based on the final
exchange function. Commenter explained that SNFs will want to replicate
their scores, so they will need their predicted rates, expected rates,
national average, baseline period rates, and major ``cut points'' used
to determine achievement and improvement points. The commenter also
suggested that the ranking of achievement and improvement scores could
be helpful to SNFs as well.
Response: We will take these comments into account as we develop
the first quarterly feedback reports for SNFs, and look forward to
additional feedback from SNFs after we provide them.
Comment: Commenter expressed support for the proposed review and
corrections process
Response: We thank the commenter for their support.
Comment: Commenter supported our proposal to provide feedback
reports to SNFs via the QIES system. However, the commenter did not
support our plan to allow SNFs to seek corrections on an annual basis,
and commenter recommended instead that we allow corrections on a
quarterly basis with an annual deadline. The commenter suggested that
the quarterly data that we provide should be sufficient to allow SNFs
to verify the accuracy of their measured performance and suggested as a
result that SNFs should be allowed to submit corrections quarterly.
Response: We understand the commenter's concern about the deadline
following each quarterly confidential feedback report, and we will
instead finalize a policy under which we will accept corrections to any
quarterly report provided during a calendar year
[[Page 52009]]
until the following March 31. We believe that this policy appropriately
balances our desire to ensure that the measure data are sufficiently
accurate with SNFs' need for sufficient information with which to
evaluate the accuracy of those reports, and provides SNFs with more
time to review each quarter's data than the 30 days that we initially
proposed.
After consideration of the public comments that we received, we are
finalizing the two-phase review and correction process as proposed,
with the exception stated above that we will accept corrections to
SNFs' quarterly confidential feedback reports during a calendar year
until the following March 31.
iii. SNF VBP Public Reporting
Section 1888(h)(9)(A) of the Act requires that we make available to
the public on the Nursing Home Compare Web site or its successor
information regarding the performance of individual SNFs with respect
to a FY, including the performance score for each SNF for the FY and
each SNF's ranking, as determined under section 1888(h)(4)(B) of the
Act. Additionally, section 1888(h)(9)(B) of the Act requires that we
periodically post aggregate information on the SNF VBP Program on the
Nursing Home Compare Web site or its successor, including the range of
SNF performance scores, and the number of SNFs receiving value-based
incentive payments and the range and total amount of those payments.
We intend to address this topic in future rulemaking. However, we
invited public comments on the best means by which to display the SNF-
specific and aggregate performance information for public consumption.
The comments we received on this topic, with their responses, appear
below.
Comment: Commenter supported public posting of SNFs performance
scores, but not their rehospitalization rates, achievement or
improvement scores. The commenter stated that achievement and
improvement scores are not required to be posted publicly by statute
and that they are not necessarily helpful to consumers. The commenter
also stated against posting the risk adjusted SNFRM or SNFPPR rates,
noting that these measures differ from other rehospitalization measures
publicly posted by CMS.
Response: We thank the commenter for this feedback. We will propose
details on public reporting of SNF VBP Program performance information
in the future and will take these comments into account at that time.
Comment: Commenter supported posting of the aggregate value-based
incentive payments, as well as the range of those payments and the
number of SNFs receiving payment adjustments, but did not support
posting individual SNF payments. The commenter noted that individual
SNF payments are the product of rehospitalization scores, volume of
admissions and patient case mix RUG payments, so actual payment
adjustments could be confusing to the public.
Response: We thank the commenter for this feedback and agree that
we will need to communicate clearly with the public about the
information that we post publicly. We will take these comments into
account when we propose details on public posting of SNF VBP payments
information in the future.
iv. Ranking SNF Performance
Section 1888(h)(4)(B) of the Act requires ranking the SNF
performance scores determined under paragraph (A) of such section from
low to high. Additionally, and as discussed in this section, we are
required to publish the ranking of SNF performance scores for a FY on
Nursing Home Compare or a successor Web site.
To meet these requirements, we proposed to order SNF performance
scores from low to high and publish those rankings on both the Nursing
Home Compare and QualityNet Web sites. However, because SNF performance
scores will not be calculated until after the performance period
concludes after CY 2017 (that is, during CY 2018), and because SNFs
must be provided their value-based incentive payment adjustments not
later than 60 days prior to the FY involved, we intend to publish the
ranking for FY 2019 SNF VBP payment implications after August 1, 2018.
We invited public comments on the most appropriate format and Web
site for the ranking's publication. The comments we received on this
topic, with their responses, appear below.
Comment: Commenter stated that any public posting of SNFs' ranking
under the Program must be clearly indicated, and suggested that rank
number 1 should be reserved for the SNF with the best rehospitalization
score, not the worst score. Commenter explained that the public may be
confused about the ranking unless clear and easy to understand
information on the ranking's direction is posted. Commenter also
supported our plan to post the ranking on the Nursing Home Compare Web
site.
Response: We thank the commenter for this feedback and will take it
into account as we develop the ranking that will be publicly posted. We
agree with the commenter that we will need to be clear about what the
ranking means when it is posted. We note that section 1888(h)(4)(B) of
the Act directs that the ranking of SNF performance scores (not SNF
rehospitalization rates) under the Program be ordered from low to high,
and we intend to be as clear as possible about SNFs' placements on the
ranking.
We will address this topic further in future rulemaking. We note
that, because we will compute FY 2019 SNF performance scores after the
completion of the performance period (finalized above as CY 2017), we
will not publish the ranking or other SNF-specific performance
information for the FY 2019 Program until at least the summer of CY
2018.
2. Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
a. Background and Statutory Authority
We seek to promote higher quality and more efficient health care
for Medicare beneficiaries, and our efforts are furthered by QRPs
coupled with public reporting of that information.
The Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act) added section 1899B to the Act that imposed new data
reporting requirements for certain PAC providers, including SNFs, and
required that the Secretary implement a SNF quality reporting program
(SNF QRP). Section 1888(e)(6)(B)(i)(II) of the Act requires that each
SNF submit, for FYs beginning on or after the specified application
date (as defined in section 1899B(a)(2)(E) of the Act), data on quality
measures specified under section 1899B(c)(1) of the Act and data on
resource use and other measures specified under section 1899B(d)(1) of
the Act in a manner and within the time frames specified by the
Secretary. In addition, section 1888(e)(6)(B)(i)(III) of the Act
requires, for FYs beginning on or after October 1, 2018, that each SNF
submit standardized patient assessment data required under section
1899B(b)(1) of the Act in a manner and within the time frames specified
by the Secretary. Section 1888(e)(6)(A)(i) of the Act requires that,
for FYs beginning with FY 2018, if a SNF does not submit data, as
applicable, on quality and resource use and other measures in
accordance with section 1888(e)(6)(B)(i)(II) of the Act and on
standardized patient assessment in accordance with section
1888(e)(6)(B)(i)(III) of the Act for such FY, the Secretary must reduce
the
[[Page 52010]]
market basket percentage described in section 1888(e)(5)(B)(ii) of the
Act by 2 percentage points. The SNF QRP applies to freestanding SNFs,
SNFs affiliated with acute care facilities, and all non-CAH swing-bed
rural hospitals.
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46427
through 46429) for information on the requirements of the IMPACT Act
In the FY 2016 SNF PPS final rule, we finalized the general
timeline and sequencing of activities under the SNF QRP. Please refer
to the FY 2016 SNF PPS final rule (80 FR 46427 through 46429) for more
information on these topics.
In addition, in implementing the SNF QRP and IMPACT Act
requirements in the FY 2016 SNF PPS final rule, we established our
approach for identifying cross-setting measures and processes for the
adoption of measures including the application and purpose of the
Measure Application Partnership (MAP) and the notice and comment
rulemaking process. For more information on these topics, please refer
to the FY 2016 SNF PPS final rule (80 FR 46427 through 46429).
b. General Considerations Used for Selection of Measures for the SNF
QRP
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46429
through 46431) for a detailed discussion of the considerations we apply
in measure selection for the SNF QRP, such as alignment with the CMS
Quality Strategy,\26\ which incorporates the three broad aims of the
National Quality Strategy.\27\ Overall, we strive to promote high
quality and efficiency in the delivery of health care to the
beneficiaries we serve. Performance improvement leading to the highest
quality health care requires continuous evaluation to identify and
address performance gaps and reduce the unintended consequences that
may arise in treating a large, vulnerable, and aging population. QRPs,
coupled with public reporting of quality information, are critical to
the advancement of health care quality improvement efforts. Valid,
reliable, and relevant quality measures are fundamental to the
effectiveness of our QRPs. Therefore, selection of quality measures is
a priority for CMS in all of its QRPs.
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\26\ http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html.
\27\ http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.
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In the FY 2017 SNF PPS proposed rule, we proposed to adopt for the
SNF QRP one measure that we are specifying under section 1899B(c)(1)(C)
of the Act to meet the Medication Reconciliation domain: (1) Drug
Regimen Review Conducted with Follow-Up for Identified Issues--Post-
Acute Care Skilled Nursing Facility Quality Reporting Program. Further,
we proposed to adopt for the SNF QRP three measures to meet the
resource use and other measure domains identified in section
1899B(d)(1) of the Act: (1) Medicare Spending per Beneficiary--Post-
Acute Care Skilled Nursing Facility Quality Reporting Program; (2)
Discharge to Community--Post Acute Care Skilled Nursing Facility
Quality Reporting Program; and (3) Potentially Preventable 30-Day Post-
Discharge Readmission Measure for Skilled Nursing Facility Quality
Reporting Program.
In our development and specification of measures, we employ a
transparent process in which we seek input from stakeholders and
national experts and engage in a process that allows for pre-rulemaking
input on each measure, as required by section 1890A of the Act.
To meet this requirement, we provided the following opportunities
for stakeholder input. Our measure development contractor convened
technical expert panels (TEPs) that included stakeholder experts and
patient representatives on July 29, 2015 for the Drug Regimen Review
Conducted with Follow-Up for Identified Issues--PAC SNF QRP, on August
25, 2015, September 25, 2015, and October 5, 2015 for the Discharge to
Community--PAC SNF QRP, on August 12 and 13, 2015 and October 14, 2015
for the Potentially Preventable 30-Day Post-Discharge Readmission
Measure for SNF QRP, and on October 29 and 30, 2015 for the Medicare
Spending per Beneficiary measures. In addition, we released draft
quality measure specifications for public comment on the Drug Regimen
Review Conducted with Follow-Up for Identified Issues--PAC SNF QRP from
September 18, 2015 to October 6, 2015, for the Discharge to Community--
PAC SNF QRP from November 9, 2015 to December 8, 2015, for the
Potentially Preventable 30-Day Post-Discharge Readmission Measure for
SNF QRP from November 2, 2015 to December 1, 2015, and for the Medicare
Spending per Beneficiary measures from January 13, 2016 to February 5,
2016. Further, we implemented a public mailbox,
[email protected], for the submission of public
comments. This PAC mailbox is accessible on our post-acute care quality
initiatives Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-MeasuresMeasures.html.
Additionally, we sought public input from the MAP PAC, Long-Term
Care Workgroup during the annual in-person meeting held December 14 and
15, 2015. The final MAP report is available at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx. The MAP is composed of multi-stakeholder groups convened
by the NQF, our current contractor under section 1890(a) of the Act,
tasked to provide input on the selection of quality and efficiency
measures described in section 1890(b)(7)(B) of the Act.
The MAP reviewed each measure that we proposed in the proposed rule
for use in the SNF QRP. For more information on the MAP, we refer
readers to the FY 2016 SNF PPS final rule (80 FR 46430 through 46431).
Further, for more information on the MAP's recommendations, we refer
readers to the MAP 2015-2016 Considerations for Implementing Measures
in Federal Programs public report at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
We received a number of general comments on our measure selection
process.
Comment: Many commenters supported the goals of the IMPACT Act,
including the implementation of cross-setting measures across PAC
settings. One of these commenters stated that the use of standardized
and interoperable patient assessment data will allow for better cross-
setting comparisons of quality and will support the development of
better quality measures with uniform risk standardization. The
commenter also recognized that the standardization of data collected
across PAC settings is an ongoing process and will require continued
refinement.
Response: We appreciate the commenters' support for the
implementation of cross-setting measures across PAC settings as
required by the IMPACT Act. We believe that standardizing patient
assessment data will allow for the exchange of data among PAC providers
in order to facilitate care coordination and improve patient outcomes.
Comment: Several commenters expressed concern with the compressed
timeline in which CMS is adopting measures for the SNF QRP.
[[Page 52011]]
Additionally, one commenter believes the ``hurried pace'' of the
development process may lead to negative unintended consequences and
may preclude stakeholder input. The commenter suggested that a less
compressed comment period and implementation timeline provided would be
less disruptive to measure development. Several commenters suggested
that the measures be refined further prior to their implementation in
the SNF QRP.
Response: We recognize the timeline and pace to implement the
requirements of the IMPACT Act is ambitious. However, we have taken
steps to ensure the scientific rigor of measure development, including
testing measures under development and soliciting stakeholder feedback
during both the measure development and rulemaking process. We have
also worked to be responsive to stakeholder concerns about the length
of various comment periods, and in response to those concerns, we have
extended our public comment periods for measures under development on
several occasions. We also encourage feedback through our IMPACT Act
PAC Quality Initiative resource and feedback mailbox at
[email protected] or at the SNF QRP resource and
feedback mailbox at [email protected]. We intend to
continually monitor, refine, and update all measures if necessary to
ensure that they do not result in unintended consequences. With regard
to refining measures prior to their implementation, we interpret this
to refer to further refinement of the measures prior to adoption. We
understand and agree that measures should be developed prior to
adoption and have engaged in several activities to ensure further
refinement which are described in the specifc measure sections below.
Comment: One commenter expressed concern that SNFs will be held
responsible for outcomes of care when other care coordination
arrangements such as Accountable Care Organizations, Medicare bundled
payments, and Medicaid managed care arrangements for dual eligibles are
available. The commenter believes that overlapping care coordination
initiatives and SNF QRP measures will cause confusion and diffuse
accountability for the outcomes of care. One commenter suggested
streamlining measures to reduce the redundancy of reporting. Another
commenter was concerned that SNFs would be confused by the various
measures, and thought that there would be unintended consequences as a
result.
Response: Although we recognize that there might be some overlap
along the lines suggested by the commenters, the SNF QRP is being
designed to assess the quality care specific furnished by SNFs to
Medicare beneficiaires. We believe that this information will be
important for quality improvement purposes. We will continue to provide
outreach and education to SNFs including trainings and National
Provider Calls to help them understand the requirements and measures
adopted for the SNF QRP. We also appreciate the concern that SNF QRP
measures be aligned to minimize reporting requirements when possible.
We will nonetheless seek, where feasible, to align the SNF QRP with
existing reporting requirements.
Comment: We received several comments regarding NQF endorsement of
the proposed measures. One commenter voiced support of the measures and
encouraged submission of the measures for NQF endorsement. Several
commenters expressed concern about the lack of NQF endorsement for
measures and suggested additional measure testing and development. One
commenter requested that CMS provide a timeline for submission of the
measures to NQF. Additionally, commenters recommended NQF endorsement
prior to public reporting.
Response: We recognize the importance of consensus endorsement and,
where possible, seek to adopt measures for the SNF QRP that are
endorsed by the NQF. To the extent that we adopt measures under our
exception authority, we intend to seek NQF-endorsement of those
measures and will do so as soon as is feasible. Regardless of whether
the measures are or are not NQF-endorsed at the time we adopt them,
they have all been tested for reliability and validity, and we believe
that the results of that testing support our conclusion that they are
sufficiently reliable and valid to warrant their adoption in the SNF
QRP. The results of our reliability and validity testing for these
measures may be found in Measure Specifications for Measures Adopted in
the FY 2017 SNF QRP Final Rule, posted on the CMS SNF QRP Web page at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
Comment: Several commenters stated that the NQF MAP committee did
not support the proposed measures; instead, they recommended that we
delay measure implementation until the measures are fully developed and
tested and brought back to the MAP for further consideration. One
commenter suggested that TEP members and other stakeholders who
provided feedback in the measure development process did not support
the measures moving forward without further testing.
Response: We interpret this comment to address the activities of
the Measures Application Partnership, a multi-stakeholder partnership
convened by NQF that provides input to the U.S. Department of Health
and Human Services (HHS) on its selection of measures for certain
Medicare programs. We would like to clarify that the MAP provided the
recommendation of ``encourage continued development'' for the proposed
measures. According to the MAP, the term ``encourage continued
development,'' is applied when a measure addresses a critical program
objective or promotes alignment but is in an earlier stage of
development. In contrast, the MAP uses the phrase ``do not support''
when it does not support a measure at all.
Since the MAP recommendation of ``encourage continued development''
for the proposed measures during the December 2015 NQF-convened PAC LTC
MAP meeting, we have further refined the measure specifications based
on additional validity and reliability testing. Our efforts included: A
pilot test in 12 post-acute care settings, including SNFs, to determine
the feasibility of assessment items for use in calculation of the Drug
Regimen Review Conducted with Follow-Up for Identified Issues measure
and further development of risk-adjusted models for the Discharge to
Community, Medicare Spending per Beneficiary and Potentially
Preventable Readmissions measures. Additional information regarding
testing that was performed since the MAP Meeting, TEP meetings, and
public comment periods is further described below in our responses to
comments on individual proposed measures.
For these reasons, we believe that the measures have been fully and
robustly developed, and believe they are appropriate for implementation
and should not be delayed.
Comment: One commenter expressed concern about a lack of
consistency and comparability of measures across PAC settings and
believed it inappropriate to compare performance across provider types
due to the lack of appropriate risk adjustment. We also received
comments from MedPAC conveying that findings from their work on a
unified PAC payment system suggest overlap in where Medicare
beneficiaries are treated for similar care in PAC settings. As a result
of this work, MedPAC
[[Page 52012]]
recommended that the IMPACT Act measures use a uniform definition,
specification, and risk adjustment method to facilitate quality
comparison across PAC settings to inform Medicare beneficiary choice,
and so that Medicare can evaluate the value of services it pays for.
MedPAC further noted that differences in rates should reflect
differences in quality of care rather than differences in the way rates
are constructed.
Response: For each of the proposed measures, we applied consistent
models where feasible in order to develop their definitions, other
technical specifications and approach to risk-adjustment.
However, there are nuances among the four PAC provider types which
must be taken into account in order to address issues such as patient
acuity and medical complexity. As a result, we have risk-adjusted
measures and included provider-specific refinements. For example, for
the Discharge to Community measure, risk adjustment for ventilator use
is included in LTCH and SNF settings, but not IRF settings. We
investigated the need for risk adjustment for ventilator use in IRFs,
but found that less than 0.01 percent of the IRF population had
ventilator use in the IRF. Given the low frequency of ventilator use in
IRFs, any associated estimates would not be reliable; thus, ventilator
use is not included as a risk adjuster in the IRF setting measure. We
believe that the measures proposed for the SNF QRP will inform
beneficiaries on the differences in quality rather than differences in
measure construction because we have taken into account the factors
necessary to ensure meaningful comparability within the SNF providers
and as able, across the post-acute providers.
Comment: A number of commenters expressed concerns regarding the
validity and reliability of IMPACT Act measures and encouraged us to
analyze data to ensure comparability across post-acute care settings,
prior to implementation.
Response: We have tested for validity and reliability all of the
IMPACT Act measures, and the results of that testing is available in
Measure Specifications for Measures Adopted in the FY 2017 SNF QRP
Final Rule, posted on the CMS SNF QRP Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
We intend to continue to monitor the reliability and validity of
the SNF QRP measures, including whether the measures are reliable and
valid for cross-setting purposes.
Comment: One commenter expressed concern that the proposed measures
could adversely affect low-volume or rural SNFs. Another commenter
expressed concerns about the ability to compare measure rates across
facilities due to varying patient volumes, recommending the use of
patient days as the denominator for SNF quality measures.
Response: We do not believe the proposed measures will adversely
affect low-volume or rural SNFs. We wish to clarify that our measures
and/or our proposals to implement these measures were designed to
mitigate any potential impact that may be caused by low volume. For
example, the statistical approach used for two of the claims-based
measures incorporates a shrinkage estimator intended to ensure that
smaller facilities are not vulnerable to rates driven by the influence
of random variation in their raw rates. Additionally, for some of the
measures, public reporting requirements exclude reporting of facilities
with fewer than 25 resident stays during the reporting period. We would
like to clarify that the quality, resource use and other measures in
the SNF QRP are based on stay-level outcomes, not day-level outcomes.
The measures examine events occurring at SNF discharge or after SNF
discharge; therefore, the measures are based on number of discharges.
For example, the proposed quality measure Drug Regimen Review Conducted
with Follow-Up for Identified Issues--PAC SNF QRP would not be
appropriate for data calculation on a daily basis. The data collected
for this measure is at admission and discharge and reflects data
recorded throughout the entire patient stay.
Comment: One commenter expressed concern that the proposed measures
will incentivize SNFs to avoid admitting medically complex residents,
which would result in unintended consequences.
Response: To mitigate the risk of creating incentives for SNFs to
avoid admitting medically complex residents, who may be at higher risk
for poor outcomes and higher costs, we have included factors related to
medical complexity in the risk adjustment methodology used in our
measures. We also intend to conduct ongoing monitoring to assess for
potential unintended consequences associated with the implementation of
these measures.
c. Policy for Retaining SNF QRP Measures Adopted for Future Payment
Determinations
In the FY 2016 SNF PPS final rule (80 FR 46431 through 46432), we
finalized our policy for measure removal and also finalized that when
we adopt a measure for the SNF QRP for a payment determination, this
measure will be automatically retained in the SNF QRP for all
subsequent payment determinations unless we propose to remove, suspend,
or replace the measure. We did not propose any new policies related to
measure retention or removal in the FY 2017 SNF PPS proposed rule. For
further information on how measures are considered for removal,
suspension, or replacement, please refer to the FY 2016 SNF PPS final
rule (80 FR 46431 through 46432).
d. Process for Adoption of Changes to SNF QRP Measures
In the FY 2016 SNF PPS final rule (80 FR 46432), we finalized our
policy pertaining to the process for adoption of non-substantive and
substantive changes to SNF QRP measures. We did not propose to make any
changes to this policy.
e. Quality Measures Previously Finalized for Use in the SNF QRP
The SNF QRP quality measures for the FY 2018 payment determinations
and subsequent years are presented in Table 11. Measure specifications
for the previously adopted measures adapted from non-SNF settings are
available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html under the downloads section at
the bottom of the page.
[[Page 52013]]
Table 11--Quality Measures Previously Finalized for Use in the SNF QRP
----------------------------------------------------------------------------------------------------------------
SNF PPS final Annual payment determination:
Measure title and NQF # rule Data collection start date Initial and subsequent APU years
----------------------------------------------------------------------------------------------------------------
Percent of Residents or Adopted in the October 1, 2016............ FY 2018 and subsequent years.
Patients with Pressure FY 2016 SNF PPS
Ulcers That Are New or Final Rule (80
Worsened (Short Stay) (NQF FR 46433
#0678). through 46440).
Application of the NQF- Adopted in the October 1, 2016............ FY 2018 and subsequent years.
endorsed Percent of FY 2016 SNF PPS
Residents Experiencing One Final Rule (80
or More Falls with Major FR 46440
Injury (Long Stay) (NQF through 46444).
#0674).
Application of Percent of Adopted in the October 1, 2016............ FY 2018 and subsequent years.
Long-Term Care Hospital FY 2016 SNF PPS
Patients with an Admission Final Rule (80
and Discharge Functional FR 46444
Assessment and a Care Plan through 46453).
That Addresses Function (NQF
#2631).
----------------------------------------------------------------------------------------------------------------
f. SNF QRP Quality, Resource Use and Other Measures for FY 2018 Payment
Determinations and Subsequent Years
For the FY 2018 payment determination and subsequent years, in
addition to the quality measures identified in Table 11 that we are
retaining under our policy described in section V.B.3., we proposed to
adopt three new measures for the SNF QRP. These three measures were
developed to meet the requirements of the IMPACT Act. They are: (1)
Medicare Spending per Beneficiary--PAC SNF QRP; (2) Discharge to
Community--PAC SNF QRP; and (3) Potentially Preventable 30-Day Post-
Discharge Readmission Measure for SNF QRP. Through the use of
standardized quality measures and standardized data, the intent of the
Act, among other obligations, is to enable interoperability and access
to longitudinal information for such providers to facilitate
coordinated care, improved outcomes, and overall quality comparisons.
The measures are described in more detail below.
For the risk adjustment of the resource use and other measures, we
understand the important role that sociodemographic status plays in the
care of patients. However, we continue to have concerns about holding
providers to different standards for the outcomes of their patients of
diverse sociodemographic status because we do not want to mask
potential disparities or minimize incentives to improve the outcomes of
disadvantaged populations. We routinely monitor the impact of
sociodemographic status on providers' results on our measures.
The NQF is currently undertaking a 2-year trial period in which new
measures and measures undergoing maintenance review will be assessed to
determine if risk-adjusting for sociodemographic factors is
appropriate. For 2-years, NQF will conduct a trial of temporarily
allowing inclusion of sociodemographic factors in the risk-adjustment
approach for some performance measures. At the conclusion of the trial,
NQF will issue recommendations on future permanent inclusion of
sociodemographic factors. During the trial, measure developers are
expected to submit information such as analyses and interpretations as
well as performance scores with and without sociodemographic factors in
the risk adjustment model.
Furthermore, the Office of the Assistant Secretary for Planning and
Evaluation (ASPE) is conducting research to examine the impact of
sociodemographic status on quality measures, resource use, and other
measures under the Medicare program as directed by the IMPACT Act. We
will closely examine the findings of the ASPE reports and related
Secretarial recommendations and consider how they apply to our quality
programs at such time as they are available.
We invited public comment on how socioeconomic and demographic
factors should be used in risk adjustment for the resource use and
other measures. The comments we received on this topic, with their
responses, appear below.
Comment: Several commenters supported the inclusion of
sociodemographic status adjustment in quality measures, resource use,
and other measures. Commenters suggested that failure to account for
these patient characteristics could penalize SNFs for providing care to
a more medically-complex and socioeconomically disadvantaged patient
population and affect provider performance. Some commenters expressed
concerns about standardization and interoperability of the measures as
it pertains to risk-adjusting, particularly for SDS characteristics.
Many commenters recommended incorporating socioeconomic factors as
risk-adjustors for the measures and several commenters suggested
conducting additional testing and/or NQF endorsement prior to
implementation of these measures. In addition, many commenters
recommended including functionality as an additional risk-adjustment
factor, and several commenters suggested risk-adjustment for cognitive
impairment. One commenter recommended varied standards for patient
outcomes with individuals of diverse SDS statuses.
A few commenters, including MedPAC, did not support risk-adjustment
of measures by SES or SDS status. One commenter did not support risk-
adjustment because it can hide disparities and create different
standards of care for SNFs based on the demographics in the facility.
MedPAC stated that risk adjustment can hide disparities in care and
suggested that risk-adjustment reduces pressure on providers to improve
quality of care for low-income Medicare beneficiaries. Instead, MedPAC
supported peer provider group comparisons with providers of similar
low-income beneficiary populations. Another commenter stated that SDS
factors should not be included in measures that assess the resident
outcome during a SNF stay, but should only be considered for measures
evaluating care after the SNF discharge.
Response: We appreciate the considerations and suggestions conveyed
in relation to the measures and the importance in balancing appropriate
risk adjustment along with ensuring access to high quality care. We
note that in the measures that are risk adjusted we do take into
account characteristics associated with medical complexity, as well as
factors such as age where appropriate to do so. For those cross-setting
post-acute measures such as those intended to satisfy the IMPACT Act
domains that use the
[[Page 52014]]
patient assessment-based data elements for risk adjustment, we have
either made such items standardized, or intend to do so as feasible.
With regard to the incorporation of additional factors, such as
cognitive impairment and function, we have and will continue to take
such factors into account, which would include further testing as part
of our ongoing measure development monitoring activities. As discussed
previously, we intend to seek NQF endorsement for our measures.
We also received suggestions pertaining to the incorporation of
socioeconomic factors as risk-adjustors for the measures, including in
those measures that pertain to after the resident was discharged from
the SNF, additional testing and/or NQF endorsement prior to
implementation of these measures, and comments that pertain to
potential consequences associated with such risk adjustors and
alternative approaches to grouping comparative data. We wish to
reiterate that as previously discussed, NQF is currently undertaking a
2-year trial period in which new measures and measures undergoing
maintenance review will be assessed to determine if risk-adjusting for
sociodemographic factors is appropriate. This trial entails temporarily
allowing inclusion of sociodemographic factors in the risk-adjustment
approach for some performance measures. At the conclusion of the trial,
NQF will issue recommendations on future permanent inclusion of
sociodemographic factors. During the trial, measure developers are
encouraged to submit information such as analyses and interpretations
as well as performance scores with and without sociodemographic factors
in the risk adjustment model. Several measures developed by CMS have
been brought to NQF since the beginning of the trial. CMS, in
compliance with NQF's guidance, has tested sociodemographic factors in
the measures' risk models and made recommendations about whether or not
to include these factors in the endorsed measure. We intend to continue
engaging in the NQF process as we consider the appropriateness of
adjusting for sociodemographic factors in our outcome measures.
Furthermore, the Office of the Assistant Secretary for Planning and
Evaluation (ASPE) is conducting research to examine the impact of
sociodemographic status on quality measures, resource use, and other
measures under the Medicare program as directed by the IMPACT Act. We
will closely examine the findings of the ASPE reports and related
Secretarial recommendations and consider how they apply to our quality
programs at such time as they are available.
i. Measure That Addresses the IMPACT Act Domain of Resource Use and
Other Measures: Total Estimated MSPB-PAC SNF QRP
We proposed an MSPB-PAC SNF QRP measure for inclusion in the SNF
QRP for the FY 2018 payment determination and subsequent years. Section
1899B(d)(1)(A) of the Act requires the Secretary to specify resource
use measures, including total estimated Medicare spending per
beneficiary, on which PAC providers consisting of SNFs, Inpatient
Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and
Home Health Agencies (HHAs) are required to submit necessary data
specified by the Secretary.
Rising Medicare expenditures for post-acute care as well as wide
variation in spending for these services underlines the importance of
measuring resource use for providers rendering these services. Between
2001 and 2013, Medicare PAC spending grew at an annual rate of 6.1
percent and doubled to $59.4 billion, while payments to inpatient
hospitals grew at an annual rate of 1.7 percent over this same
period.\28\ A study commissioned by the Institute of Medicine found
that variation in PAC spending explains 73 percent of variation in
total Medicare spending across the United States.\29\
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\28\ MedPAC, ``A Data Book: Health Care Spending and the
Medicare Program,'' (2015). 114.
\29\ Institute of Medicine, ``Variation in Health Care Spending:
Target Decision Making, Not Geography,'' (Washington, DC: National
Academies 2013). 2.
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We reviewed the NQF's consensus-endorsed measures and were unable
to identify any NQF-endorsed resource use measures for PAC settings. As
such, we proposed this MSPB-PAC SNF QRP measure under the Secretary's
authority to specify non--NQF-endorsed measures under section
1899B(e)(2)(B) of the Act. Given the current lack of resource use
measures for PAC settings, our MSPB-PAC SNF QRP measure would provide
valuable information to SNF providers on their relative Medicare
spending in delivering services to approximately 1.7 million Medicare
beneficiaries.\30\
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\30\ 2013 figures. MedPAC, ``Medicare Payment Policy,'' Report
to the Congress (2015). xvii-xviii.
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The MSPB-PAC SNF QRP episode-based measure would provide actionable
and transparent information to support SNF providers' efforts to
promote care coordination and deliver high quality care at a lower cost
to Medicare. The MSPB-PAC SNF QRP measure holds SNF providers
accountable for the Medicare payments within an ``episode of care''
(episode), which includes the period during which a patient is directly
under the SNF's care, as well as a defined period after the end of the
SNF treatment, which may be reflective of and influenced by the
services furnished by the SNF. MSPB-PAC SNF QRP episodes, constructed
according to the methodology described below, have high levels of
Medicare spending with substantial variation. In FY 2014, Medicare FFS
beneficiaries experienced 1,534,773 MSPB-PAC SNF QRP episodes. The mean
payment-standardized, risk-adjusted episode spending for these episodes
is $26,279. There is substantial variation in the Medicare payments for
these MSPB-PAC SNF QRP episodes--ranging from approximately $6,090 at
the 5th percentile to approximately $60,050 at the 95th percentile.
This variation is partially driven by variation in payments occurring
after SNF treatment.
Evaluating Medicare payments during an episode creates a continuum
of accountability between providers that should improve post-treatment
care planning and coordination. While some stakeholders throughout the
measure development process supported the MSPB-PAC measures and felt
that measuring Medicare spending was critical for improving efficiency,
others believed that resource use measures did not reflect quality of
care in that they do not take into account patient outcomes or
experience beyond those observable in claims data. However, SNFs
involved in the provision of high-quality PAC care as well as
appropriate discharge planning and post-discharge care coordination
would be expected to perform well on this measure since beneficiaries
would likely experience fewer costly adverse events (for example,
avoidable hospitalizations, infections, and emergency room usage).
Further, it is important that the cost of care be explicitly measured
so that, in conjunction with other quality measures, we can publicly
report which SNFs provide high quality care at lower cost.
We developed a MSPB-PAC measure for each of the four PAC settings.
We proposed an LTCH-specific MSPB-PAC measure in the FY 2017 IPPS/LTCH
proposed rule (81 FR 25216 through 25220), an IRF-specific MSBP-PAC
measure in the FY 2017 IRF proposed rule (81 FR 24197 through 24201), a
SNF-specific MSPB-PAC measure in the FY 2017 SNF proposed rule (81 FR
24258 through 24262), and a HHA-specific MSBP-PAC measure in the CY
[[Page 52015]]
2017 HH proposed rule (81 FR 43760 through 43764). The four setting-
specific MSPB-PAC measures are closely aligned in terms of episode
construction and measure calculation. Each MSPB-PAC measure assesses
Medicare Part A and Part B spending within an episode, and the
numerator and denominator are defined similarly. However, setting-
specific measures allow us to account for differences between settings
in payment policy, the types of data available, and the underlying
health characteristics of beneficiaries.
The MSPB-PAC measures mirror the general construction of the
inpatient prospective payment system (IPPS) hospital MSPB measure,
which was adopted for the Hospital IQR Program beginning with the FY
2014 program, and was implemented in the Hospital VBP Program beginning
with the FY 2015 program. The measure was endorsed by the NQF on
December 6, 2013 (NQF #2158).\31\ The hospital MSPB measure evaluates
hospitals' Medicare spending relative to the Medicare spending for the
national median hospital during a hospital MSPB episode. It assesses
Medicare Part A and Part B payments for services performed by hospitals
and other healthcare providers within a hospital MSPB episode, which is
comprised of the periods immediately prior to, during, and following a
patient's hospital stay.32 33 Similarly, the MSPB-PAC
measures assess all Medicare Part A and Part B payments for fee-for-
service (FFS) claims with a start date during the episode window
(which, as discussed in this section, is the time period during which
Medicare FFS Part A and Part B services are counted towards the MSPB-
PAC SNF QRP episode). There are differences between the MSPB-PAC
measures and the hospital MSPB measure to reflect differences in
payment policies and the nature of care provided in each PAC setting.
For example, the MSPB-PAC measures exclude a limited set of services
(for example, for clinically unrelated services) provided to a
beneficiary during the episode window, while the hospital MSPB measure
does not exclude any services.
---------------------------------------------------------------------------
\31\ QualityNet, ``Measure Methodology Reports: Medicare
Spending per Beneficiary (MSPB) Measure,'' (2015). http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772053996.
\32\ QualityNet, ``Measure Methodology Reports: Medicare
Spending per Beneficiary (MSPB) Measure,'' (2015). http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772053996.
\33\ FY 2012 IPPS/LTCH PPS Final Rule (76 FR 51619).
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MSPB-PAC episodes may begin within 30 days of discharge from an
inpatient hospital as part of a patient's trajectory from an acute to a
PAC setting. A SNF stay beginning within 30 days of discharge from an
inpatient hospital would therefore be included once in the hospital's
MSPB measure, and once in the SNF provider's MSPB-PAC measure. Aligning
the hospital MSPB and MSPB-PAC measures in this way creates continuous
accountability and aligns incentives to improve care planning and
coordination across inpatient and PAC settings.
We sought and considered the input of stakeholders throughout the
measure development process for the MSPB-PAC measures. We convened a
TEP consisting of 12 panelists with combined expertise in all of the
PAC settings on October 29 and 30, 2015 in Baltimore, Maryland. A
follow-up email survey was sent to TEP members on November 18, 2015 to
which seven responses were received by December 8, 2015. The MSPB-PAC
TEP Summary Report is available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/Technical-Expert-Panel-on-Medicare-Spending-Per-Beneficiary.pdf. The measures were also presented to the
MAP Post-Acute Care/Long-Term Care (PAC/LTC) Workgroup on December 15,
2015. As the MSPB-PAC measures were under development, there were three
voting options for members: Encourage continued development, do not
encourage further consideration, and insufficient information.\34\ The
MAP PAC/LTC workgroup voted to ``encourage continued development'' for
each of the MSPB-PAC measures.\35\ The MAP PAC/LTC workgroup's vote of
``encourage continued development'' was affirmed by the MAP
Coordinating Committee on January 26, 2016.\36\ The MAP's concerns
about the MSPB-PAC measures, as outlined in their final report ``MAP
2016 Considerations for Implementing Measures in Federal Programs:
Post-Acute Care and Long-Term Care'' and Spreadsheet of Final
Recommendations, were taken into consideration during the measure
development process and are discussed as part of our responses to
public comments, described below.37 38
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\34\ National Quality Forum, Measure Applications Partnership,
``Process and Approach for MAP Pre-Rulemaking Deliberations, 2015-
2016'' (February 2016) http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81693.
\35\ National Quality Forum, Measure Applications Partnership
Post-Acute Care/Long-Term Care Workgroup, ``Meeting Transcript--Day
2 of 2'' (December 15, 2015) 104-106 http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81470.
\36\ National Quality Forum, Measure Applications Partnership,
``Meeting Transcript--Day 1 of 2'' (January 26, 2016) 231-232 http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81637.
\37\ National Quality Forum, Measure Applications Partnership,
``MAP 2016 Considerations for Implementing Measures in Federal
Programs: Post-Acute Care and Long-Term Care'' Final Report,
(February 2016) http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
\38\ National Quality Forum, Measure Applications Partnership,
``Spreadsheet of MAP 2016 Final Recommendations'' (February 1, 2016)
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81593.
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Since the MAP's review and recommendation of continued development,
CMS continued to refine risk adjustment models and conduct measure
testing for the IMPACT Act measures consistent with the MAP's
recommendations. The IMPACT Act measures are consistent with the
information submitted to the MAP and support the scientific
acceptability of these measures for use in quality reporting programs.
In addition, a public comment period, accompanied by draft measures
specifications, was open from January 13 to 27, 2016 and extended to
February 5. A total of 45 comments on the MSPB-PAC measures were
received during this 3.5 week period. The comments received also
covered each of the MAP's concerns as outlined in their Final
Recommendations.\39\ The MSPB-PAC Public Comment Summary Report is
available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/2016_03_24_mspb_pac_public_comment_summary_report.pdf and the MSPB-PAC
Public Comment Supplementary Materials are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/2016_03_24_mspb_pac_public_comment_summary_report_supplementary_materials.pdf: These documents contain the public comments, along with our
responses including statistical analyses. The MSPB-PAC SNF QRP measure,
along with the other MSPB-PAC measures, as applicable, will be
submitted for NQF endorsement when feasible.
---------------------------------------------------------------------------
\39\ National Quality Forum, Measure Applications Partnership,
``Spreadsheet of MAP 2016 Final Recommendations'' (February 1, 2016)
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81593.
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To calculate the MSPB-PAC SNF QRP measure for each SNF provider, we
first
[[Page 52016]]
define the construction of the MSPB-PAC SNF QRP episode, including the
length of the episode window as well as the services included in the
episode. Next, we apply the methodology for the measure calculation.
The specifications are discussed further in this section. More detailed
specifications for the MSPB-PAC measures, including the MSPB-PAC SNF
QRP measure, are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
The comments we received on this topic, with their responses,
appear below.
Comment: Several commenters expressed concern about the lack of NQF
endorsement for proposed measures; some believed that the measure
should not be finalized until NQF endorsement is obtained.
Response: We thank the commenters for their concern regarding the
lack of NQF endorsement and refer readers to section III.D.2.b. where
we also discuss this topic.
Comment: Several commenters noted the NQF MAP committee did not
endorse the proposed measure, believing that the measure should not be
finalized until the support of the MAP is obtained.
Response: We appreciate the comments about the NQF MAP committee,
and direct readers to section III.D.2.b. where we also discuss this
topic.
Comment: Some commenters recommended the use of uniform single
MSPB-PAC measure that could be used to compare providers' resource use
across settings, but they also recognized that we do not have a uniform
PPS for all the PAC settings currently. In the absence of a single PAC
PPS, they recommend a single MSPB-PAC measure for each setting that
could be used to compare providers within a setting. Under a single
measure, the episode definitions, service inclusions/exclusions, and
risk adjustment methods would be the same across all PAC settings.
Response: We thank the commenters. The four separate MSPB-PAC
measures reflect the unique characteristics of each PAC setting and the
population it serves. The four setting specific MSPB-PAC measures are
defined as consistently as possible across settings given the
differences in the payment systems for each setting, and types of
patients served in each setting. We have taken into consideration these
differences and aligned the specifications, such as episode
definitions, service inclusions/exclusions and risk adjustment methods
for each setting, to the extent possible while ensuring the accuracy of
the measures in each PAC setting.
Each of the measures assess Medicare Part A and Part B spending
during the episode window which begins upon admission to the provider's
care and ends 30 days after the end of the treatment period. The
service-level exclusions are harmonized across settings. The definition
of the numerator and denominator is the same across settings. However,
specifications differ between settings when necessary to ensure that
the measures accurately reflect patient care and align with each
setting's payment system. For example, Medicare pays LTCHs and IRFs a
stay-level payment based on the assigned MS-LTC-DRG and CMG,
respectively, while SNFs are paid a daily rate based on the RUG level,
and HHA providers are reimbursed based on a fixed 60-day period for
standard home health claims. While the definition of the episode window
is consistent across settings and is based on the period of time that a
beneficiary is under a given provider's care, the duration of the
treatment period varies to reflect how providers are reimbursed under
the PPS that applies to each setting. The length of the post-treatment
period is consistent between settings. There are also differences in
the services covered under the PPS that applies to each setting: For
example, durable medical equipment, prosthetics, orthotics, and
supplies (DMEPOS) claims are covered LTCH, IRF, and SNF services but
are not covered HHA services. This affects the way certain first-day
service exclusions are defined for each measure.
We recognize that beneficiaries may receive similar services as
part of their overall treatment plan in different PAC settings, but
believe that there are some important differences in beneficiaries'
care profiles that are difficult to capture in a single measure that
compares resource use across settings.
Also, the risk adjustment models for the MSPB-PAC measures share
the same covariates to the greatest extent possible to account for
patient case mix. However, the measures also incorporate additional
setting-specific information where available to increase the predictive
power of the risk adjustment models. For example, the MSPB-PAC LTCH QRP
risk adjustment model uses MS-LTC-DRGs and Major Diagnostic Categories
(MDCs) and the MSPB-PAC IRF QRP model includes Rehabilitation
Impairment Categories (RICs). The HH and SNF settings do not have
analogous variables that directly reflect a patient's clinical profile.
We will continue to work towards a more uniform measure across
settings as we gain experience with these measures, and we plan to
conduct further research and analyses about comparability of resource
use measures across settings for clinically similar patients, different
treatment periods and windows, risk adjustment, service exclusions, and
other factors.
Comment: A few commenters noted that the MSPB-PAC measures are
resource use measures that are not a standalone indicator of quality.
Response: We appreciate the comment regarding the proposed MSPB-PAC
measures as resource use measures. The MSPB-PAC SNF QRP measure is one
of four QRP measures that were proposed in the FY 2017 SNF PPS proposed
rule for inclusion in the SNF QRP: In addition to the MSPB-PAC SNF QRP
measure, these proposed measures were the Discharge to Community--PAC
SNF QRP measure (81 FR 24262 through 24264), the Potentially
Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP (81
FR 24264 through 24267), and the Drug Regimen Review Conducted With
Follow-Up for Identified Issues--PAC SNF QRP measure (81 FR 24267
through 24269). As part of the SNF QRP, the MSPB-PAC SNF QRP measure
will be paired with quality measures; we direct readers to section
III.D.2.e. for a discussion of quality measures previously finalized
for use in the SNF QRP. We believe it is important that the cost of
care be explicitly measured so that, in conjunction with other quality
measures, we can publicly report which SNF providers are involved in
the provision of high quality care at lower cost.
Comment: One commenter expressed concern over the short timeframe
available for stakeholder input.
Response: We appreciate the feedback regarding the timing issues
related to IMPACT Act implementation. It is our intent to move forward
with IMPACT Act implementation in a manner in which the measure
development process continues to be transparent, and includes input and
collaboration from experts, the PAC provider community, and the public
at large. It is of the utmost importance to us to continue to engage
stakeholders, including providers as well as residents and their
families, throughout the measure development lifecycle through their
participation in our measure development public comment periods,
[[Page 52017]]
the pre-rulemaking process, TEPs convened by our measure development
contractors, open door forums and other opportunities. We have provided
multiple opportunities for stakeholder input on the MSPB-PAC measures,
including the TEP, NQF MAP public comment period and in-person meeting,
pre-rulemaking public comment period, and 60-day public comment period
on the proposed SNF QRP rule. A summary of TEP proceedings, the MSPB-
PAC Public Comment Summary Report and MSPB-PAC Public Comment
Supplementary Materials are available at the links provided above. We
thank all stakeholders for their thoughtful feedback on and engagement
with the measure development and rulemaking process.
(a) Episode Construction
An MSPB-PAC SNF QRP episode begins at the episode trigger, which is
defined as the patient's admission to a SNF. The admitting facility is
the attributed provider, for whom the MSPB-PAC SNF QRP measure is
calculated. The episode window is the time period during which Medicare
FFS Part A and Part B services are counted towards the MSPB-PAC SNF QRP
episode. Because Medicare FFS claims are already reported to the
Medicare program for payment purposes, SNF providers would not be
required to report any additional data to CMS for calculation of this
measure. Thus, there would be no additional data collection burden from
the implementation of this measure.
The episode window is comprised of a treatment period and an
associated services period. The treatment period begins at the trigger
(that is, on the day of admission to the SNF) and ends on the day of
discharge from that SNF. Readmissions to the same facility occurring
within 7 or fewer days do not trigger a new episode, and instead are
included in the treatment period of the original episode. When two
sequential stays at the same SNF occur within 7 or fewer days of one
another, the treatment period ends on the day of discharge for the
latest SNF stay. The treatment period includes those services that are
provided directly or reasonably managed by the SNF provider that are
directly related to the beneficiary's care plan. The associated
services period is the time during which Medicare Part A and Part B
services (with certain exclusions) are counted towards the episode. The
associated services period begins at the episode trigger and ends 30
days after the end of the treatment period. The distinction between the
treatment period and the associated services period is important
because clinical exclusions of services may differ for each period.
Certain services are excluded from the MSPB-PAC SNF QRP episodes
because they are clinically unrelated to SNF care, and/or because SNF
providers may have limited influence over certain Medicare services
delivered by other providers during the episode window. These limited
service-level exclusions are not counted towards a given SNF provider's
Medicare spending to ensure that beneficiaries with certain conditions
and complex care needs receive the necessary care. Certain services
that are determined to be outside of the control of a SNF provider
include planned hospital admissions, management of certain preexisting
chronic conditions (for example, dialysis for end-stage renal disease
(ESRD), and enzyme treatments for genetic conditions), treatment for
preexisting cancers, organ transplants, and preventive screenings (for
example, colonoscopy and mammograms). Exclusion of such services from
the MSPB-PAC SNF QRP episode ensures that facilities do not have
disincentives to treat patients with certain conditions or complex care
needs.
An MSPB-PAC episode may begin during the associated services period
of an MSPB-PAC SNF QRP episode in the 30 days post-treatment. One
possible scenario occurs where a SNF provider discharges a beneficiary
who is then admitted to an IRF within 30 days. The IRF claim would be
included once as an associated service for the attributed provider of
the first MSPB-PAC SNF QRP episode and once as a treatment service for
the attributed provider of the second MSPB-PAC IRF QRP episode. As in
the case of overlap between hospital and PAC episodes discussed
earlier, this overlap is necessary to ensure continuous accountability
between providers throughout a beneficiary's trajectory of care, as
both providers share incentives to deliver high quality care at a lower
cost to Medicare. Even within the SNF setting, one MSPB-PAC SNF QRP
episode may begin in the associated services period of another MSPB-PAC
SNF QRP episode in the 30 days post-treatment. The second SNF claim
would be included once as an associated service for the attributed SNF
provider of the first MSPB-PAC SNF QRP episode and once as a treatment
service for the attributed SNF provider of the second MSPB-PAC SNF QRP
episode. Again, this ensures that SNF providers have the same
incentives throughout both MSPB-PAC SNF QRP episodes to deliver quality
care and engage in patient-focused care planning and coordination. If
the second MSPB-PAC SNF QRP episode were excluded from the second SNF
provider's MSPB-PAC SNF QRP measure, that provider would not share the
same incentives as the first SNF provider of first MSPB-PAC SNF QRP
episode. The MSPB-PAC SNF QRP measure was designed to benchmark the
resource use of each attributed provider against what its spending is
expected to be as predicted through risk adjustment. As discussed
further in this section, the measure takes the ratio of observed
spending to expected spending for each episode and then takes the
average of those ratios across all of the attributed provider's
episodes. The measure is not a simple sum of all costs across a
provider's episodes, thus mitigating concerns about double counting.
The comments we received on this topic, with their responses,
appear below.
Comment: One commenter expressed concern about how claims are
counted and attributed to providers.
Response: We appreciate the commenter's concern, but note that
there were no further specifics detailing the nature of this concern.
We designed the attribution process to hold SNF providers accountable
for the Medicare payments within an ``episode of care'' (episode),
which includes the period during which a patient is directly under the
SNF's care, as well as a defined period after the end of the SNF
treatment. An MSPB-PAC SNF QRP episode begins at the episode trigger,
which is defined as the patient's admission to a SNF. The admitting
facility is the attributed provider, for whom the MSPB-PAC SNF QRP
measure is calculated. The episode window is the time period during
which Medicare FFS Part A and Part B services are counted towards the
MSPB-PAC SNF QRP episode. The standardized allowed amounts on the
claims for those services are summed to calculate observed episode
spending. Further details on episode construction and attribution, as
they relate to how claims are counted are in the MSPB-PAC Measure
Specifications, a link for which has been provided above.
(b) Measure Calculation
Medicare payments for Part A and Part B claims for services
included in MSPB-PAC SNF QRP episodes, defined according to the
methodology above, are used to calculate the MSPB-PAC SNF QRP measure.
Measure calculation involves determination of the episode exclusions,
the approach for standardizing payments for geographic payment
differences, the methodology
[[Page 52018]]
for risk adjustment of episode spending to account for differences in
patient case mix, and the specifications for the measure numerator and
denominator.
(i) Exclusion Criteria
In addition to service-level exclusions that remove some payments
from individual episodes, we exclude certain episodes in their entirety
from the MSPB-PAC SNF QRP measure to ensure that the MSPB-PAC SNF QRP
measure accurately reflects resource use and facilitates fair and
meaningful comparisons between SNF providers. The episode-level
exclusions are as follows:
Any episode that is triggered by a SNF claim outside the
50 states, DC, Puerto Rico, and U.S. Territories.
Any episode where the claim(s) constituting the attributed
SNF provider's treatment have a standard allowed amount of zero or
where the standard allowed amount cannot be calculated.
Any episode in which a beneficiary is not enrolled in
Medicare FFS for the entirety of a 90-day lookback period (that is, a
90-day period prior to the episode trigger) plus episode window
(including where the beneficiary dies), or is enrolled in Part C for
any part of the lookback period plus episode window.
Any episode in which a beneficiary has a primary payer
other than Medicare for any part of the 90-day lookback period plus
episode window.
Any episode where the claim(s) constituting the attributed
SNF provider's treatment include at least one related condition code
indicating that it is not a prospective payment system bill.
The comments we received on this topic, with their responses,
appear below.
Comment: One commenter expressed general support for the list of
episode-level exclusions proposed for the MSPB-PAC SNF QRP measure.
Response: We thank the commenter for its support.
(ii) Standardization and Risk Adjustment
Section 1899B(d)(2)(C) of the Act requires that the MSPB-PAC
measures are adjusted for the factors described under section
1886(o)(2)(B)(ii) of the Act, which include adjustment for factors such
as age, sex, race, severity of illness, and other factors that the
Secretary determines appropriate. Medicare payments included in the
MSPB-PAC SNF QRP measure are payment standardized and risk-adjusted.
Payment standardization removes sources of payment variation not
directly related to clinical decisions and facilitates comparisons of
resource use across geographic areas. We proposed to use the same
payment standardization methodology that was used in the NQF-endorsed
hospital MSPB measure. This methodology removes geographic payment
differences, such as wage index and geographic practice cost index
(GPCI), incentive payment adjustments, and other add-on payments that
support broader Medicare program goals including indirect graduate
medical education (IME) and hospitals serving a disproportionate share
of uninsured patients (DSH).\40\
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\40\ QualityNet, ``CMS Price (Payment) Standardization--Detailed
Methods'' (Revised May 2015) https://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228772057350.
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Risk adjustment uses patient claims history to account for case-mix
variation and other factors that affect resource use but are beyond the
influence of the attributed SNF provider. To assist with risk
adjustment, we create mutually exclusive and exhaustive clinical case
mix categories using the most recent institutional claim in the 60 days
prior to the start of the MSPB-PAC SNF QRP episode. The beneficiaries
in these clinical case mix categories have a greater degree of clinical
similarity than the overall SNF patient population, and allow us to
more accurately estimate Medicare spending. Our MSPB-PAC SNF QRP
measure, adapted for the SNF setting from the NQF-endorsed hospital
MSPB measure uses a regression framework with a 90-day hierarchical
condition category (HCC) lookback period and covariates including the
clinical case mix categories, HCC indicators, age brackets, indicators
for originally disabled, ESRD enrollment, and long-term care status,
and selected interactions of these covariates where sample size and
predictive ability make them appropriate. We sought and considered
public comment regarding the treatment of hospice services occurring
within the MSPB-PAC SNF QRP episode window. Given the comments
received, we proposed to include the Medicare spending for hospice
services but risk adjust for them, such that MSPB-PAC SNF QRP episodes
with hospice services are compared to a benchmark reflecting other
MSPB-PAC SNF QRP episodes with hospice services. We believe this
strikes a balance between the measure's intent of evaluating Medicare
spending and ensuring that providers do not have incentives against the
appropriate use of hospice services in a patient-centered continuum of
care.
We understand the important role that sociodemographic factors,
beyond age, play in the care of patients. However, we continue to have
concerns about holding providers to different standards for the
outcomes of their patients of diverse sociodemographic status because
we do not want to mask potential disparities or minimize incentives to
improve the outcomes of disadvantaged populations. We will monitor the
impact of sociodemographic status on providers' results on our
measures.
The NQF is currently undertaking a 2-year trial period in which new
measures and measures undergoing maintenance review will be assessed to
determine if risk-adjusting for sociodemographic factors is
appropriate. For 2 years, NQF will conduct a trial of temporarily
allowing inclusion of sociodemographic factors in the risk-adjustment
approach for some performance measures. At the conclusion of the trial,
NQF will issue recommendations on future permanent inclusion of
sociodemographic factors. During the trial, measure developers are
expected to submit information such as analyses and interpretations as
well as performance scores with and without sociodemographic factors in
the risk adjustment model.
Furthermore, the Office of the Assistant Secretary for Planning and
Evaluation (ASPE) is conducting research to examine the impact of
sociodemographic status on quality measures, resource use, and other
measures under the Medicare program as required by the IMPACT Act. We
will closely examine the findings of the ASPE reports and related
Secretarial recommendations and consider how they apply to our quality
programs at such time as they are available.
While we conducted analyses on the impact of age by sex on the
performance of the MSPB-PAC SNF QRP risk-adjustment model, we did not
propose to adjust the MSPB-PAC SNF QRP measure for socioeconomic
factors. As this MSPB-PAC SNF QRP measure would be submitted for NQF
endorsement, we prefer to await the results of this trial and study
before deciding whether to risk adjust for socioeconomic factors. We
will monitor the results of the trial, studies, and recommendations. We
invited public comment on how socioeconomic and demographic factors
should be used in risk adjustment for the MSPB-PAC SNF QRP measure. The
comments we received on this topic, with their responses, appear below.
[[Page 52019]]
Comment: Several commenters recommended that the risk adjustment
model for the MSPB-PAC SNF QRP measure include variables for SES/SDS
factors. A commenter recommended that a ``fairer'' approach than using
SES/SDS factors as risk adjustment variables would be to compare
resource use levels that have not been adjusted for SES/SDS factors
across peer providers (that is, providers with similar shares of
beneficiaries with similar SES characteristics).
Response: With regard to the suggestions that the model include
sociodemographic factors and the suggestion pertaining to an approach
with which to convey data comparisons, we refer readers to section
III.D.2.f. where we also discuss these topics.
Comment: Some commenters recommended that additional variables be
included in risk adjustment to better capture clinical complexity. A
few commenters suggested the inclusion of functional and cognitive
status and other patient assessment data. Commenters recommended that
additional variables should include obesity, amputations, CVAs
(hemiplegia/paresis), and ventilator status.
Response: We thank the commenters for their suggestions. The HCC
indicators that are already included in the risk adjustment model
account for amputations, hemiplegia, and paresis. We believe that the
other risk adjustment variables adequately adjust for ventilator
dependency and obesity by accounting for HCCs, clinical case mix
categories, and prior inpatient and ICU length of stay.
We recognize the importance of accounting for beneficiaries'
functional and cognitive status in the calculation of predicted episode
spending. We considered the potential use of functional status
information in the risk adjustment models for the MSPB-PAC measures.
However, we decided to not include this information derived from
current setting-specific assessment instruments given the move towards
standardized data as mandated by the IMPACT Act. We will revisit the
inclusion of functional status in these measures' risk adjustment
models in the future when the standardized functional status data
mandated by the IMPACT Act-mandated become available. Once they are
available, we will take a gradual and systematic approach in evaluating
how they might be incorporated. We intend to implement any changes if
appropriate based on testing.
Comment: One commenter expressed concern that the measures will
give incentive to SNFs to avoid admitting medically complex residents,
which would result in unintended consequences.
Response: To mitigate the risk of creating incentives for SNFs to
avoid admitting medically complex residents, who may be at higher risk
for poor outcomes and higher costs, we have included factors related to
medical complexity in the risk adjustment methodology for the MSPB-PAC
SNF QRP measure. We also intend to conduct ongoing monitoring to assess
for potential unintended consequences associated with the
implementation of this measure.
Comment: One commenter recommended that SNFs providing palliative
care should be treated the same way as SNFs providing hospice care.
Response: We thank the commenter for their concern and note that
the risk adjustment model used in the MSPB-PAC SNF QRP measure does not
adjust for the type of care provided in the SNF, such as hospice-type
or palliative care services. However, the episode spending for
beneficiaries who receive hospice care within the episode window is
benchmarked only against the expected episode-level spending of similar
beneficiaries. This is achieved through the inclusion of a risk
adjustment indicator for beneficiaries for whom Medicare pays hospice
claims during the episode window. We adjust for beneficiaries with
hospice claims as these patients have different characteristics from
those who are not receiving hospice care services; one requirement of
eligibility for hospice services under Part A is that beneficiaries
must be terminally ill with a life expectancy of 6 months or less. In
contrast, palliative care services can encompass any comfort care
services (such as pain medication) at any stage of treatment of illness
or condition. Given the challenges of identifying the range of services
that could indicate palliative care and the wide variety of patients
receiving this type of care, we believe that adjusting for the presence
of hospice claims and not palliative care services supports the goal of
providing fair comparisons between providers.
(iii) Measure Numerator and Denominator
The MPSB-PAC SNF QRP measure is a payment-standardized, risk-
adjusted ratio that compares a given SNF provider's Medicare spending
against the Medicare spending of other SNF providers within a
performance period. Similar to the hospital MSPB measure, the ratio
allows for ease of comparison over time as it obviates the need to
adjust for inflation or policy changes.
The MSPB-PAC SNF QRP measure is calculated as the ratio of the
MSPB-PAC Amount for each SNF provider divided by the episode-weighted
median MSPB-PAC Amount across all SNF providers. To calculate the MSPB-
PAC Amount for each SNF provider, one calculates the average of the
ratio of the standardized episode spending over the expected episode
spending (as predicted in risk adjustment), and then multiplies this
quantity by the average episode spending level across all SNF providers
nationally. The denominator for a SNF provider's MSPB-PAC SNF QRP
measure is the episode-weighted national median of the MSPB-PAC Amounts
across all SNF providers. An MSPB-PAC SNF QRP measure of less than 1
indicates that a given SNF provider's resource use is less than that of
the national median SNF provider during a performance period.
Mathematically, this is represented in equation (A) below:
[GRAPHIC] [TIFF OMITTED] TR05AU16.018
Where
Yij = attributed standardized spending for episode i and
provider j
Yij = expected standardized spending for episode i and
provider j, as predicted from risk adjustment
[[Page 52020]]
nj = number of episodes for provider j
n = total number of episodes nationally
i [egr] {Ij{time} = all episodes i in the set of episodes
attributed to provider j.
The comments we received on this topic, with their responses,
appear below.
Comment: A few commenters expressed concern about comparing mean to
median values leading to inaccurate measure calculation. Commenters
requested clarification on proposed values to ensure fairness.
Response: We appreciate the commenters' concerns. As noted in the
MSPB-PAC Public Comment Summary Report for which a link has been
provided above, we clarify that a provider's MSPB-PAC Amount is the
average of observed over expected spending across a provider's
episodes. Comparing a provider's MSPB-PAC Amount to the national median
MSPB-PAC Amount does not affect the rank ordering of providers, and
will therefore not lead to inaccurate measure calculations because the
attributed provider's rank relative to the median will not change.
Comment: One commenter recommended including payments made by the
SNF to non-Medicare payers so that providers cannot simply shift costs
to other payers.
Response: We thank the commenter for the input and note that this
measure only includes beneficiaries who are continuously enrolled in
Medicare FFS for the entirety of a 90-day lookback period (that is, a
90-day period prior to the episode trigger) plus episode window. We do
not have the ability to assess payments made by private payers or track
beneficiary coinsurance or deductibles paid for plans outside of
Medicare. CMS will monitor this issue using administrative claims data
from Medicare as a part of ongoing measure monitoring and evaluation.
Comment: One commenter recommended that a geographic-specific (for
example, state or regional) median should be used instead of the
national median, citing differences in cost, patient population, and
regulation.
Response: We appreciate the commenter's input. As noted in the
proposed rule, (81 FR 24260), we proposed to use the same payment
standardization methodology as that used in the NQF-endorsed hospital
MSPB measure to account for variation in Medicare spending. This
methodology removes geographic payment differences, such as wage index
and geographic practice cost index (GPCI), incentive payment
adjustments, and other add-on payments that support broader Medicare
program goals including indirect graduate medical education (IME) and
hospitals serving a disproportionate share of uninsured patients (DSH).
We believe that this approach accounts for the differences that the
commenter raises while also maintaining consistency with the NQF-
endorsed hospital MSPB measure's methodology for addressing regional
variation through payment standardization.
(c) Data Sources
The MSPB-PAC SNF QRP resource use measure is an administrative
claims-based measure. It uses Medicare Part A and Part B claims from
FFS beneficiaries and Medicare eligibility files.
(d) Cohort
The measure cohort includes Medicare FFS beneficiaries with a SNF
treatment period ending during the data collection period.
(e) Reporting
We intend to provide initial confidential feedback to providers,
prior to public reporting of this measure, based on Medicare FFS claims
data from discharges in CY 2016. We intend to publicly report this
measure using claims data from discharges in CY 2017.
We proposed to use a minimum of 20 episodes for reporting and
inclusion in the SNF QRP. For the reliability calculation, as described
in the measure specifications, a link for which has been provided
above, we used data from FY 2014. The reliability results support the
20 episode case minimum, and 100 percent of SNF providers had moderate
or high reliability (above 0.4).
The comments we received on this topic, with their responses,
appear below.
Comment: Several commenters supported a period during which
providers would be able to preview and correct measure and quality
data.
Response: We appreciate the comments, and direct readers to section
III.D.2.n. where we discuss this topic in detail.
Comment: Some commenters recommended an initial confidential data
preview period for providers, prior to public reporting.
Response: Providers will receive a confidential preview report with
30 days for review in advance of their data and information being
publicly displayed.
Comment: Some commenters recommended that the MSPB-PAC SNF QRP
measure be tested for reliability and validity prior to finalization.
Response: The MSPB-PAC SNF QRP measure has been tested for
reliability using FY 2014 data. The reliability results support the 20
episode case minimum, and 100 percent of SNF providers had moderate or
high reliability (above 0.4). Further details on the reliability
calculation are provided in the MSPB-PAC Measure Specifications, a link
for which has been provided above.
Comment: One commenter suggested that descriptive statistics on the
measure score by provider-level characteristics (for example, rural/
urban status and bed size) would be useful to evaluate measure design
decisions.
Response: We thank the commenter for their input. The following
table 12 shows the MSPB-PAC SNF provider scores by provider
characteristics, calculated using FY 2014 data.
Table 12--MSPB-PAC SNF Scores by Provider Characteristics
--------------------------------------------------------------------------------------------------------------------------------------------------------
Score percentile
Provider characteristic Number of Mean ----------------------------------------------------------------------------
providers score 1st 10th 25th 50th 75th 90th 99th
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Providers...................................... 15,446 1.01 0.38 0.66 0.84 1.01 1.18 1.35 1.69
Urban/Rural:
Urban.......................................... 10,656 1.03 0.46 0.73 0.87 1.02 1.18 1.35 1.68
Rural.......................................... 4,786 0.96 0.29 0.56 0.74 0.96 1.16 1.35 1.71
Unknown........................................ 4 1.12 0.89 0.89 0.90 1.05 1.34 1.51 1.51
Ownership Type:
For profit..................................... 10,705 1.07 0.47 0.77 0.92 1.06 1.22 1.39 1.72
Non-profit..................................... 3,693 0.87 0.32 0.56 0.70 0.86 1.03 1.18 1.56
Government..................................... 1,008 0.89 0.20 0.49 0.66 0.87 1.12 1.31 1.66
Unknown........................................ 40 0.52 0.18 0.31 0.38 0.52 0.62 0.79 0.89
[[Page 52021]]
Census Division:
New England.................................... 943 0.91 0.44 0.68 0.79 0.91 1.04 1.14 1.40
Middle Atlantic................................ 1,708 1.00 0.46 0.69 0.84 1.00 1.16 1.30 1.59
East North Central............................. 3,009 1.07 0.50 0.76 0.92 1.06 1.21 1.39 1.69
West North Central............................. 1,989 0.82 0.27 0.52 0.67 0.82 0.97 1.12 1.43
South Atlantic................................. 2,369 1.03 0.41 0.75 0.90 1.03 1.17 1.31 1.60
East South Central............................. 1,083 1.07 0.34 0.64 0.88 1.08 1.28 1.44 1.72
West South Central............................. 2,076 1.13 0.40 0.75 0.96 1.13 1.31 1.49 1.79
Mountain....................................... 732 0.90 0.23 0.61 0.78 0.92 1.05 1.15 1.46
Pacific........................................ 1,529 1.03 0.43 0.68 0.84 1.01 1.20 1.40 1.75
Other.......................................... 8 0.51 0.39 0.39 0.43 0.53 0.56 0.68 0.68
Bed Count:
0-49........................................... 1,877 0.82 0.24 0.49 0.61 0.79 1.00 1.20 1.70
50-99.......................................... 5,799 1.00 0.36 0.64 0.82 0.99 1.17 1.36 1.70
100-199........................................ 6,846 1.06 0.52 0.78 0.91 1.05 1.20 1.36 1.67
200-299........................................ 726 1.08 0.55 0.78 0.91 1.06 1.23 1.42 1.69
300 +.......................................... 198 1.03 0.45 0.75 0.87 1.01 1.16 1.35 1.62
No. of Episodes:
0-99........................................... 10,048 1.01 0.33 0.63 0.82 1.01 1.20 1.40 1.73
100-249........................................ 4,298 1.01 0.52 0.75 0.88 1.01 1.15 1.28 1.53
250-499........................................ 960 0.96 0.52 0.69 0.83 0.97 1.08 1.20 1.45
500-1000....................................... 136 0.96 0.57 0.74 0.88 0.96 1.08 1.19 1.35
1000 +......................................... 4 0.86 0.73 0.73 0.80 0.87 0.92 0.98 0.98
--------------------------------------------------------------------------------------------------------------------------------------------------------
In summary, after consideration of the public comments we received,
we are finalizing the specifications of the MSPB-PAC SNF QRP resource
use measure, as proposed. A link for the measure specifications has
been provided above.
Specifically, we are finalizing the definition of an MSPB-PAC SNF
QRP episode, beginning from episode trigger. An episode window
comprises a treatment period beginning at the trigger and ending upon
discharge, and an associated services period beginning at the trigger
and ending 30 days after the end of the treatment period. Readmissions
to the same SNF within 7 or fewer days do not trigger a new episode and
are instead included in the treatment period of the first episode.
We exclude certain services that are clinically unrelated to SNF
care and/or because SNF providers may have limited influence over
certain Medicare services delivered by other providers during the
episode window. We also exclude certain episodes in their entirety from
the MSPB-PAC SNF QRP measure, such as where a beneficiary is not
enrolled in Medicare FFS for the entirety of the lookback period plus
episode window.
We finalize the inclusion of Medicare payments for Part A and Part
B claims for services included in the MSPB-PAC SNF QRP episodes to
calculate the MSPB-PAC SNF QRP measure.
We are finalizing our proposal to risk adjust using covariates
including age brackets, HCC indicators, prior inpatient stay length,
ICU stay length, clinical case mix categories, and indicators for
originally disabled, ESRD enrollment, long-term care status, and
hospice claim in episode window. The measure also adjusts for
geographic payment differences such as wage index and GPCI, and adjusts
for Medicare payment differences resulting from IME and DSH.
We calculate the individual providers' MSPB-PAC Amount which is
inclusive of MSPB-PAC SNF QRP observed episode spending over the
expected episode spending as predicted through risk adjustment.
Individual SNF providers' scores are calculated as their individual
MSPB-PAC Amount divided by the median MSPB-PAC amount across all SNFs.
ii. Measure to Address the IMPACT Act Domain of Resource Use and Other
Measures: Discharge to Community--Post Acute Care (PAC) Skilled Nursing
Facility (SNF) Quality Reporting Program (QRP)
Sections 1899B(d)(1)(B) and 1899B(a)(2)(E)(ii) of the Act require
the Secretary to specify a measure to address the domain of discharge
to community by SNFs, LTCHs, and IRFs by October 1, 2016, and HHAs by
January 1, 2017. We proposed to adopt the measure, Discharge to
Community--PAC SNF QRP, for the SNF QRP for the FY 2018 payment
determination and subsequent years as a Medicare FFS claims-based
measure to meet this requirement.
This measure assesses successful discharge to the community from a
SNF setting, with successful discharge to the community including no
unplanned rehospitalizations and no death in the 31 days following
discharge from the SNF. Specifically, this measure reports a SNF's
risk-standardized rate of Medicare FFS residents who are discharged to
the community following a SNF stay, and do not have an unplanned
readmission to an acute care hospital or LTCH in the 31 days following
discharge to community, and who remain alive during the 31 days
following discharge to community. The term ``community'', for this
measure, is defined as home or self care, with or without home health
services, based on Patient Discharge Status Codes 01, 06, 81, and 86 on
the Medicare FFS claim.41 42 This measure is conceptualized
uniformly across the PAC settings, in terms of the definition of the
discharge to community outcome, the approach to risk adjustment, and
the measure calculation.
---------------------------------------------------------------------------
\41\ National Uniform Billing Committee Official UB-04 Data
Specifications Manual 2017, Version 11, July 2016, Copyright 2016,
American Hospital Association.
\42\ This definition is not intended to suggest that board and
care homes, assisted living facilities, or other settings included
in the definition of ``community'' for the purpose of this measure
are the most integrated setting for any particular individual or
group of individuals under the Americans with Disabilities Act (ADA)
and section 504.
---------------------------------------------------------------------------
Discharge to a community setting is an important health care
outcome for
[[Page 52022]]
many residents for whom the overall goals of post-acute care include
optimizing functional improvement, returning to a previous level of
independence, and avoiding institutionalization. Returning to the
community is also an important outcome for many residents who are not
expected to make functional improvement during their SNF stay, and for
residents who may be expected to decline functionally due to their
medical condition. The discharge to community outcome offers a multi-
dimensional view of preparation for community life, including the
cognitive, physical, and psychosocial elements involved in a discharge
to the community.43 44
---------------------------------------------------------------------------
\43\ El-Solh AA, Saltzman SK, Ramadan FH, Naughton BJ. Validity
of an artificial neural network in predicting discharge destination
from a postacute geriatric rehabilitation unit. Archives of physical
medicine and rehabilitation. 2000;81(10):1388-1393.
\44\ Tanwir S, Montgomery K, Chari V, Nesathurai S. Stroke
rehabilitation: Availability of a family member as caregiver and
discharge destination. European journal of physical and
rehabilitation medicine. 2014;50(3):355-362.
---------------------------------------------------------------------------
In addition to being an important outcome from a resident and
family perspective, patients and residents discharged to community
settings, on average, incur lower costs over the recovery episode,
compared with those discharged to institutional
settings.45 46 Given the high costs of care in institutional
settings, encouraging SNFs to prepare residents for discharge to
community, when clinically appropriate, may have cost-saving
implications for the Medicare program.\47\ Also, providers have
discovered that successful discharge to community was a major driver of
their ability to achieve savings, where capitated payments for post-
acute care were in place.\48\ For residents who require long-term care
due to persistent disability, discharge to community could result in
lower long-term care costs for Medicaid and for residents' out-of-
pocket expenditures.\49\
---------------------------------------------------------------------------
\45\ Dobrez D, Heinemann AW, Deutsch A, Manheim L, Mallinson T.
Impact of Medicare's prospective payment system for inpatient
rehabilitation facilities on stroke patient outcomes. American
journal of physical medicine & rehabilitation/Association of
Academic Physiatrists. 2010;89(3):198-204.
\46\ Gage B, Morley M, Spain P, Ingber M. Examining Post Acute
Care Relationships in an Integrated Hospital System. Final Report.
RTI International;2009.
\47\ Ibid.
\48\ Doran JP, Zabinski SJ. Bundled payment initiatives for
Medicare and non-Medicare total joint arthroplasty patients at a
community hospital: Bundles in the real world. The journal of
arthroplasty. 2015;30(3):353-355.
\49\ Newcomer RJ, Ko M, Kang T, Harrington C, Hulett D, Bindman
AB. Health Care Expenditures After Initiating Long-term Services and
Supports in the Community Versus in a Nursing Facility. Medical
Care. 2016; 54(3):221-228.
---------------------------------------------------------------------------
Analyses conducted for ASPE on PAC episodes, using a 5 percent
sample of 2006 Medicare claims, revealed that relatively high average,
unadjusted Medicare payments are associated with discharge to
institutional settings from IRFs, SNFs, LTCHs or HHAs, as compared with
payments associated with discharge to community settings.\50\ Average,
unadjusted Medicare payments associated with discharge to community
settings ranged from $0 to $4,017 for IRF discharges, $0 to $3,544 for
SNF discharges, $0 to $4,706 for LTCH discharges, and $0 to $992 for
HHA discharges. In contrast, payments associated with discharge to non-
community settings were considerably higher, ranging from $11,847 to
$25,364 for IRF discharges, $9,305 to $29,118 for SNF discharges,
$12,465 to $18,205 for LTCH discharges, and $7,981 to $35,192 for HHA
discharges.\51\
---------------------------------------------------------------------------
\50\ Gage B, Morley M, Spain P, Ingber M. Examining Post Acute
Care Relationships in an Integrated Hospital System. Final Report.
RTI International;2009.
\51\ Ibid.
---------------------------------------------------------------------------
Measuring and comparing facility-level discharge to community rates
is expected to help differentiate among facilities with varying
performance in this important domain, and to help avoid disparities in
care across resident groups. Variation in discharge to community rates
has been reported within and across post-acute settings; across a
variety of facility-level characteristics, such as geographic location
(for example, regional location, urban or rural location), ownership
(for example, for-profit or nonprofit), and freestanding or hospital-
based units; and across patient-level characteristics, such as race and
gender.52 53 54 55 56 57 Discharge to community rates in the
IRF setting have been reported to range from about 60 to 80
percent.58 59 60 61 62 63 Longer-term studies show that
rates of discharge to community from IRFs have decreased over time as
IRF length of stay has decreased.64 65 Greater variation in
discharge to community rates is seen in the SNF setting, with rates
ranging from 31 to 65 percent.66 67 68 69 In the
[[Page 52023]]
SNF Medicare FFS population, using CY 2013 national claims data, we
found that approximately 44 percent of residents were discharged to the
community. A multi-center study of 23 LTCHs demonstrated that 28.8
percent of 1,061 patients who were ventilator-dependent on admission
were discharged to home.\70\ A single-center study revealed that 31
percent of LTCH hemodialysis patients were discharged to home.\71\ One
study noted that 64 percent of beneficiaries who were discharged from
the home health episode did not use any other acute or post-acute
services paid by Medicare in the 30 days after discharge.\72\ However,
significant numbers of patients were admitted to hospitals (29 percent)
and lesser numbers to SNFs (7.6 percent), IRFs (1.5 percent), home
health (7.2 percent) or hospice (3.3 percent).\73\
---------------------------------------------------------------------------
\52\ Reistetter TA, Karmarkar AM, Graham JE, et al. Regional
variation in stroke rehabilitation outcomes. Archives of physical
medicine and rehabilitation. 2014; 95(1):29-38.
\53\ El-Solh AA, Saltzman SK, Ramadan FH, Naughton BJ. Validity
of an artificial neural network in predicting discharge destination
from a postacute geriatric rehabilitation unit. Archives of physical
medicine and rehabilitation. 2000; 81(10):1388-1393.
\54\ March 2015 Report to the Congress: Medicare Payment Policy.
Medicare Payment Advisory Commission; 2015.
\55\ Bhandari VK, Kushel M, Price L, Schillinger D. Racial
disparities in outcomes of inpatient stroke rehabilitation. Archives
of physical medicine and rehabilitation. 2005; 86(11):2081-2086.
\56\ Chang PF, Ostir GV, Kuo YF, Granger CV, Ottenbacher KJ.
Ethnic differences in discharge destination among older patients
with traumatic brain injury. Archives of physical medicine and
rehabilitation. 2008; 89(2):231-236.
\57\ Berges IM, Kuo YF, Ostir GV, Granger CV, Graham JE,
Ottenbacher KJ. Gender and ethnic differences in rehabilitation
outcomes after hip-replacement surgery. American journal of physical
medicine & rehabilitation/Association of Academic Physiatrists.
2008; 87(7):567-572.
\58\ Galloway RV, Granger CV, Karmarkar AM, et al. The Uniform
Data System for Medical Rehabilitation: Report of patients with
debility discharged from inpatient rehabilitation programs in 2000-
2010. American journal of physical medicine & rehabilitation/
Association of Academic Physiatrists. 2013; 92(1):14-27.
\59\ Morley MA, Coots LA, Forgues AL, Gage BJ. Inpatient
rehabilitation utilization for Medicare beneficiaries with multiple
sclerosis. Archives of physical medicine and rehabilitation. 2012;
93(8):1377-1383.
\60\ Reistetter TA, Graham JE, Deutsch A, Granger CV, Markello
S, Ottenbacher KJ. Utility of functional status for classifying
community versus institutional discharges after inpatient
rehabilitation for stroke. Archives of physical medicine and
rehabilitation. 2010; 91(3):345-350.
\61\ Gagnon D, Nadeau S, Tam V. Clinical and administrative
outcomes during publicly-funded inpatient stroke rehabilitation
based on a case-mix group classification model. Journal of
rehabilitation medicine. 2005; 37(1):45-52.
\62\ DaVanzo J, El-Gamil A, Li J, Shimer M, Manolov N, Dobson A.
Assessment of patient outcomes of rehabilitative care provided in
inpatient rehabilitation facilities (IRFs) and after discharge.
Vienna, VA: Dobson DaVanzo & Associates, LLC; 2014.
\63\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating Siebens
Domain Management Model for Inpatient Rehabilitation to Increase
Functional Independence and Discharge Rate to Home in Geriatric
Patients. Archives of physical medicine and rehabilitation. 2015;
96(7):1310-1318.
\64\ Galloway RV, Granger CV, Karmarkar AM, et al. The Uniform
Data System for Medical Rehabilitation: Report of patients with
debility discharged from inpatient rehabilitation programs in 2000-
2010. American journal of physical medicine & rehabilitation/
Association of Academic Physiatrists. 2013; 92(1):14-27.
\65\ Mallinson T, Deutsch A, Bateman J, et al. Comparison of
discharge functional status after rehabilitation in skilled nursing,
home health, and medical rehabilitation settings for patients after
hip fracture repair. Archives of physical medicine and
rehabilitation. 2014; 95(2):209-217.
\66\ El-Solh AA, Saltzman SK, Ramadan FH, Naughton BJ. Validity
of an artificial neural network in predicting discharge destination
from a postacute geriatric rehabilitation unit. Archives of physical
medicine and rehabilitation. 2000; 81(10):1388-1393.
\67\ Hall RK, Toles M, Massing M, et al. Utilization of acute
care among patients with ESRD discharged home from skilled nursing
facilities. Clinical journal of the American Society of Nephrology:
CJASN. 2015; 10(3):428-434.
\68\ Stearns SC, Dalton K, Holmes GM, Seagrave SM. Using
propensity stratification to compare patient outcomes in hospital-
based versus freestanding skilled-nursing facilities. Medical care
research and review: MCRR. 2006; 63(5):599-622.
\69\ Wodchis WP, Teare GF, Naglie G, et al. Skilled nursing
facility rehabilitation and discharge to home after stroke. Archives
of physical medicine and rehabilitation. 2005; 86(3):442-448.
\70\ Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al. Post-ICU
mechanical ventilation at 23 long-term care hospitals: A multicenter
outcomes study. Chest. 2007;131(1):85-93.
\71\ Thakar CV, Quate-Operacz M, Leonard AC, Eckman MH. Outcomes
of hemodialysis patients in a long-term care hospital setting: A
single-center study. American journal of kidney diseases: The
official journal of the National Kidney Foundation. 2010;55(2):300-
306.
\72\ Wolff JL, Meadow A, Weiss CO, Boyd CM, Leff B. Medicare
home health patients' transitions through acute and post-acute care
settings. Medical care. 2008;46(11):1188-1193.
\73\ Ibid.
---------------------------------------------------------------------------
Discharge to community is an actionable health care outcome, as
targeted interventions have been shown to successfully increase
discharge to community rates in a variety of post-acute
settings.74 75 76 77 Many of these interventions involve
discharge planning or specific rehabilitation strategies, such as
addressing discharge barriers and improving medical and functional
status.78 79 80 81 The effectiveness of these interventions
suggests that improvement in discharge to community rates among post-
acute care residents is possible through modifying provider-led
processes and interventions.
---------------------------------------------------------------------------
\74\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating Siebens
Domain Management Model for Inpatient Rehabilitation to Increase
Functional Independence and Discharge Rate to Home in Geriatric
Patients. Archives of physical medicine and rehabilitation.
2015;96(7):1310-1318.
\75\ Wodchis WP, Teare GF, Naglie G, et al. Skilled nursing
facility rehabilitation and discharge to home after stroke. Archives
of physical medicine and rehabilitation. 2005;86(3):442-448.
\76\ Berkowitz RE, Jones RN, Rieder R, et al. Improving
disposition outcomes for patients in a geriatric skilled nursing
facility. Journal of the American Geriatrics Society.
2011;59(6):1130-1136.
\77\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating use of
the Siebens Domain Management Model during inpatient rehabilitation
to increase functional independence and discharge rate to home in
stroke patients. PM & R: The journal of injury, function, and
rehabilitation. 2015;7(4):354-364.
\78\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating Siebens
Domain Management Model for Inpatient Rehabilitation to Increase
Functional Independence and Discharge Rate to Home in Geriatric
Patients. Archives of physical medicine and rehabilitation.
2015;96(7):1310-1318.
\79\ Wodchis WP, Teare GF, Naglie G, et al. Skilled nursing
facility rehabilitation and discharge to home after stroke. Archives
of physical medicine and rehabilitation. 2005;86(3):442-448.
\80\ Berkowitz RE, Jones RN, Rieder R, et al. Improving
disposition outcomes for patients in a geriatric skilled nursing
facility. Journal of the American Geriatrics Society.
2011;59(6):1130-1136.
\81\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating use of
the Siebens Domain Management Model during inpatient rehabilitation
to increase functional independence and discharge rate to home in
stroke patients. PM & R: The journal of injury, function, and
rehabilitation. 2015;7(4):354-364.
---------------------------------------------------------------------------
A TEP convened by our measure development contractor was strongly
supportive of the importance of measuring discharge to community
outcomes, and implementing the measure, Discharge to Community--PAC SNF
QRP in the SNF QRP. The panel provided input on the technical
specifications of this measure, including the feasibility of
implementing the measure, as well as the overall measure reliability
and validity. A summary of the TEP proceedings is available on the PAC
Quality Initiatives Downloads and Videos Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
We also solicited stakeholder feedback on the development of this
measure through a public comment period held from November 9, 2015,
through December 8, 2015. Several stakeholders and organizations,
including the MedPAC, among others, supported this measure for
implementation. The public comment summary report for the measure is
available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
The NQF-convened MAP met on December 14 and 15, 2015, and provided
input on the use of this Discharge to Community--PAC SNF QRP measure in
the SNF QRP. The MAP encouraged continued development of the measure to
meet the mandate of the IMPACT Act. The MAP supported the alignment of
this measure across PAC settings, using standardized claims data. More
information about the MAP's recommendations for this measure is
available at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
Since the MAP's review and recommendation of continued development,
we have continued to refine risk-adjustment models and conduct measure
testing for this measure, as recommended by the MAP. This measure is
consistent with the information submitted to the MAP, and the original
MAP submission and our continued refinements support its scientific
acceptability for use in quality reporting programs. As discussed with
the MAP, we fully anticipate that additional analyses will continue as
we submit this measure to the ongoing measure maintenance process.
We reviewed the NQF's consensus-endorsed measures and were unable
to identify any NQF-endorsed resource use or other measures for post-
acute care focused on discharge to community. In addition, we are
unaware of any other post-acute care measures for discharge to
community that have been endorsed or adopted by other consensus
organizations. Therefore, we proposed the measure, Discharge to
Community--PAC SNF QRP, under the Secretary's authority to specify
non--NQF-endorsed measures under section 1899B(e)(2)(B) of the Act.
We proposed to use data from the Medicare FFS claims and Medicare
eligibility files to calculate this measure. We proposed to use data
from the ``Patient Discharge Status Code'' on Medicare FFS claims to
determine whether a resident was discharged to a community setting for
calculation of this measure. In all PAC settings, we tested the
accuracy of determining discharge to a community setting using the
``Patient Discharge Status Code'' on the PAC claim by examining whether
discharge to community coding based on PAC claim data agreed with
discharge to community coding based on PAC assessment data. We found
agreement between the two data sources in all PAC settings, ranging
from 94.6 percent to 98.8 percent. Specifically, in the SNF setting,
using 2013 data, we found 94.6 percent agreement in discharge to
community codes when comparing discharge status codes on claims and the
Discharge Status (A2100) on the Minimum Data Set (MDS) 3.0 discharge
assessment, when the claims and MDS assessment had the same discharge
date. We further examined the accuracy of the ``Patient Discharge
Status Code'' on the PAC claim by assessing how frequently discharges
to
[[Page 52024]]
an acute care hospital were confirmed by follow-up acute care claims.
We discovered that 88 percent to 91 percent of IRF, LTCH, and SNF
claims with acute care discharge status codes were followed by an acute
care claim on the day of, or day after, PAC discharge. We believed
these data support the use of the claims ``Patient Discharge Status
Code'' for determining discharge to a community setting for this
measure. In addition, this measure can feasibly be implemented in the
SNF QRP because all data used for measure calculation are derived from
Medicare FFS claims and eligibility files, which are already available
to CMS.
Based on the evidence discussed above, we proposed to adopt the
measure, Discharge to Community--PAC SNF QRP, for the SNF QRP for FY
2018 payment determination and subsequent years. This measure is
calculated using 1 year of data. We proposed a minimum of 25 eligible
stays in a given SNF for public reporting of the measure for that SNF.
Since Medicare FFS claims data are already reported to the Medicare
program for payment purposes, and Medicare eligibility files are also
available, SNFs will not be required to report any additional data to
CMS for calculation of this measure. The measure denominator is the
risk-adjusted expected number of discharges to community. The measure
numerator is the risk-adjusted estimate of the number of residents who
are discharged to the community, do not have an unplanned readmission
to an acute care hospital or LTCH in the 31-day post-discharge
observation window, and who remain alive during the post-discharge
observation window. The measure is risk-adjusted for variables such as
age and sex, principal diagnosis, comorbidities, ventilator status,
ESRD status, and dialysis, among other variables. For technical
information about the proposed measure, including information about the
measure calculation, risk adjustment, and denominator exclusions, we
referred readers to the document titled, Proposed Measure
Specifications for Measures Proposed in the FY 2017 SNF QRP Proposed
Rule available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
We stated in the proposed rule that we intend to provide initial
confidential feedback to SNFs, prior to public reporting of this
measure, based on Medicare FFS claims data from discharges in CY 2016.
We intend to publicly report this measure using claims data from
discharges in CY 2017. We plan to submit this measure to the NQF for
consideration for endorsement.
We invited public comment on our proposal to adopt the measure,
Discharge to Community--PAC SNF QRP, for the SNF QRP. The comments we
received on this topic, with our responses, appear below.
Comment: Several commenters, including MedPAC, supported the
Discharge to Community--PAC SNF QRP measure, noting that it is a
critical measure assessing the ability of a PAC provider to
rehabilitate patients and enable them to return to the home and
community-based setting. One commenter noted that measuring the rate
that the various PAC settings discharge patients to the community,
without an admission (or readmission) to an acute care hospital within
30 days, is one of the most relevant patient-centered measures that
exists in the post-acute care area. Commenters noted that most older
adults want to live independently in their homes and communities, that
returning home following care was an important concern of Medicare
beneficiaries, and that successful transitions to community would
decrease potentially preventable readmissions. Two commenters supported
CMS's efforts to develop aligned yet distinctive risk-adjusted
discharge to community measures for IRFs, SNFs and LTCHs, given the
inherent variability in patient/resident profiles across these
settings. Commenters agreed that discharge to community was an
important outcome not just for patients expected to make functional
improvement and return to their previous level of independence, but
also for patients not expected to make functional improvement, or those
who may be expected to decline functionally due to their medical
condition. One commenter stated that achieving a standardized and
interoperable patient assessment data set and stable quality measures
as quickly as possible would allow for better cross-setting comparisons
and the evolution of better quality measures with uniform risk
standardization. One commenter expressed support for the use of claims
data over assessment data in calculating the Discharge to Community--
PAC SNF QRP measure, stating that assessment data could be susceptible
to gaming by providers.
Response: We thank the commenters for their support of the
Discharge to Community--PAC SNF QRP measure, and their recognition of
its patient-centeredness, its relevance for patients with a range of
functional abilities and prognosis, and its potential to reduce post-
discharge readmissions. We also thank commenters for their support of
use of claims data, and their support of standardized and interoperable
patient assessment data and quality measures. As mandated by the IMPACT
Act, we are moving toward the goal of standardized patient assessment
data and quality measures across PAC settings.
Comment: One commenter interpreted our measure proposal language as
suggesting that functional improvement is not a requirement, and
encouraged that Medicare coverage for maintenance nursing and therapy
be ensured and reflected by the measure.
Response: Our intent in the measure proposal was to acknowledge
that discharge to community can be an important goal even for patients
who may not be able to make functional improvement. This measure does
not impact Medicare coverage rules for maintenance nursing and therapy.
Comment: Several commenters requested that ``home'' be defined
broadly to reflect the place an individual calls ``home'', including
assisted living facilities, residential care settings, or other
congregate community housing.
Response: We agree with the commenters that ``home'' should be
defined broadly for the discharge to community measure. In addition to
home, our definition of community includes settings such as group home,
foster care, and independent living and other residential care
arrangements.\82\ For further details on measure specifications,
including the definition of community, we refer readers to the Measure
Specifications for Measures Adopted in the FY 2017 SNF QRP Final Rule,
posted on the CMS SNF QRP Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
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\82\ National Uniform Billing Committee Official UB-04 Data
Specifications Manual 2017, Version 11, July 2016, Copyright 2016,
American Hospital Association.
---------------------------------------------------------------------------
Comment: Several commenters expressed concerns regarding the use of
the Patient Discharge Status Code variable to define community
discharges. Commenters emphasized that it was important to ensure that
only home and community based settings were included in the definition
of
[[Page 52025]]
community, and were concerned that Code 01 (Discharge to home or self
care), which is included in the definition of community, included
institutional settings such as jail or law enforcement. One commenter
expressed that many settings included under Code 01 do not satisfy the
home and community based settings rule, and may be inconsistent with
the integration mandate of the Americans with Disabilities Act.
Commenters strongly recommended that we either revise discharge status
code 01 to exclude non community-based settings, or use alternative
variables to capture discharge to community.
Response: We agree with the commenters that the discharge to
community measure should only capture discharges to home and community
based settings. We believe that the comment referring to the ``home and
community based settings rule'' refers to Medicaid regulations
applicable to services authorized under sections 1915(c), 1915(i) and
1915(k) of the Act, which are provided through waivers or state plans
amendments approved by CMS. We would like to clarify that this measure
only captures discharges to home and community based settings, not to
institutional settings, and is consistent with both Medicaid
regulations requiring home and community based settings to support
integration, and also with the Americans with Disabilities Act (ADA),
based on Patient Discharge Status Codes 01, 06, 81, and 86 on the
Medicare FFS PAC claim.\83\ Discharges to jail or law enforcement are
not included under Code 01 of the Patient Discharge Status Code; rather
these are included under Code 21 (Discharged/transferred to Court/Law
Enforcement).
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\83\ Ibid.
---------------------------------------------------------------------------
We also note that Title II of the ADA regulations requires public
entities to administer services, programs, and activities in the most
integrated setting appropriate to the needs of qualified individuals
with disabilities (28 CFR 35.130(d)). The preamble discussion of the
``integration regulation'' explains that ``the most integrated
setting'' is one that enables individuals with disabilities to interact
with nondisabled persons to the fullest extent possible. Integrated
settings are those that provide individuals with disabilities
opportunities to live, work, and receive services in the greater
community, like individuals without disabilities (28 CFR part 35, app.
A (2010) (addressing Sec. 35.130)).
Comment: Several commenters stated that PAC patients/residents
discharged to a nursing facility as long-term care residents should not
be considered discharges to community, particularly if they were
discharged to the nursing facility from the Medicare-certified skilled
nursing part of the same nursing home, and even if they resided in a
long-term nursing facility at baseline. Commenters emphasized that a
nursing home does not represent an individual's own home in their own
community. These commenters interpreted the proposed measure
specifications as allowing these discharges to a nursing facility to be
coded as ``group home'', ``foster care'', or ``other residential care
arrangement'' under discharge status code 01. Commenters expressed
concern that coding discharges from the SNF to residential/long-term
care facility within the same nursing home as discharges to community
would unfairly advantage SNFs and artificially inflate their discharge
to community rates, would disadvantage other PAC providers, would
negate the value of the measure, and would miscommunicate facility's
actual discharge to community performance to the average Medicare
beneficiary. Commenters also noted that including nursing facility
discharges as community discharges could incentivize SNFs to not do the
hard work that actual, meaningful discharge planning to the community
requires.
Response: We agree with the commenters that discharges to long-term
care nursing facilities, or any other institutional settings, should
not be coded as discharges to community. We also recognize the
differences in required discharge planning processes and resources for
discharging a patient/resident to the community compared with
discharging to a long-term nursing facility. The discharge to community
measure only captures discharges to home and community based settings
as discharges to community, based on Patient Discharge Status Codes 01,
06, 81, and 86 on the Medicare FFS PAC claim.\84\ These codes do not
include discharges to long-term care nursing facilities or any other
institutional setting that may violate the integration mandate of title
II of the ADA. Instead, depending on the nature of the facility to
which patients/residents are discharged, such discharges may be coded
on the Medicare FFS claim as 04, 64, 84, 92, or another appropriate
code for an institutional discharge.
---------------------------------------------------------------------------
\84\ Ibid.
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In response to the commenters' concerns that SNFs may be unfairly
advantaged by this measure as compared with other PAC providers, we
would like to note that, in our measure development samples, the
national discharge to community rate for SNFs was 47.26 percent, while
this rate for IRFs was considerably higher (69.51 percent). Further,
using an MDS-claims linked longitudinal file, we found that, of SNF
stays that had a pre-hospitalization non-PPS MDS assessment suggesting
prior nursing facility residence, two-thirds had a discharge status
code of 30 (still patient), and approximately 18 percent had a
discharge status code of 02 (acute hospital); less than 5 percent of
these patients had a discharge status code of 01 (discharge to home or
self care).
Comment: Several commenters recommended that the discharge to
community measure should entirely exclude baseline long-stay nursing
facility residents, as they could not be reasonably expected to
discharge to the community after their PAC stay. One commenter noted
that the measure fails to consider when a patient's ``home'' is a
custodial nursing facility and the patient's post-acute episode
involves a discharge back to his or her ``home.'' Another commenter
noted that baseline nursing facility residents have a very different
discharge process back to the nursing facility compared with patients
discharged to the community. This commenter recommended that different
measures be developed for the baseline nursing facility resident
population, such as return to prior level of function, improvement in
function, prevention of further functional decline, development of
pressure ulcers, or accidental falls. This commenter also recognized
our current efforts in monitoring transitions of care and quality
requirements in long-term care facilities. One commenter suggested that
we use the Minimum Data Set to identify and exclude baseline nursing
facility residents.
Response: We appreciate the commenters' concerns and their
recommendation to exclude baseline nursing facility residents from the
discharge to community measure, and to distinguish baseline custodial
nursing facility residents who are discharged back to the nursing
facility after their SNF stay. We recognize that patients/residents who
permanently lived in a nursing facility at baseline may not be expected
to discharge back to a home and community based setting after their PAC
stay. We also recognize that, for baseline nursing facility residents,
a discharge back to their nursing facility represents a discharge to
their baseline residence. We agree with the commenter about the
differences in discharge planning processes when discharging a patient/
resident to the community
[[Page 52026]]
compared with discharging to a long-term nursing facility. However,
using Medicare FFS claims alone, we are unable to accurately identify
baseline nursing facility residents. Potential future modifications of
the measure could include the assessment of the feasibility and impact
of excluding baseline nursing facility residents from the measure
through the addition of patient assessment-based data. However, we note
that, currently, the IRF-PAI is the only PAC assessment that contains
an item related to pre-hospital baseline living setting.
Comment: One commenter raised concerns that the measure does not
exclude individuals admitted to a SNF for Part A services, but who have
an expressed goal to remain in the facility for long-term care and
never be discharged back to community. The commenter specifically noted
that there appears to be a relationship between SNF turnover rate and
discharge to community rates. They noted that SNFs with low turnover,
which they offered as a marker for being a primarily long-term care
facility, had low discharge to community rates compared with SNFs with
high turnover.
Response: This measure risk adjusts for several case-mix variables
that may be related to preferences for facility-based long-term care
such as age, diagnoses from the prior acute stay, comorbidities in the
year preceding PAC admission, length of prior acute stay, number of
prior hospitalizations in the past year, and ventilator use. Further,
by excluding patients on hospice and those whose prior acute stay was
for medical treatment of cancer, we are excluding SNF residents who may
be more likely to transfer to a nursing facility at the end of their
SNF stay. There are no claims data we could currently use to identify
residents with an expressed goal to remain in the nursing home for
long-term care. As we agree this is an important aspect of this measure
work, we will consider assessing the ability to identify residents with
an expressed goal to remain in the nursing home for long-term care, and
the impact of such an exclusion on the measure performance.
Comment: MedPAC recommended that we confirm discharge to a
community setting with the absence of a subsequent claim to a hospital,
IRF, SNF, or LTCH, to ensure that discharge to community rates reflect
actual facility performance. Other commenters also recommended that we
assess the reliability and validity of the Patient Discharge Status
code on PAC claims, expressing concerns about the accuracy of these
data without further definition and validation. Commenters cited MedPAC
and other studies, noting that Patient Discharge Status Codes often
have low reliability, and this could impact accurate portrayal of
measure performance.
Response: We are committed to developing measures based on reliable
and valid data. This measure does confirm the absence of hospital or
LTCH claims following discharge to a community setting. Unplanned
hospital and LTCH readmissions following the discharge to community,
including those on the day of SNF discharge, are considered an
unfavorable outcome. We will consider verifying the absence of IRF and
SNF claims following discharge to a community setting, as we continue
to refine this measure. Nonetheless, we would like to note that an ASPE
report on post-acute care relationships found that, following discharge
to community settings from IRFs, LTCHs, or SNFs in a 5 percent Medicare
sample, IRFs or SNFs were very infrequently reported as the next site
of post-acute care.\85\
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\85\ Gage B, Morley M, Spain P, Ingber M. Examining Post Acute
Care Relationships in an Integrated Hospital System Final Report.
RTI International; 2009.
---------------------------------------------------------------------------
Because the discharge to community measure is a measure of
discharge destination from the PAC setting, we have chosen to use the
PAC-reported discharge destination (from the Medicare FFS claims) to
determine whether a patient/resident was discharged to the community
(based on discharge status codes 01, 06, 81, 86). We assessed the
reliability of the claims discharge status code by examining agreement
between discharge status on claims and assessment instruments for the
same stay in all four PAC settings. We found between 94 and 99 percent
agreement in coding of community discharges on matched claims and
assessments in each of the PAC settings. We also assessed how
frequently discharges to acute care, as indicated on the PAC claim,
were confirmed by follow-up acute care claims, and found that 88
percent to 91 percent of IRF, LTCH, and SNF claims indicating acute
care discharge were followed by an acute care claim on the day of, or
day after, PAC discharge. We believe that these data support the use of
the ``Patient Discharge Status Code'' from the PAC claim for
determining discharge to a community setting for this measure.
The use of the claims discharge status code to identify discharges
to the community was discussed at length with the TEP convened by our
measure development contractor. TEP members did not express significant
concerns regarding the accuracy of the claims discharge status code in
coding community discharges, nor about our use of the discharge status
code for defining this quality measure. A summary of the TEP
proceedings is available on the PAC Quality Initiatives Downloads and
Videos Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
Comment: One commenter recommended that, in all PAC settings,
patients who are discharged home and then admitted to a SNF or nursing
facility during the 31-day post-discharge window not be counted as
successful discharges to the community. The commenter suggested that
MDS data could be used to identify individuals admitted to nursing
homes.
Response: We agree that it is important to track whether patients
remain in the community in the post-discharge observation window in
order to ensure that facilities are appropriately discharging patients
to the community. In the measure, we examine post-discharge unplanned
acute care or LTCH readmissions, thereby accounting for more serious,
acute readmissions in the post-discharge window. In future versions of
the measure, we will consider looking for IRF, SNF, and nursing
facility admissions and readmissions in the 31-day post-discharge
window when examining discharge to community outcomes.
Comment: A few commenters requested clarification on the
calculation of the discharge to community measure rates. One commenter
questioned why estimates were used rather than observed rates.
Response: A successful discharge to community outcome includes
patients discharged to the community who remain alive for 31 days post-
discharge with no unplanned readmission. The method used requires the
use of estimates because the observed rates are statistically adjusted
to account for patient mix in each facility. The statistical model also
estimates facility-level effects. In brief, we first calculate the sum
of the probabilities of discharge to community of all patients/
residents in the facility, including both the impact of patient/
resident characteristics and the impact of the facility; this equals
the ``predicted number'' of discharges to community after adjusting for
the facility's case mix. We then calculate the ``expected number'' of
discharges to community for the same
[[Page 52027]]
patients/residents at the average facility. The ratio of the predicted-
to-expected number of discharges to community is a measure of the
degree to which discharges to community are higher or lower than what
would otherwise be expected at the average facility. This ratio is
multiplied by the mean discharge to community rate for all facility
stays for the measure, yielding the risk-standardized discharge to
community rate for each facility.
Details on the risk adjustment methodology and measure calculation
algorithm for the discharge to community measure are available in the
Measure Specifications for Measures Adopted in the FY 2017 SNF QRP
Final Rule, posted on the CMS SNF QRP Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html. Specifically, we refer readers to Sections 2.1.8--
Statistical Risk Model and Risk Adjustment Covariates, and 2.1.9--
Measure Calculation Algorithm.
Comment: One commenter had concerns that there was overlap between
the potentially preventable readmission measure and the discharge to
community measure under the SNF QRP. The commenter noted that using two
separate measures may be confusing to consumers and providers, making
it challenging for SNFs to track and improve performance on these
metrics.
Response: There are distinct differences between the discharge to
community and potentially preventable readmission measures under the
SNF QRP. Although there may be some overlap in the outcomes captured
across the two measures (for example, residents who have a potentially
preventable readmission also have an unsuccessful discharge to
community) each measure has a distinct purpose, outcome definition, and
measure population. For example, the discharge to community measure
assesses the rate of successful discharges to the community, defined as
discharge to a community setting without post-discharge unplanned
readmissions or death, while the potentially preventable readmission
measure assesses the rate of readmissions that may be potentially
prevented for patients/residents discharged to lower levels of care
from the SNF.
Our goal is to develop measures that are meaningful to patients and
consumers, and assist them in making informed choices when selecting
post-acute providers. Since the goal of PAC for most patients and
family members is to be discharged to the community and remain in the
community, from a patient/consumer perspective, it is important to
assess whether a patient remained in the community after discharge and
to separately report discharge to community rates. In addition to
assessing the success of community discharges, the inclusion of post-
discharge readmission and death outcomes is intended to avoid the
potential unintended consequence of inappropriate discharges to the
community.
Analysis on our measure development sample has shown that, of SNF
patients discharged to the community, approximately 15 percent had an
unplanned readmission in the post-discharge observation window. The
mean number of days from SNF discharge to readmission was 12.2 with a
standard deviation of 9.7; 25 percent of readmissions occurred within 3
days of SNF discharge, and 50 percent within 10 days. Ignoring these
post-discharge readmissions occurring soon after discharge to community
would fail to reflect our intent with this measure.
Comment: One commenter suggested that the discharge to community
measure examine emergency room visits in the post-discharge observation
window, in addition to unplanned readmissions. The commenter noted that
this addition would impose no additional data collection burden on SNFs
or hospitals, since these data are already collected by us.
Response: The discharge to community measure captures patients that
are discharged to the community and remain in the community post-
discharge. An emergency room visit that does not result in
hospitalization would not be considered a failure to remain in the
community. Nevertheless, we will assess emergency room visit rates in
the post-discharge observation window to monitor for increasing rates,
and potential indication of poor quality of care or inappropriate
community discharges.
Comment: Some commenters had questions regarding death in the post-
discharge window. One commenter requested clarification as to why an
unexpected death, such as an accidental death, in the post-discharge
observation window would count against a SNF's measure rate on the
discharge to community measure. Another commenter recommended that the
measure exclude patients who have been discharged to the community and
expire within the post-discharge observation window. The commenter
stated that the types of patients treated in SNFs varied greatly, and
including post-discharge death in the measure could lead to an
inaccurate reflection of the quality of care furnished by the SNF.
Response: Including 31-day post-discharge mortality outcomes is
intended to identify successful discharges to community, and to avoid
the potential unintended consequence of inappropriate community
discharges. We have found, through our analyses on our measure
development sample, that death in the 31 days following discharge to
community is an infrequent event, with only 2.0 percent of SNF Medicare
FFS beneficiaries discharged to community dying during that period. In
addition, accidental or unrelated deaths in the post-discharge window
are expected to be rare and randomly distributed. We do not expect such
deaths to disproportionately affect measure rates for specific
facilities. Finally, we do not expect facilities to achieve a 0 percent
death rate in the measure's post-discharge observation window; however,
one focus of the measure is to identify facilities with unexpectedly
high rates of death for quality monitoring purposes.
Comment: A few commenters requested clarification on whether
patients who are discharged to home under hospice care qualify as a
discharge to community for the purposes of the measure. One commenter
also requested clarification on how a patient who elects hospice care
after SNF discharge but within the post-discharge observation window
would be counted in the measure. Two commenters suggested that patients
who die on hospice within the post-discharge observation window not be
excluded from the discharge to community measures, but instead be
considered successful discharges to the community. One commenter noted
that dying at home is the preference of the majority of Americans, and
nursing homes should not be penalized for helping a person choose where
they want their life to end. The other commenter believed that
excluding patients on hospice could create an incentive to keep dying
individuals in a SNF or discharge them to the hospital.
Response: The discharge to community measure excludes patients
discharged to home- or facility-based hospice care. Thus, discharges to
hospice are not considered discharges to community, but rather are
excluded from the measure calculation. We are are adding an exclusion
of patients/residents with a hospice benefit in the post-discharge
observation window to the proposed Discharge to Community--PAC SNF QRP
measure, in response to
[[Page 52028]]
public comments received on this measure proposal, comments received
during measure development, and our ongoing analysis and testing.
In response to commenters' concerns about the exclusion of hospice
patients/residents, we would like to note that we that we reached the
decision to exclude patients/residents discharged to hospice after
discussion with our TEP members and hospice clinical experts,
comparison of post-discharge death rates for hospice and non-hospice
patients/residents, and comparison of discharge planning and goals of
care for hospice and non-hospice patients/residents. We concluded that
it would be conceptually confusing to include in the discharge to
community outcome both patients/residents who are successfully
rehabilitated to live in the community for whom death is an undesirable
outcome, and patients/residents who are terminally ill, and wish to die
in the comfort of their home. The rationale for the added exclusion of
patients/residents with a post-discharge hospice benefit aligns with
the rationale for exclusion of discharges to hospice.
Comment: One commenter suggested that the measure does not
appropriately account for patients who seek other end-of-life care in
the community, beyond hospice.
Response: There are no current data sources available that would
enable us to identify patients seeking end-of-life care that is
separate from hospice services.
Comment: One commenter suggested that we revise the measure name to
reflect that it only applies to the Medicare FFS population. The
commenter was concerned that, in many states, a large proportion of
Medicare beneficiaries served by SNFs are not enrolled in Medicare FFS;
thus, the measure may not reflect a SNF's overall discharge to
community rate, but rather the discharge to community rate among FFS
beneficiaries only.
Response: We will take the commenter's suggestion into
consideration.
Comment: Several commenters had concerns that the risk adjustment
methodology does not include adjustment for sociodemographic or
socioeconomic status. Commenters noted the importance of home and
community supports such as caregiver availability, willingness, and
ability to support the person in the community, and availability of an
established home in determining a beneficiary's ability to be
discharged to community and remain in their home or community setting.
Commenters believed that sociodemographic and socioeconomic factors
were strong predictors of return to the community, and since they were
outside a provider's control, they should be accounted for in risk
adjustment. One commenter expressed concern that the measure does not
adjust for regional differences in community-based needs and supports
that result from factors such as geographic variance in availability of
affordable housing. Another commenter suggested that the measure
account for rurality, since limited alternative services may be
available in rural areas, making discharge to community less feasible.
Response: We understand the importance of home and community
supports and availability of housing for ensuring a successful
discharge to community outcome. The discharge to community measure is a
claims-based measure and, currently, there are no standardized data on
variables such as living status, family and caregiver supports, or
housing availability across across the four PAC settings. We appreciate
and will consider the commenter's suggestion to account for potential
challenges of discharging patients to the community in rural areas. As
we refine the measure in the future, we will consider testing and
adding additional relevant data sources and standardized items for risk
adjustment of this measure. With regard to the suggestions regarding
risk adjustment pertaining to sociodemographic and socioeconomic
factors, we refer the readers to section III.D.2.f. for a more detailed
discussion of the role of SES/SDS factors in risk adjustment of our
measures.
Comment: One commenter raised concerns that the measure does not
adjust for factors that are unique to certain specific provider types,
such as providers offering dedicated services to specialty residents,
for example, those with HIV/AIDS. The commenter noted that providers
caring for these populations may encounter greater challenges in
discharging patients to the community due to special needs such as
affordable and safe housing, mental health and substance abuse
counseling, and medication management and supports.
Response: We appreciate the commenters' suggestion that the
discharge to community measure should adjust for providers primarily
caring for specialty populations that may encounter greater challenges
with discharge to community settings. Our risk adjustment model
accounts for a comprehensive list of diagnoses and comorbidities,
including HIV/AIDS. We will consider testing for an association between
providers primarily caring for specialty populations and discharge to
community outcomes as we refine this measure.
Comment: One commenter emphasized the relationship between
functional gains made by patients during their SNF stay and their
ability to discharge to the community. The commenter stated that return
to one's previous home represents part of the goal of care;
additionally, it is also important that the patient is able to function
to the greatest possible extent in the home and community setting, and
achieve the highest quality of life possible. The commenter recommended
that we delay adopting this measure until it incorporates metrics that
assess whether patients achieved their functional and independence
goals based on their plan of care and their specific condition.
Many other commenters suggested that we include functional status
in the risk adjustment for the discharge to community measure.
Commenters noted that the literature demonstrates evidence that higher
functional and cognitive status are strong predictors of individuals'
ability to live independently, whereas lower functional status was a
strong predictor of requiring long-term nursing home placement. Another
commenter noted that functional status is associated with increased
risk of 30-day all-cause hospital readmissions, and since readmissions
and discharge to community are closely related, functional status risk
adjustment is also important for this measure. One commenter suggested
that the SNF and LTCH measures include risk adjustment that is similar
to the risk adjustment for Case-Mix Groups (CMGs) in the IRF setting
and Activities of Daily Living in the HHA setting. One commenter
interpreted the measure proposal as stating that we will not adjust the
quality measures, including the discharge to community measure, to
account for functional status of beneficiaries until such data are
collected under the IMPACT Act.
Response: We agree that it is important to assess various aspects
of patient outcomes that are indicative of successful discharge from
the SNF setting. We also agree that functional status may be related to
discharge to community outcomes, and that it is important to test
functional status risk adjustment when assessing discharge to community
outcomes. The discharge to community measure does include functional
status risk adjustment in the IRF setting using CMGs from claims, and
in the home health setting using Activities of Daily Living from
claims.
[[Page 52029]]
As mandated by the IMPACT Act, we are moving toward the goal of
collecting standardized patient assessment data for functional status
across PAC settings. Currently, the SNF Quality Reporting Program
includes a process measure related to functional status assessment:
Application of Percent of Long-Term Care Hospital Patients with an
Admission and Discharge Functional Assessment and a Care Plan That
Addresses Function (NQF #2631). Once standardized functional status
data become available across settings, it is our intent to use these
data to assess patients' functional gains during their PAC stay, and to
examine the relationship between functional status, discharge
destination, and patients' ability to discharge to community. As we
examine these relationships between functional outcomes and discharge
to community outcomes in the future, we will assess the feasibility of
leveraging these standardized patient assessment data to incorporate
functional outcomes into the discharge to community measure.
Standardized cross-setting patient assessment data will also allow us
to examine interrelationships between the quality and resource use
measures in each PAC setting, to understand how these measures are
correlated.
Comment: One commenter stated that ventilator use is included as a
risk adjuster in the LTCH setting only, but should be used across all
settings. This commenter also requested information on the hierarchical
logistic regression modeling and variables that will be used for risk
adjustment.
Response: We would like to clarify that risk adjustment for
ventilator use is included in both LTCH and SNF settings. We
investigated the need for risk adjustment for ventilator use in IRFs,
but found that less than 0.01 percent of the IRF population (19 patient
stays in 2012, and 9 patient stays in 2013) had ventilator use in the
IRF. Given the low frequency of ventilator use in IRFs, any associated
estimates would not be reliable; thus, ventilator use is not included
as a risk adjuster in the IRF setting measure. However, we will
continue to assess this risk adjuster for inclusion in the IRF model
for this measure.
For details on measure specifications, modeling, and calculations,
we refer readers to the Measure Specifications for Measures Adopted in
the FY 2017 SNF QRP Final Rule, posted on the CMS SNF QRP Web page at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
Comment: Two commenters conveyed concerns about unintended
consequences of the discharge to community measure. One commenter was
concerned about increased costs to the health care system in instances
where patients have difficult transitions to community, have subsequent
difficulty accessing SNF care, and experience costlier inpatient care
as a consequence. Another commenter had concerns that the discharge to
community measure may limit access to specialty services, limit access
to care for low-income populations; create perverse incentives for
providers; or impact the finances of post-acute care providers based on
factors beyond their control. One commenter stated that effective risk
adjustment would be important to avoid unintended consequences of
decreased access for patients who may need a longer SNF stay.
Response: We appreciate the commenter's concerns regarding
potential unintended consequences of the discharge to community
measure. We expect that, on average, discharges to community settings
rather than institutional settings will result in lower healthcare
costs. To avoid potential unintended consequences of inappropriate
discharges to the community, this measure examines acute care and LTCH
readmissions and death in the 31-day post-discharge observation window;
the measure thus incentivizes providers to ensure safe transitions to
the community without post-discharge unplanned readmissions. In future
modifications of the measure, we will consider looking for IRF, SNF,
and nursing facility admissions and readmissions in the 31-day post-
discharge window when examining discharge to community outcomes. With
regard to the commenter's concern that the measure may result in
decreased access for patients who may need a longer SNF stay, we would
like to clarify that the measure does not examine the length of a SNF
stay and does not incentivize facilities to avoid patients/residents
who may need a longer stay in the facility. The measure examines
discharge destination from the SNF, irrespective of their length of
stay.
As with all our measures, we will monitor for unintended
consequences as part of measure monitoring and evaluation to ensure
that measures do not reduce quality of care or access for patients,
result in disparities for certain patient sub-groups, or adversely
affect healthcare spending.
Comment: One commenter conveyed appreciation that the measure would
be revised using an ICD-9 to ICD-10 crosswalk.
Response: We thank the commenter for their appreciation of proposed
measure updates using the ICD-9 to ICD-10 crosswalk, as stated in the
Proposed Measure Specifications for Measures Proposed in the FY 2017
SNF QRP Proposed Rule.
Comment: One commenter encouraged us to provide PAC settings with
access to measure performance data as early as possible so providers
have time to adequately review these data, and implement strategies to
decrease readmissions where necessary.
Response: We intend to provide initial confidential feedback to PAC
providers, prior to public reporting of this measure, based on Medicare
FFS claims data from discharges in CY 2016.
Comment: Several commenters expressed concern about the lack of NQF
endorsement for the measure, and suggested additional measure testing
and development. One commenter requested that we provide a timeline for
submission of the proposed measures to NQF. Additionally, commenters
recommended NQF endorsement prior to implementation or public
reporting.
Response: We thank the commenter for their comments regarding NQF
endorsement. We would like to clarify that the discharge to community
measure has been fully developed and tested. We plan to submit the
Discharge to Community--PAC SNF QRP measure to the NQF for
consideration for endorsement.
Final Decision: After careful consideration of the public comments,
we are finalizing our proposal to adopt the measure, Discharge to
Community--PAC SNF QRP as a Medicare FFS claims-based measure for the
FY 2018 payment determination and subsequent years, with the added
exclusion of residents with a hospice benefit in the 31-day post-
discharge observation window. For measure specifications, we refer
readers to the Measure Specifications for Measures Adopted in the FY
2017 SNF QRP Final Rule, posted on the CMS SNF QRP Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
[[Page 52030]]
iii. Measure To Address the IMPACT Act Domain of Resource Use and Other
Measures: Potentially Preventable 30-Day Post-Discharge Readmission
Measure for Skilled Nursing Facility Quality Reporting Program
Sections 1899B(a)(2)(E)(ii) and 1899B(d)(1)(C) of the Act require
the Secretary to specify measures to address the domain of all-
condition risk-adjusted potentially preventable hospital readmission
rates by SNFs, LTCHs, and IRFs by October 1, 2016, and HHAs by January
1, 2017. We proposed the measure Potentially Preventable 30-Day Post-
Discharge Readmission Measure for SNF QRP as a Medicare FFS claims-
based measure to meet this requirement for the FY 2018 payment
determination and subsequent years.
The measure assesses the facility-level risk-standardized rate of
unplanned, potentially preventable hospital readmissions for Medicare
FFS beneficiaries in the 30 days post-SNF discharge. The SNF admission
must have occurred within up to 30 days of discharge from a prior
proximal hospital stay which is defined as an inpatient admission to an
acute care hospital (including IPPS, CAH, or a psychiatric hospital).
Hospital readmissions include readmissions to a short-stay acute care
hospitals or an LTCH, with a diagnosis considered to be unplanned and
potentially preventable. This measure is claims-based, requiring no
additional data collection or submission burden for SNFs. Because the
measure denominator is based on SNF admissions, each Medicare
beneficiary may be included in the measure multiple times within the
measurement period. Readmissions counted in this measure are identified
by examining Medicare FFS claims data for readmissions to either acute
care hospitals (IPPS or CAH) or LTCHs that occur during a 30-day window
beginning two days after SNF discharge. This measure is conceptualized
uniformly across the PAC settings, in terms of the measure definition,
the approach to risk adjustment, and the measure calculation. Our
approach for defining potentially preventable hospital readmissions is
described in more detail below.
Hospital readmissions among the Medicare population, including
beneficiaries that utilize PAC, are common, costly, and often
preventable.86 87 MedPAC and a study by Jencks et al.
estimated that 17 to 20 percent of Medicare beneficiaries discharged
from the hospital were readmitted within 30 days. MedPAC found that
more than 75 percent of 30-day and 15-day readmissions and 84 percent
of 7-day readmissions were considered ``potentially preventable.'' \88\
In addition, MedPAC calculated that annual Medicare spending on
potentially preventable readmissions would be $12 billion for 30-day,
$8 billion for 15-day, and $5 billion for 7-day readmissions in
2005.\89\ For hospital readmissions from SNFs, MedPAC deemed 76 percent
of readmissions as ``potentially avoidable''--associated with $12
billion in Medicare expenditures.\90\ Mor et al. analyzed 2006 Medicare
claims and SNF assessment data (Minimum Data Set), and reported a 23.5
percent readmission rate from SNFs, associated with $4.3 billion in
expenditures.\91\ Fewer studies have investigated potentially
preventable readmission rates from the remaining post-acute care
settings.
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\86\ Friedman, B., and Basu, J.: The rate and cost of hospital
readmissions for preventable conditions. Med. Care Res. Rev.
61(2):225-240, 2004. doi:10.1177/1077558704263799.
\87\ Jencks, S.F., Williams, M.V., and Coleman, E.A.:
Rehospitalizations among patients in the Medicare Fee-for-Service
Program. N. Engl. J. Med. 360(14):1418-1428, 2009. doi:10.1016/
j.jvs.2009.05.045.
\88\ MedPAC: Payment policy for inpatient readmissions, in
Report to the Congress: Promoting Greater Efficiency in Medicare.
Washington, DC, pp. 103-120, 2007. Available from http://www.medpac.gov/documents/reports/Jun07_EntireReport.pdf.
\89\ ibid.
\90\ ibid.
\91\ Mor, V., Intrator, O., Feng, Z., et al.: The revolving door
of rehospitalization from skilled nursing facilities. Health Aff.
29(1):57-64, 2010. doi:10.1377/hlthaff.2009.0629.
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We have addressed the high rates of hospital readmissions in the
acute care setting, as well as in PAC. For example, we developed the
following measure: Skilled Nursing Facility 30-Day All-Cause
Readmission Measure (SNFRM) (NQF #2510), as well as similar measures
for other PAC providers (NQF #2502 for IRFs and NQF #2512 for
LTCHs).\92\ These measures are endorsed by the NQF, and the NQF
endorsed SNF measure (NQF #2510) was adopted into the SNF VBP Program
in the FY 2016 SNF final rule (80 FR 46411 through 46419). Note that
these NQF endorsed measures assess all-cause unplanned readmissions.
---------------------------------------------------------------------------
\92\ National Quality Forum: All-Cause Admissions and
Readmissions Measures. pp. 1-319, April 2015. Available from http://www.qualityforum.org/Publications/2015/04/All-Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx.
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Several general methods and algorithms have been developed to
assess potentially avoidable or preventable hospitalizations and
readmissions for the Medicare population. These include the Agency for
Healthcare Research and Quality's (AHRQ's) Prevention Quality
Indicators, approaches developed by MedPAC, and proprietary approaches,
such as the 3M \TM\ algorithm for Potentially Preventable
Readmissions.93 94 95 Recent work led by Kramer et al. for
MedPAC identified 13 conditions for which readmissions were deemed as
potentially preventable among SNF and IRF populations.96 97
Although much of the existing literature addresses hospital
readmissions more broadly and potentially avoidable hospitalizations
for specific settings like long-term care, these findings are relevant
to the development of potentially preventable readmission measures for
PAC.98 99 100
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\93\ Goldfield, N.I., McCullough, E.C., Hughes, J.S., et al.:
Identifying potentially preventable readmissions. Health Care Finan.
Rev. 30(1):75-91, 2008. Available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195042/.
\94\ Agency for Healthcare Quality and Research: Prevention
Quality Indicators Overview. 2008.
\95\ MedPAC: Online Appendix C: Medicare Ambulatory Care
Indicators for the Elderly. pp. 1-12, prepared for Chapter 4, 2011.
Available from http://www.medpac.gov/documents/reports/Mar11_Ch04_APPENDIX.pdf?sfvrsn=0.
\96\ Kramer, A., Lin, M., Fish, R., et al.: Development of
Inpatient Rehabilitation Facility Quality Measures: Potentially
Avoidable Readmissions, Community Discharge, and Functional
Improvement. pp. 1-42, 2015. Available from http://www.medpac.gov/documents/contractor-reports/development-of-inpatient-rehabilitation-facility-quality-measures-potentially-avoidable-readmissions-community-discharge-and-functional-improvement.pdf?sfvrsn=0.
\97\ Kramer, A., Lin, M., Fish, R., et al.: Development of
Potentially Avoidable Readmission and Functional Outcome SNF Quality
Measures. pp. 1-75, 2014. Available from http://www.medpac.gov/documents/contractor-reports/mar14_snfqualitymeasures_contractor.pdf?sfvrsn=0.
\98\ Allaudeen, N., Vidyarthi, A., Maselli, J., et al.:
Redefining readmission risk factors for general medicine patients.
J. Hosp. Med. 6(2):54-60, 2011. doi:10.1002/jhm.805.
\99\ Gao, J., Moran, E., Li, Y.-F., et al.: Predicting
potentially avoidable hospitalizations. Med. Care 52(2):164-171,
2014. doi:10.1097/MLR.0000000000000041.
\100\ Walsh, E.G., Wiener, J.M., Haber, S., et al.: Potentially
avoidable hospitalizations of dually eligible Medicare and Medicaid
beneficiaries from nursing facility and home[hyphen]and
community[hyphen]based services waiver programs. J. Am. Geriatr.
Soc. 60(5):821-829, 2012. doi:10.1111/j.1532-5415.2012.03920.x.
---------------------------------------------------------------------------
Potentially Preventable Readmission Measure Definition: We
conducted a comprehensive environmental scan, analyzed claims data, and
obtained input from a TEP to develop a definition and list of
conditions for which hospital readmissions are potentially preventable.
The Ambulatory Care Sensitive Conditions and Prevention Quality
Indicators, developed by AHRQ, served as the starting point in this
work. For patients in the 30-day post-PAC
[[Page 52031]]
discharge period, a potentially preventable readmission (PRR) refers to
a readmission for which the probability of occurrence could be
minimized with adequately planned, explained, and implemented post
discharge instructions, including the establishment of appropriate
follow-up ambulatory care. Our list of PPR conditions is categorized by
3 clinical rationale groupings:
Inadequate management of chronic conditions;
Inadequate management of infections; and
Inadequate management of other unplanned events.
Additional details regarding the definition for potentially
preventable readmissions are available in the document titled, Proposed
Measure Specifications for Measures Proposed in the FY 2017 SNF QRP
Proposed Rule, available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
This measure focuses on readmissions that are potentially
preventable and also unplanned. Similar to the SNF 30-Day All-Cause
Readmission Measure (NQF #2510), this measure uses the current version
of the CMS Planned Readmission Algorithm as the main component for
identifying planned readmissions. A complete description of the CMS
Planned Readmission Algorithm, which includes lists of planned
diagnoses and procedures, can be found on the CMS Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html. In addition
to the CMS Planned Readmission Algorithm, this measure incorporates
procedures that are considered planned in post-acute care settings, as
identified in consultation with TEPs. Full details on the planned
readmissions criteria used, including the CMS Planned Readmission
Algorithm and additional procedures considered planned for post-acute
care, can be found in the document titled, Proposed Measure
Specifications for Measures Proposed in the FY 2017 SNF QRP Proposed
Rule at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
This measure, Potentially Preventable 30-Day Post-Discharge
Readmission Measure for Skilled Nursing Facility Quality Reporting
Program, assesses potentially preventable readmission rates while
accounting for patient demographics, principal diagnosis in the prior
hospital stay, comorbidities, and other patient factors. While
estimating the predictive power of patient characteristics, the model
also estimates a facility-specific effect, common to patients treated
in each facility. This measure is calculated for each SNF based on the
ratio of the predicted number of risk-adjusted, unplanned, potentially
preventable hospital readmissions that occur within 30 days after a SNF
discharge, including the estimated facility effect, to the estimated
predicted number of risk-adjusted, unplanned inpatient hospital
readmissions for the same patients treated at the average SNF. A ratio
above 1.0 indicates a higher than expected readmission rate (worse)
while a ratio below 1.0 indicates a lower than expected readmission
rate (better). This ratio is referred to as the standardized risk ratio
(SRR). The SRR is then multiplied by the overall national raw rate of
potentially preventable readmissions for all SNF stays. The resulting
rate is the risk-standardized readmission rate (RSRR) of potentially
preventable readmissions.
An eligible SNF stay is followed until: (1) The 30-day post-
discharge period ends; or (2) the patient is readmitted to an acute
care hospital (IPPS or CAH) or LTCH. If the readmission is unplanned
and potentially preventable, it is counted as a readmission in the
measure calculation. If the readmission is planned, the readmission is
not counted in the measure rate.
This measure is risk adjusted. The risk adjustment modeling
estimates the effects of patient characteristics, comorbidities, and
select health care variables on the probability of readmission. More
specifically, the risk-adjustment model for SNFs accounts for
demographic characteristics (age, sex, original reason for Medicare
entitlement), principal diagnosis during the prior proximal hospital
stay, body system specific surgical indicators, comorbidities, length
of stay during the patient's prior proximal hospital stay, intensive
care unit (ICU) utilization, end-stage renal disease status, and number
of acute care hospitalizations in the preceding 365 days.
This measure is calculated using 1 calendar year of FFS claims
data, to ensure the statistical reliability of this measure for
facilities. In addition, we proposed a minimum of 25 eligible stays for
public reporting of the measure.
A TEP convened by our measure development contractor provided
recommendations on the technical specifications of this measure,
including the development of an approach to define potentially
preventable hospital readmission for PAC. Details from the TEP
meetings, including TEP members' ratings of conditions proposed as
being potentially preventable, are available in the TEP Summary Report
available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html. We
also solicited stakeholder feedback on the development of this measure
through a public comment period held from November 2 through December
1, 2015. Comments on the measure varied, with some commenters
supportive of the measure, while others either were not in favor of the
measure, or suggested potential modifications to the measure
specifications, such as including standardized function data. A summary
of the public comments is also available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
The MAP encouraged continued development of the measure.
Specifically, the MAP stressed the need to promote shared
accountability and ensure effective care transitions. More information
about the MAP's recommendations for this measure is available at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx. At the time, the risk-adjustment model was still under
development. Following completion of that development work, we were
able to test for measure validity and reliability as identified in the
measure specifications document provided above. Testing results are
within range for similar outcome measures finalized in public reporting
and value-based purchasing programs, including the SNFRM (NQF #2510)
adopted into the SNF VBP Program in the FY 2016 SNF final rule (80 FR
46411 through 46419).
We reviewed the NQF's consensus endorsed measures and were unable
to identify any NQF endorsed measures focused on potentially
preventable
[[Page 52032]]
hospital readmissions. We are unaware of any other measures for this
IMPACT Act domain that have been endorsed or adopted by other consensus
organizations. Therefore, we proposed the Potentially Preventable 30-
Day Post-Discharge Readmission Measure for SNF QRP, under the
Secretary's authority to specify non-NQF-endorsed measures under
section 1899B(e)(2)(B) of the Act, for the SNF QRP for the FY 2018
payment determination and subsequent years given the evidence
previously discussed above.
We plan to submit the measure to the NQF for consideration of
endorsement. We stated in the proposed rule that we intended to provide
initial confidential feedback to SNFs, prior to public reporting of
this measure, based on 1 calendar year of claims data from discharges
in CY 2016. We also stated that we intended to publicly report this
measure using claims data from CY 2017.
We invited public comment on our proposal to adopt the measure,
Potentially Preventable 30-Day Post-Discharge Readmission Measure for
SNF QRP. We received several comments, which are summarized with our
responses below.
Comment: MedPAC and several other commenters expressed general
support for the proposed Potentially Preventable 30-Day Post-Discharge
Readmission Measure for SNF QRP. One commenter noted that the PPR
measure would supplement the all-cause readmission measure by creating
an incentive for SNFs to focus attention on managing SNF residents that
are chronically ill as well as to manage or avoid infections. Some
commenters specifically supported the post-PAC discharge readmission
window, noting that SNFs should be accountable for safe transitions to
the community or next care setting.
Response: We thank commenters for their support of this measure.
Comment: One commenter specifically supported the inclusion of
infectious conditions in the ``inadequate management of infections''
and ``inadequate management of other unplanned events'' categories in
the measure's definition of potentially preventable hospital
readmissions. Another commenter expressed support for the inclusion of
chronic conditions and infections as conditions for which readmissions
would be considered potentially preventable. Another commenter
expressed appreciation for the focus on preventable readmissions, but
urged us to continue evaluating and testing the measure to ensure that
the codes used for the PPR definition are clinically relevant. One
commenter expressed concern over being ``penalized'' for readmissions
that are clinically unrelated to a patient's original reason for SNF
admission.
Response: We thank commenters for their support of this measure
domain and the list of PPR conditions developed for this measure.
Though readmissions may be considered potentially preventable even if
they may not appear to be clinically related to the patient's original
reason for SNF admission, there is substantial evidence that the
conditions included in the definition may be preventable with
adequately planned, explained, and implemented post-discharge
instructions, including the establishment of appropriate follow-up
ambulatory care. Furthermore, this measure is based on Medicare FFS
claims data, and it may not always be feasible to determine whether a
subsequent readmission is or is not clinically related to the reason
why the patient was receiving SNF care. We intend to conduct ongoing
evaluation and monitoring of this measure.
Comment: Several commenters expressed concern over the cross-
setting alignment of the proposed PPR measures. One commenter
encouraged us to assess readmission measures across the agency's
programs to ensure that they promote collaboration and support
readmission reduction efforts. MedPAC commented that the measure
definition and risk adjustment should be identical across PAC settings
so that potentially preventable readmission rates can be compared
across settings. Another commenter expressed concern specifically over
the ``nonalignment'' between the IRF and SNF versions of the measure,
adding that this may lead to confusion.
Response: The PPR definition (that is, list of conditions for which
readmissions would be considered potentially preventable) is aligned
for measures with the same readmission window, regardless of PAC
setting. Specifically, the post-PAC discharge PPR measures that were
developed for each of the PAC settings contain the same list of PPR
conditions. Although there are some minor differences in the
specifications across the measures (for example, years of data used to
calculate the measures to ensure reliability and some of the measure
exclusions necessary to attribute responsibility to the individual
settings), the IMPACT Act PPR measures are standardized. As described
for all IMPACT Act measures in section III.D.2.f., the statistical
approach for risk adjustment is also aligned across the measures;
however, there is variation in the exact risk adjusters. The risk-
adjustment models are empirically driven and differ between measures as
a consequence of case mix differences, which is necessary to ensure
that the estimates are valid.
Comment: One commenter expressed concern that the post-discharge
readmission window provides an opportunity for patient health to
decline following discharge due to factors beyond providers' control,
including patient behavior, noting these factors vary considerably
among patients. The commenter suggested the measure reflect the shared
responsibility of all parties involved in a patient's care, such as
caregivers and the patients themselves. The commenter also suggested we
clarify how patients that expire within the readmission window are
handled in the measure.
Response: The focus of the PPR measure is to identify excess PPR
rates for the purposes of quality improvement. There is substantial
evidence that certain readmissions can be prevented with adequately
planned, explained, and implemented post-discharge instructions,
including the establishment of appropriate follow-up ambulatory care.
We are aware that there are certain patient characteristics that may
increase the risk of readmission, and a number of these conditions are
accounted for in the risk-adjustment model. We would also like to
clarify that patients who expire during the SNF stay are excluded
because there is no post-SNF discharge window to observe the outcome.
However, we do include patients that expire during the post-SNF
discharge readmission window to assess the outcome as it is relevant
for all patients discharged from SNFs. This is also consistent with
other NQF-endorsed readmission measures.
Comment: Several commenters raised concerns over the risk-
adjustment approach for the PPR measures, urging us to incorporate
factors such as cognitive and functional status, supply variables, and
SES/SDS factors into the measure's risk adjustment. One commenter noted
that assessment instruments, such as the MDS, provide data sources for
various patient clinical characteristics. Furthermore, the commenter
expressed that because the IMPACT Act mandates the standardization of
assessment instruments, the IMPACT Act measures should incorporate
standardized items as risk adjusters.
Another commenter supported the proposed risk-adjustment
methodology commenting that it will provide a valid assessment of
quality of care in
[[Page 52033]]
preventing unplanned, preventable hospital readmissions.
Response: The risk-adjustment model takes into account medical
complexity, as patients with multiple risk factors will rate as having
higher risk of readmission. For those cross-setting post-acute measures
such as those intended to satisfy the IMPACT Act domains that use the
patient assessment-based data elements for risk adjustment, we have
either made such items standardized, or intend to do so as feasible. We
wish to note that we intend to evaluate the feasibility of including
functional and cognitive status when standardized assessment data
become available. With regard to the suggestions pertaining to risk
adjustment methodologies pertaining to sociodemographic factors we
refer the readers to section section III.D.2.f. where we also discuss
these topics.
Comment: Some commenters cautioned against potential unintended
consequences of the measure, in particular, noting that the measure
could incentivize SNFs to delay necessary readmission to the hospital
or prolong the SNF stay. One commenter noted that the measure could
cause SNFs to be selective about the patients they admit (that is,
``cherry pick'' their patients), and suggested that an appropriate risk
adjustment could prevent this.
Response: We intend to conduct ongoing monitoring to assess for
potential unintended consequences associated with the implementation of
this measure, and we will take these suggestions into account. A major
goal of risk adjustment is to ensure that patient case mix is taken
into account in order to allow for fair comparisons of facilities. The
risk of readmission for patients in poor health is taken into account
by the risk-adjustment model used in the calculation of this measure.
Given this is a post-SNF discharge measure, SNFs would have no
incentive to delay hospital readmissions.
Comment: One commenter suggested that the PPR measure incorporate
both inpatient and emergency room (ER) visits because a measure that
captures both would be more understandable to consumers. Another
expressed concern regarding overlap between the proposed PPR measure
and the discharge to community measure, and the implications for
quality improvement.
Response: We appreciate the comment suggesting that the measure
include inpatient as well as ER visits. However, we wish to clarify
that the PPR measure was developed to fulfill the IMPACT Act's
statutory requirement for a measure to address the domain of
potentially preventable hospital readmissions. We agree that ER or
emergency department visits are also an important outcome, but they are
not hospital readmissions.
We discuss above the similarities and differences between the PPR
and discharge to community measure. Although there are conceptual
similarities between the measures, we believe that each measure
provides important information for quality improvement purposes and
will enable SNFs to target different aspects of care provided.
Comment: One commenter provided comments on the statistical
approach used to calculate the measure, recommending that we use the
actual readmission rate (that is, observed) as the numerator of the SRR
rather than the predicted number of readmissions, or provide evidence
to justify this more complicated methodology. The commenter
acknowledged the aims of the risk-adjustment model but suggested using
the actual instead of the predicted number of readmissions so that the
numerator of the SRR is clearer and more actionable for facilities, and
is not likely to result in substantial changes to the relative ranking
of facilities. The same commenter also indicated support for the
current minimum denominator size--25 patients--for public reporting but
suggested that a minimum size of 30 would improve the reliability of
the measurement.
Response: The statistical approach for this measure, including the
use of the predicted to expected readmission rate, is used in several
other readmission measures, including the SNFRM (NQF #2510) and other
NQF-endorsed readmission measures. Not using this approach would render
providers with small numbers of eligible patient stays excessively
vulnerable to reported rates driven by the influence of random
variation in performance, limiting the value of the public reporting
their measure performance. We would also like to note that facilities
will be given their observed rates in their reports.
We acknowledge that increasing the minimum denominator size for
public reporting of this measure may increase the reliability of the
measure, but doing so would prevent a substantial number of facilities
from reporting this measure.
Comment: One commenter commented that we should not finalize this
measure because the measure was still under development and the MAP did
not vote to support it, but instead encouraged continued development.
In addition, this commenter said we should submit the measure for NQF
endorsement and only propose NQF endorsed measures. Another commenter
encouraged additional testing and evaluation of the measure prior to
implementation.
Response: We intend to submit this measure to NQF for consideration
of endorsement. Although the measure is not currently endorsed, we did
conduct additional testing subsequent to the MAP meeting. Based on that
testing, we were able to complete the risk adjustment model and
evaluate facilities' PPR rates, and we made the results of our analyses
available at the time of the proposed rule. We found that testing
results were similar to the SNFRM (NQF #2510) and allowed us to
conclude that the measure is sufficiently developed, valid and reliable
for adoption in the SNF QRP.
Comment: One commenter expressed concern that we used language that
suggested all readmissions are preventable and recommends the use of
the term ``may be avoidable'' in place of ``should be avoidable'' in
describing readmissions. The commenter was concerned that the language
used would imply that the goal of the measure is for providers to reach
zero percent PPR.
Another commenter expressed concern about the accuracy of claims-
based data, but supported the effort to limit the data collection
burden placed on providers.
Response: We agree with the commenter that this is a measure of
potentially preventable readmissions and that not all readmissions are
preventable. We wish to clarify that the PPR rate is not expected to be
0. The goal of the measure is to identify excess PPR rates for the
purposes of quality improvement.
With respect to the use of claims data to calculate this measure,
multiple studies have been conducted to examine the validity of using
Medicare hospital claims to calculate several NQF endorsed quality
measures for public reporting.101 102 103 These studies
supported the use of claims data as a valid means for risk adjustment
and assessing similar outcomes. Additionally, although assessment and
other data sources may be valuable for
[[Page 52034]]
risk adjustment, we are not aware of another data source aside from
Medicare claims data that could be used to reliably assess the outcome
of potentially preventable hospital readmissions post-SNF discharge.
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\101\ Bratzler DW, Normand SL, Wang Y, et al. An administrative
claims model for profiling hospital 30-day mortality rates for
pneumonia patients. PLoS One 2011;6(4):e17401.
\102\ Keenan PS, Normand SL, Lin Z, et al. An administrative
claims measure suitable for profiling hospital performance on the
basis of 30-day all-cause readmission rates among patients with
heart failure. Circulation 2008;1(1):29-37.
\103\ Krumholz HM, Wang Y, Mattera JA, et al. An administrative
claims model suitable for profiling hospital performance based on
30-day mortality rates among patients with heart failure.
Circulation 2006;113:1693-1701.
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Final Decision: After careful consideration of the public comments,
we are finalizing our proposal to adopt the measure, Potentially
Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP
beginning with the FY 2018 payment determination. Measure
Specifications for Measures Adopted in the FY 2017 SNF QRP Final Rule
are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
g. SNF QRP Quality Measure Finalized for the FY 2020 Payment
Determination and Subsequent Years
We proposed to adopt one new quality measure to meet the
requirements of the IMPACT Act for the FY 2020 payment determination
and subsequent years. The measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC SNF QRP, addresses the IMPACT Act
quality domain of Medication Reconciliation.
1. Quality Measure Addressing the IMPACT Act Domain of Medication
Reconciliation: Drug Regimen Review Conducted With Follow-Up for
Identified Issues--Post Acute Care (PAC) Skilled Nursing Facility
Quality Reporting Program
Sections 1899B (a)(2)(E)(i)(III) and 1899B(c)(1)(C) of the Act
require the Secretary to specify a quality measure to address the
domain of medication reconciliation by October 1, 2018 for IRFs, LTCHs
and SNFs; and by January 1, 2017 for HHAs. We proposed to adopt the
quality measure, Drug Regimen Review Conducted with Follow-Up for
Identified Issues--PPAC SNF QRP, for the SNF QRP as a resident-
assessment based, cross-setting quality measure to meet the IMPACT Act
requirements with data collection beginning October 1, 2018 for the FY
2020 payment determinations and subsequent years.
This measure assesses whether PAC providers were responsive to
potential or actual clinically significant medication issue(s) when
such issues were identified. Specifically, the proposed quality measure
reports the percentage of resident stays in which a drug regimen review
was conducted at the time of admission and timely follow-up with a
physician occurred each time potential clinically significant
medication issues were identified throughout that stay. For this
proposed quality measure, a drug regimen review is defined as the
review of all medications or drugs the patient is taking to identify
any potential clinically significant medication issues. This proposed
quality measure utilizes both the processes of medication
reconciliation and a drug regimen review, in the event an actual or
potential medication issue occurred. The measure informs whether the
PAC facility identified and addressed each clinically significant
medication issue and if the facility responded or addressed the
medication issue in a timely manner. Of note, drug regimen review in
PAC settings is generally considered to include medication
reconciliation and review of the patient's drug regimen to identify
potential clinically significant medication issues.\104\ (Please note:
In the proposed rule, footnote 94 was inadvertently labeled ibid, which
attributed the reference to the American Geriatric Society. In this
final rule, we have corrected the reference and replaced it with the
intended one, Institute of Medicine. Preventing Medication Errors.
Washington, DC: National Academies Press; 2006.) This measure is
applied uniformly across the PAC settings.
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\104\ Institute of Medicine. Preventing Medication Errors.
Washington, DC: National Academies Press; 2006.
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Medication reconciliation is a process of reviewing an individual's
complete and current medication list. Medication reconciliation is a
recognized process for reducing the occurrence of medication
discrepancies that may lead to Adverse Drug Events (ADEs).\105\
Medication discrepancies occur when there is conflicting information
documented in the medical records. The World Health Organization
regards medication reconciliation as a standard operating protocol
necessary to reduce the potential for ADEs that cause harm to patients.
Medication reconciliation is an important patient safety process that
addresses medication accuracy during transitions in resident care and
in identifying preventable ADEs.\106\ The Joint Commission added
medication reconciliation to its list of National Patient Safety Goals
(2005), suggesting that medication reconciliation is an integral
component of medication safety.\107\ The Society of Hospital Medicine
published a statement in agreement of the Joint Commission's emphasis
and value of medication reconciliation as a patient safety goal.\108\
There is universal agreement that medication reconciliation directly
addresses resident safety issues that can result from medication
miscommunication and unavailable or incorrect information.\109\ \110\
\111\
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\105\ Ibid.
\106\ Leotsakos A., et al. Standardization in patient safety:
The WHO High 5s project. Int J Qual Health Care. 2014:26(2):109-116.
\107\ The Joint Commission. 2016 Long Term Care: National
Patient Safety Goals Medicare/Medicaid Certification-based Option.
(NPSG.03.06.01).
\108\ Greenwald, J.L., Halasyamani, L., Greene, J., LaCivita,
C., et al. (2010). Making inpatient medication reconciliation
patient centered, clinically relevant and implementable: A consensus
statement on key principles and necessary first steps. Journal of
Hospital Medicine, 5(8), 477-485.
\109\ Leotsakos A., et al. Standardization in patient safety:
The WHO High 5s project. Int J Qual Health Care. 2014:26(2):109-116.
\110\ The Joint Commission. 2016 Long Term Care: National
Patient Safety Goals Medicare/Medicaid Certification-based Option.
(NPSG.03.06.01).
\111\ IHI. Medication Reconciliation to Prevent Adverse Drug
Events [Internet]. Cambridge, MA: Institute for Healthcare
Improvement; [cited 2016 Jan 11]. Available from: http://www.ihi.org/topics/adesmedicationreconciliation/Pages/default.aspx.
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The performance of timely medication reconciliation is valuable to
the process of drug regimen review. Preventing and responding to ADEs
is of critical importance as ADEs account for significant increases in
health services utilization and costs \112\ \113\ \114\ including
subsequent emergency room visits and re-hospitalizations.\115\ Annual
health care costs from ADEs in the United States are estimated at $3.5
billion, resulting in 7,000 deaths annually.\116\
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\112\ Institute of Medicine. Preventing Medication Errors.
Washington, DC: National Academies Press; 2006.
\113\ Jha AK, Kuperman GJ, Rittenberg E, et al. Identifying
hospital admissions due to adverse drug events using a computer-
based monitor. Pharmacoepidemiol Drug Saf. 2001;10(2):113-119.
\114\ Hohl CM, Nosyk B, Kuramoto L, et al. Outcomes of emergency
department patients presenting with adverse drug events. Ann Emerg
Med. 2011;58:270-279.
\115\ Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human:
Building a Safer Health System Washington, DC: National Academies
Press; 1999.
\116\ Greenwald, J.L., Halasyamani, L., Greene, J., LaCivita,
C., et al. (2010). Making inpatient medication reconciliation
patient centered, clinically relevant and implementable: A consensus
statement on key principles and necessary first steps. Journal of
Hospital Medicine, 5(8), 477-485.
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Medication errors include the duplication of medications, delivery
of an incorrect drug, inappropriate drug omissions, or errors in the
dosage, route, frequency, and duration of medications. Medication
errors are one of the most common types of medical errors and can occur
at any point in the process of ordering and delivering a medication.
Medication errors have the potential to
[[Page 52035]]
result in an ADE.\117\ \118\ \119\ \120\ \121\ \122\ Inappropriately
prescribed medications are also considered a major healthcare concern
in the United States for the elderly population, with costs of roughly
$7.2 billion annually.\123\
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\117\ Institute of Medicine. To err is human: Building a safer
health system. Washington, DC: National Academies Press; 2000.
\118\ Lesar TS, Briceland L, Stein DS. Factors related to errors
in medication prescribing. JAMA. 1997:277(4): 312-317.
\119\ Bond CA, Raehl CL, & Franke T. Clinical pharmacy services,
hospital pharmacy staffing, and medication errors in United States
hospitals. Pharmacotherapy. 2002:22(2): 134-147.
\120\ Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, et
al. Incidence of adverse drug events and potential adverse drug
events. Implications for prevention. JAMA. 1995:274(1): 29-34.
\121\ Barker KN, Flynn EA, Pepper GA, Bates DW, & Mikeal RL.
Medication errors observed in 36 health care facilities. JAMA. 2002:
162(16):1897-1903.
\122\ Bates DW, Boyle DL, Vander Vliet MB, Schneider J, & Leape
L. Relationship between medication errors and adverse drug events. J
Gen Intern Med. 1995:10(4): 199-205.
\123\ Fu, Alex Z., et al. ``Potentially inappropriate medication
use and healthcare expenditures in the US community-dwelling
elderly.'' Medical care 45.5 (2007): 472-476.
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There is strong evidence that medication discrepancies occur during
transfers from acute care facilities to post-acute care facilities.
Discrepancies occur when there is conflicting information documented in
the medical records. Almost one-third of medication discrepancies have
the potential to cause patient harm.\124\ Medication discrepancies upon
admission to SNFs have been reported as occurring at a rate of more
than 21 percent. It has been found that at least one medication
discrepancy occurred in more than 71 percent of all the SNF
admissions.\125\ An estimated fifty percent of patients experienced a
clinically important medication error after hospital discharge in an
analysis of two tertiary care academic hospitals.\126\
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\124\ Wong, Jacqueline D., et al. ``Medication reconciliation at
hospital discharge: Evaluating discrepancies.'' Annals of
Pharmacotherapy 42.10 (2008): 1373-1379.
\125\ Tjia, J., Bonner, A., Briesacher, B.A., McGee, S.,
Terrill, E., & Miller, K. (2009). Medication discrepancies upon
hospital to skilled nursing facility transitions. Journal of general
internal medicine, 24(5), 630-635.
\126\ Kripalani S, Roumie CL, Dalal AK, et al. Effect of a
pharmacist intervention on clinically important medication errors
after hospital discharge: A randomized controlled trial. Ann Intern
Med. 2012:157(1):1-10.
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Medication reconciliation has been identified as an area for
improvement during transfer from the acute care facility to the
receiving post-acute care facility. Post-acute care facilities report
gaps in medication information between the acute care hospital and the
receiving post-acute care setting when performing medication
reconciliation.127 128 Hospital discharge has been
identified as a particularly high risk point in time, with evidence
that medication reconciliation identifies high levels of
discrepancy.\129\ \130\ \131\ \132\ \133\ \134\ Also, there is evidence
that medication reconciliation discrepancies occur throughout the
patient stay.\135\ \136\ For older patients who may have multiple
comorbid conditions and thus multiple medications, transitions between
acute and post-acute care settings can be further complicated,\137\ and
medication reconciliation and patient knowledge (medication literacy)
can be inadequate post-discharge.\138\ The proposed quality measure,
Drug Regimen Review Conducted with Follow-Up for Identified Issues--PAC
SNF QRP, provides an important component of care coordination for PAC
settings and would affect a large proportion of the Medicare population
who transfer from hospitals into PAC services each year. For example,
in 2013, 1.7 million Medicare FFS beneficiaries had SNF stays, 338,000
beneficiaries had IRF stays, and 122,000 beneficiaries had LTCH
stays.\139\
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\127\ Gandara, Esteban, et al. ``Communication and information
deficits in patients discharged to rehabilitation facilities: An
evaluation of five acute care hospitals.'' Journal of Hospital
Medicine 4.8 (2009): E28-E33.
\128\ Gandara, Esteban, et al. ``Deficits in discharge
documentation in patients transferred to rehabilitation facilities
on anticoagulation: Results of a system wide evaluation.'' Joint
Commission Journal on Quality and Patient Safety 34.8 (2008): 460-
463.
\129\ Coleman EA, Smith JD, Raha D, Min SJ. Post hospital
medication discrepancies: Prevalence and contributing factors. Arch
Intern Med. 2005 165(16):1842-1847.
\130\ Wong JD, Bajcar JM, Wong GG, et al. Medication
reconciliation at hospital discharge: Evaluating discrepancies. Ann
Pharmacother. 2008 42(10):1373-1379.
\131\ Hawes EM, Maxwell WD, White SF, Mangun J, Lin FC. Impact
of an outpatient pharmacist intervention on medication discrepancies
and health care resource utilization in post hospitalization care
transitions. Journal of Primary Care & Community Health. 2014;
5(1):14-18.
\132\ Foust JB, Naylor MD, Bixby MB, Ratcliffe SJ. Medication
problems occurring at hospital discharge among older adults with
heart failure. Research in Gerontological Nursing. 2012, 5(1): 25-
33.
\133\ Pherson EC, Shermock KM, Efird LE, et al. Development and
implementation of a post discharge home-based medication management
service. Am J Health Syst Pharm. 2014; 71(18): 1576-1583.
\134\ Pronovosta P, Weasta B, Scwarza M, et al. Medication
reconciliation: A practical tool to reduce the risk of medication
errors. J Crit Care. 2003; 18(4): 201-205.
\135\ Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, et
al. Incidence of adverse drug events and potential adverse drug
events. Implications for prevention. JAMA. 1995:274(1): 29-34.
\136\ Himmel, W., M. Tabache, and M. M. Kochen. ``What happens
to long-term medication when general practice patients are referred
to hospital?.''European journal of clinical pharmacology 50.4
(1996): 253-257.
\137\ Chhabra, P.T., et al. (2012). ``Medication reconciliation
during the transition to and from LTC settings: A systematic
review.'' Res Social Adm Pharm 8(1): 60-75.
\138\ Kripalani S, Roumie CL, Dalal AK, et al. Effect of a
pharmacist intervention on clinically important medication errors
after hospital discharge: A randomized controlled trial. Ann Intern
Med. 2012:157(1):1-10.
\139\ March 2015 Report to the Congress: Medicare Payment
Policy. Medicare Payment Advisory Commission; 2015.
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A TEP convened by our measure development contractor provided input
on the technical specifications of this proposed quality measure, Drug
Regimen Review Conducted with Follow-Up for Identified Issues--PAC SNF
QRP, including components of reliability, validity and the feasibility
of implementing the measure across PAC settings. The TEP supported the
measure's implementation across PAC settings and was supportive of our
plans to standardize this measure for cross-setting development. A
summary of the TEP proceedings is available on the PAC Quality
Initiatives Downloads and Video Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
We solicited stakeholder feedback on the development of this
measure by means of a public comment period held from September 18
through October 6, 2015. Through public comments submitted by several
stakeholders and organizations, we received support for implementation
of this measure. The public comment summary report for the measure is
available on the CMS Public Comment Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
The NQF-convened MAP met on December 14 and 15, 2015 and provided
input on the use of this proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues--PAC SNF QRP. The MAP
encouraged continued development of the proposed quality measure to
meet the mandate added by the IMPACT Act. The MAP agreed with the
measure gaps identified by us including medication reconciliation, and
stressed that medication reconciliation be present as an ongoing
process. More information about the MAPs recommendations for this
measure is available at http://www.qualityforum.org/Publications/2016/
02/
[[Page 52036]]
MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-
_PAC-LTC.aspx.
Since the MAP's review and recommendation of continued development,
we have continued to refine this measure consistent with the MAP's
recommendations. The measure is consistent with the information
submitted to the MAP and support its scientific acceptability for use
in quality reporting programs. Therefore, we proposed this measure for
implementation in the SNF QRP as required by the IMPACT Act.
We reviewed the NQF's endorsed measures and identified one NQF-
endorsed cross-setting quality measure related to medication
reconciliation, which applies to the SNF, LTCH, IRF, and HHA settings
of care: Care for Older Adults (COA) (NQF #0553). The quality measure,
Care for Older Adults (COA) (NQF #0553) assesses the percentage of
adults 66 years and older who had a medication review. The Care for
Older Adults (COA) (NQF #0553) measure requires at least one medication
review conducted by a prescribing practitioner or clinical pharmacist
during the measurement year and the presence of a medication list in
the medical record. This is in contrast to the proposed quality
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC SNF QRP, which reports the percentage of resident stays in
which a drug regimen review was conducted at the time of admission and
that timely follow-up with a physician occurred each time one or more
potential clinically significant medication issues were identified
throughout that stay.
After careful review of both quality measures, we decided to
propose the quality measure, Drug Regimen Review Conducted with Follow-
Up for Identified Issues--PAC SNF QRP for the following reasons:
The IMPACT Act requires the implementation of quality
measures using patient assessment data that are standardized and
interoperable across PAC settings. The quality measure, Drug Regimen
Review Conducted with Follow-Up for Identified Issues--PAC SNF QRP,
employs three standardized resident-assessment data elements for each
of the four PAC settings so that data are standardized, interoperable,
and comparable; whereas, the Care for Older Adults (COA), (NQF #0553)
quality measure does not contain data elements that are standardized
across all four PAC settings.
The quality measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC SNF QRP, requires the
identification of potential clinically significant medication issues at
the beginning, during and at the end of the resident's stay to capture
data on each resident's complete PAC stay; whereas, the Care for Older
Adults (COA), (NQF #0553) quality measure only requires annual
documentation in the form of a medication list in the medical record of
the target population.
The quality measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC SNF QRP, includes identification
of the potential clinically significant medication issues and
communication with the physician (or physician designee), as well as
resolution of the issue(s) within a rapid timeframe (by midnight of the
next calendar day); whereas, the Care for Older Adults (COA), (NQF
#0553) quality measure does not include any follow-up or timeframe in
which the follow-up would need to occur.
The quality measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC SNF QRP, does not have age
exclusions; whereas, the Care for Older Adults (COA), (NQF #0553)
quality measure limits the measure's population to patients aged 66 and
older.
The quality measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC SNF QRP, will be reported to SNFs
quarterly to facilitate internal quality monitoring and quality
improvement in areas such as resident safety, care coordination and
resident satisfaction; whereas, the Care for Older Adults (COA), (NQF
#0553) quality measure would not enable quarterly quality updates, and
thus data comparisons within and across PAC providers would be
difficult due to the limited data and scope of the data collected.
Therefore, based on the evidence discussed above, we proposed to
adopt the quality measure entitled, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC SNF QRP, for the SNF QRP for FY
2020 payment determination and subsequent years. We plan to submit the
quality measure to the NQF for consideration for endorsement.
The calculation of the proposed quality measure would be based on
the data collection of three standardized items to be included in the
MDS. The collection of data by means of the standardized items would be
obtained at admission and discharge. For more information about the
data submission required for this measure, please see section V.B.9. of
the FY 2017 SNF PPS proposed rule (81 FR 24270 through 24273).
The standardized items used to calculate this proposed quality
measure do not duplicate existing items currently used for data
collection within the MDS. The measure denominator is the number of
resident stays with a discharge or expired assessment during the
reporting period. The measure numerator is the number of stays in the
denominator where the medical record contains documentation of a drug
regimen review conducted at: (1) Admission; and (2) discharge with a
look back through the entire resident stay, with all potential
clinically significant medication issues identified during the course
of care and followed-up with a physician or physician designee by
midnight of the next calendar day. This measure is not risk adjusted.
For technical information about this measure including information
about the measure calculation and discussion pertaining to the
standardized items used to calculate this measure, refer to the
document titled, Proposed Measure Specifications for Measures Proposed
in the FY 2017 SNF QRP Proposed Rule available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
Data for the proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues--PAC SNF QRP, would be
collected using the MDS with submission through the Quality Improvement
Evaluation System (QIES) Assessment Submission and Processing (ASAP)
system.
We invited public comment on our proposal to adopt the quality
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC SNF QRP, for the SNF QRP. The comments we received on this
topic, with their responses, appear below.
Comment: Several commenters, including MedPAC, expressed support
for the quality measure. Further, several commenters expressed
appreciation to us for proposing a quality measure to address the
IMPACT Act domain, Medication Reconciliation, acknowledging the
importance of medication reconciliation for addressing resident safety
issues. Several commenters emphasized the importance of preventing and
responding to Adverse Drug Events (ADEs) to reduce health services
utilization and associated healthcare costs and emphasized that
medication
[[Page 52037]]
reconciliation is fundamental to resident safety during care
transitions.
Response: We appreciate the commenters' support for the quality
measure and the recognition of the importance of medication
reconciliation as addressed in the measure. We agree that medication
reconciliation is an important patient safety process for addressing
medication accuracy during transitions in patient care and identifying
preventable Adverse Drug Events (ADEs), which may lead to reduced
health services utilization and associated costs.
Comment: We received several comments regarding concerns about
whether the measure has continued to be refined since the NQF-convened
MAP meeting in December 2015. Many commenters noted that the MAP
recommended ``continued development'' for the measure and requested
evidence of robust testing of the measure to support measure validity.
Several commenters requested that we test this measure prior to
implementing it as part of the quality reporting system. One commenter
further expressed that testing would enable us to more fully understand
the benefits and limitations of the measure and its implication for
providers and patients. Several commenters expressed concern that the
measure was not NQF endorsed.
Response: Since the time of the NQF-convened MAP, with our measure
contractor, we tested this measure in a pilot test involving twelve
post-acute care facilities (IRF, SNF, LTCH), representing variation
across geographic location, size, profit status, and clinical records
system. Two clinicians in each facility collected data on a sample of
10 to 20 patients for a total of 298 records (147 qualifying pairs).
Analysis of agreement between coders within each participating facility
indicated a 71 percent agreement for item DRR-01 \140\ Drug Regimen
Review (admission); 69 percent agreement for item DRR-02 \141\
Medication Follow-up (admission); and 61 percent agreement for DRR-03
\142\ Medication Intervention (During Stay and Discharge). Overall,
pilot testing enabled us to verify feasibility of the measure.
Furthermore, measure development included convening a technical expert
panel (TEP) to provide input on the technical specifications of this
proposed quality measure, including components of reliability, validity
and the feasibility of implementing the measure across PAC settings.
The TEP included SNF stakeholders and supported the measure's
implementation across PAC settings and was supportive of our plans to
standardize this measure for cross-setting development. A summary of
the TEP proceedings is available on the PAC Quality Initiatives
Downloads and Videos Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
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\140\ DRR pilot items DRR-01, DRR-02 and DRR-03 are equivalent
to the proposed rule DRR PAC instrument items N. 2001, N. 2003 and
N. 2005.
\141\ DRR pilot items DRR-01, DRR-02 and DRR-03 are equivalent
to the proposed rule DRR PAC instrument items N. 2001, N. 2003 and
N. 2005.
\142\ DRR pilot items DRR-01, DRR-02 and DRR-03 are equivalent
to the proposed rule DRR PAC instrument items N. 2001, N. 2003 and
N. 2005.
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As noted above, we plan to conduct further testing on this measure
once we have started collecting data from the PAC settings. Analysis of
this data will allow us to evaluate whether the measure satisfies NQF
endorsement criteria (for example, measure performance). Once we have
completed this additional measure performance testing, we plan to
submit the measure to NQF for endorsement.
Comment: We received several comments about the lack of a specific
definition of clinically significant medication issues for the measure.
Several commenters were concerned that the phrase could be interpreted
differently by the many providers involved in a resident's treatment,
and that this could result in a challenge to collect reliable and
accurate data for this quality measure. Several commenters requested
that we provide additional guidance regarding this definition. One
commenter suggested that it was premature for us to provide clarifying
language because a related proposed rule regarding Discharge Planning
(Reform of Requirements for Long-Term Care Facilities, 80 FR 42168) has
not been finalized. One commenter further conveyed that, without
further guidance on the definition of clinically significant, there are
likely to be variations in measure performance that are not based on
differences in care, but rather on differences in data collection.
Response: For this measure, potential clinically significant
medication issues are defined as those issues that, in the clinician's
professional judgment, warrant interventions, such as alerting the
physician and/or others, and the timely completion of any recommended
actions (by midnight of the next calendar day) so as to avoid and
mitigate any untoward or adverse outcomes. The definition of
``clinically significant'' in this measure was conceptualized during
the measure development process. For purposes of the measure, the
decision regarding whether or not a medication issue is ``clinically
significant'' will need to be made on a case-by-case basis, but we also
intend to provide additional guidance and training on this issue.
Comment: We received several comments related to the State
Operations Manual (SOM) Sec. 483.60(c). One commenter requested that
we provide further guidance on how the measure relates to the
``medication regimen review'' within the SOM. Many commenters
recommended that the definitions of potentially clinically significant
medication issues and drug regimen review align with similar
definitions in the SOM. One commenter further requested that we allow
the existing SNF SOM required reviews to fulfill the requirements of
the measure. One commenter further noted that the definitions contained
in the measure are not as clinically detailed (as the SOM), are not PAC
setting inclusive, and do not acknowledge the need for a multiple
disciplinary team. The commenter also noted that the SOM uses the term
``medication'' rather than ``drug'' and offers that ``medication'' is a
more appropriate title to the measure. One commenter conveyed a need
for clarification in how the measure will interface with the current
SNF requirements for drug regimen review. One commenter expressed
concern that the requirements of the measure potentially conflict with
the requirements CMS SNF State Operations Manual.
Response: We acknowledge the commenters' request to align other
regulatory requirements involving medication regimen review with the
measure such as the State Operations Manual Sec. 483.60(c). We would
like to note that during the development of this measure, the
definitions as detailed in the SOM were taken into consideration. We do
not believe that the measure's use of terminology of ``clinically
significant'' overrides the guidance as outlined in the SOM. Further,
we wish to clarify that the specification of the measure does not
preclude the activities of drug regimen reviews that are consistent
with the SOM. We would like to reiterate that this measure was
developed to assess whether PAC providers were responsive to potential
or actual clinically significant medication issue(s) when such issues
were identified and was not developed for regulatory purposes for
Skilled Nursing Facilities to be in compliance with the requirements of
the 42 CFR part 483. In particular, the SOM
[[Page 52038]]
Appendix PP--Guidance to Surveyors for Long Term Care Facilities, under
Sec. 483.60(c) Drug Regimen Review, references pharmacy services
requirements where: (1) The drug regimen of each resident must be
reviewed at least once a month by a licensed pharmacist; and (2) The
pharmacist must report any irregularities to the attending physician,
and the director of nursing, and these reports must be acted upon. The
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC SNF QRP reports the percentage of resident stays in which a
drug regimen review was conducted at the time of admission, and timely
follow-up with a physician occurred each time potential clinically
significant medication issues were identified throughout that stay.
Comment: Several commenters were concerned that the measure does
not meet the medication reconciliation domain of the IMPACT Act. In
particular, these commenters believe that the proposed quality measure
goes beyond the statutory mandate by incorporating drug regimen
(medication) review into the measure. Commenters supported measure
development related to the concepts of drug regimen review and
medication reconciliation in reducing unnecessary rehospitalizations,
preventable adverse events, and improving health care outcomes, but
maintained that the services provided as part of drug regimen review
are distinctly different from the services provided as part of
medication reconciliation, and that they are completed by different
members of the care team. One commenter conveyed that the measure has
not been proven to be relevant to medication reconciliation.
Response: We disagree with the commenters' suggestion that the
measure does not meet the requirements of the IMPACT Act. Medication
reconciliation and drug regimen review are interrelated activities;
while medication reconciliation is a process that identifies the most
accurate and current list of medications, particularly during
transitions of care, it also includes the evaluation of the name,
dosage, frequency, and route. Drug regimen review is a process that
necessitates and includes the review of all medications for additional
purposes such as the identification of potential adverse effects. The
process of drug regimen review includes medication reconciliation at
the time of resident transitions and throughout the resident's stay.
Therefore, we believe that medication reconciliation and drug regimen
review are processes that are appropriate to combine in a single
measure for purposes of the SNF QRP.
Comment: We received several comments regarding the time frame for
the measure and resulting burden. Several commenters noted that
requiring SNFs to notify the physician within one day was unreasonable.
One commenter was concerned that the requirement that a physician be
contacted within a day was too prescriptive, given that it may take
more than a day for a physician to return a call, and suggested that we
adopt a more reasonable standard. Further, another commenter suggested
that this timeline created a mandate that many SNFs simply won't be
able to meet. One commenter acknowledged that medication issues need to
be resolved with urgency, but conveyed that the timeframe requirements
of the measure are not feasible, citing limitations with the
prescriber's and the hospitalist's availability to respond to issues
and limited access to information technology that supports the prompt
resolution of issues. Another commenter also noted that while
clinically significant medical issues are required to be reported in a
timely process, the word timely has not been adequately defined. One
commenter suggested that we abandon the measure and instead verify that
medication reconciliation is provided upon admission. Another commenter
suggested that we clarify whether physician follow up is only required
for clinically significant issues, rather than each time the drug
regimen review is conducted.
Several commenters conveyed concern that the time frame of the
measure (for example, following up by midnight of the next calendar
day) will create challenges for rural SNFs without an in-house pharmacy
or physicians, and that the measure will increase operational and
financial challenges for long-term care providers. A few commenters
asked us to consider reforms to mitigate the burden for providers
located in rural areas. Another commenter conveyed that additional
questions on the MDS would result in additional staff cost and effort.
One commenter noted that many SNFs have not implemented electronic
medical records, which will increase the burden associated with
collecting this information. One commenter recommended that we work
with stakeholders to develop a policy that aligns with the resident's
best interest and accounts for the complex post-acute care setting.
Response: We appreciate the challenges that SNFs face when they
have to coordinate resident care with a treatment team that may include
physicians, non-physician practitioners, pharmacists and others, and
also appreciate that some of these treatment team members might not
work full-time at the SNF. However, we chose to set the intervention
timeline as midnight of the next calendar day because we believe this
timeline is consistent with current standard clinical practice where a
clinically significant medication issue arises. We believe that high
quality care should be provided wherever resident services are
administered, including small and rural facilities, and that these
activities, in addition to any regulatory requirements, ensure such
high quality care is provided and patient harm avoided.
Comment: We received several comments related to the role of
pharmacists in drug regimen review. One commenter expressed concern
that the measure would require frequent consultant pharmacist visits to
the SNF without providing more funding to cover additional expenses.
Many commenters suggested that we redefine the measure to allow the SNF
to determine which licensed professional provides the medication
reconciliation. These commenters recommended that we recognize the
essential role that pharmacists play in providing services to
beneficiaries. One commenter submitted a study that noted the monetary
savings that drug regimen review by pharmacists have provided to post-
acute care residential facilities. Several commenters expressed that
pharmacists should receive compensation for service they provide around
this measure. One commenter encouraged us to consider ways in which to
provide incentives to LTC pharmacies for the savings and improved care.
Response: We recognize the essential role that pharmacists, as well
as other members of the SNF treatment team, play in furnishing services
to Medicare beneficiaries. This measure does not supersede or conflict
with current CMS guidance or regulations related to drug regimen
review. The measure also does not specify what clinical professional is
required to perform these activities.
Comment: We received several comments pertaining to the scope of
the measure. One commenter conveyed that the CMS definition of
Medication Reconciliation in a measure for hospitals differs from the
definition for purposes of the proposed SNF QRP measure. One commenter
conveyed opposition to the measure, expressing that the measure
calculation proposes to capture a number of action steps within this
single measure. Many commenters
[[Page 52039]]
expressed concerns that the measure may not accurately capture SNF
performance, given all the work that the SNF and pharmacy undertake to
ensure that medication-related issues are addressed prior to dispensing
medication.
Response: The Drug Regimen Review Conducted with Follow-Up for
Identified Issues--PAC SNF QRP measure evaluates medication
reconciliation in conjunction with drug regimen review in the post
acute care setting, which distinguishes it from solely medication
reconciliation that is conducted in the hospital which we believe the
commenter is referring to. We believe it is appropriate that the
measure captures multiple action steps in a single measure as drug
regimen review is a multifaceted process that should take place
throughout the resident's stay.
Comment: We received a comment suggesting that we inaccurately
represented that an article by American Geriatric Society suggests (and
therefore aides our position) that drug regimen review includes a
medication reconciliation and review of the patient's drug regimen to
identify potential issues.
Response: The commenter is correct regarding an inaccurate
reference. We inadvertently attributed reference to the American
Geriatric Society in our discussion. Therefore, we have corrected the
reference and replaced it with the intended one (Institute of Medicine.
Preventing Medication Errors. Washington, DC: National Academies Press;
2006).
Comment: One commenter supported the need for medication
reconciliation, but had concerns about factors outside the facility's
control. The commenter conveyed the challenge of medication
reconciliation across the continuum, conveying the importance of a
discharge summary from the prior care setting that includes a thorough
medication list, by indication, in avoiding therapeutic duplication.
The commenter suggested that we consider the need for increased
collaboration with hospitals to address this issue. Other commenters,
including MedPAC, suggested that we develop a measure that evaluates
whether PAC providers are sending medication lists home or to the next
level of care. These commenters suggested that requiring providers to
transfer medication lists may improve monitoring of the patient's
condition, which may help prevent readmissions and unintended medical
harm. Another commenter recommended that we add a medication management
measure to fully address patients' medication management routine needs
in order to prepare patients for discharge to PAC settings or the
community.
Response: We appreciate the comments about the importance of
collaboration across the continuum of care, as well as the value of a
detailed discharge summary from the prior level of care. We believe
that all providers should strive to ensure accurate, sufficient, and
efficient patient-centered care during their care transitions across
the continuum, including medication oversight. Thus while we may
implement quality measures that address gaps in quality, such as
information exchange during care transitions, ultimately providers must
act to ensure that such coordination is taking place.
We appreciate the commenter's comment and interest in future
quality measure development, including measures related to sending a
medication list at discharge and adding a medication management
measure. As a requirement of this measure and as with common clinical
practice, PAC facilities are expected to document information
pertaining to the process of drug regimen review, which includes
medication reconciliation, in the resident's discharge medical record.
However, we will take the commenters recommendations into consideration
as we continue to develop additional quality measures under the domain
of Medication Reconciliation.
Comment: One commenter encouraged us to make the reporting of the
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC SNF QRP, available to SNFs in real time through the CASPER
Quality Measures report in QIES ASAP system.
Response: We thank the commenter for their suggestion. We
anticipate making this measure information available to SNFs in the
CASPER Quality Measures reports beginning approximately in October,
2020. Confidential SNF feedback on this measure will be made available
to SNFs in October, 2019.
Comment: We received a comment about the role of registered nurses
in the medication reconciliation process. The commenter recognized the
critical importance of medication reconciliation and cited research
demonstrating that registered nurses (RNs) are more likely to identify
medication discrepancies in nursing facilities than licensed practical
nurses (LPNs); the commenter encouraged us, in the Conditions of
Participation for Skilled Nursing Facilities (SNFs) and Nursing
Facilities (NFs), to require that facilities employ RNs 24 hours per
day.
Response: We thank the commenter for recognizing the importance of
medication reconciliation and the role of registered nurses in the
medication reconciliation process.
Comment: We received a comment about materials that were posted on
the CMS Public Comment Web site for a public comment period held from
September 18 through October 6, 2015. The comment specifically included
specific questions regarding the language used in the ``Importance''
section of the Measure Justification Form, which requests the measure
developer quote verbatim currently published clinical practice
guidelines. The commenter noted the absence of an ``Outcome 1,'' which
is defined as functional status, in the quoted material. Additionally,
the commenter expressed concern about specific targets within the goal
of reducing polypharmacy and about guidelines for calculating
creatinine clearance levels and about the Cockcroft Gault Score.
Finally, the commenter noted that it is clinically unrealistic to have
an expected outcome of ``No adverse drug reactions, no drugs ordered to
treat side effects or adverse reaction.''
Response: We thank the commenter for their comments but wish to
clarify that the document they reference, the Measure Justification
Form, was posted for a prior public comment period that was not part of
the proposed rule. We also wish to clarify that language that was
commented on was derived directly from published clinical practice
guidelines and not by CMS.
Final Decision: After consideration of the public comments, we are
finalizing our proposal to adopt the measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues--PAC SNF QRP measure for
the SNF QRP for the FY 2020 payment determination and subsequent years,
as described in the Measure Specifications for Measures Adopted in the
FY 2017 SNF QRP final rule, available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
h. SNF QRP Quality Measures and Measure Concepts Under Consideration
for Future Years
We invited comment on the importance, relevance, appropriateness,
and applicability for each of the quality measures in Table 13 for
future years in
[[Page 52040]]
the SNF QRP. We are developing a measure related to the IMPACT Act
domain, accurately communicating the existence of and providing for the
transfer of health information and care preferences of an individual to
the individual, family caregiver of the individual, and providers of
services furnishing items and services to the individual, when the
individual transitions. We are considering the possibility of adding
quality measures that rely on the patient's perspective; that is,
measures that include patient-reported experience of care and health
status data. For this purpose, we are considering a measure focused on
pain and four measures focused on function that rely on the collection
of patient-reported data. Finally, we are considering a measure related
to health and well-being, Percent of Residents or Patients Who Were
Assessed and Appropriately Given the Seasonal Influenza Vaccine, and a
measure related to patient safety, Percent of SNF Residents Who Newly
Received an Antipsychotic Medication.
Table 13--SNF QRP Quality Measures Under Consideration for Future Years
------------------------------------------------------------------------
------------------------------------------------------------------------
IMPACT Act Domain................. Accurately communicating the
existence of and providing for the
transfer of health information and
care preferences of an individual
to the individual, family caregiver
of the individual, and providers of
services furnishing items and
services to the individual, when
the individual transitions.
IMPACT Act Measure................ Transfer of health
information and care preferences
when an individual transitions.
NQS Priority...................... Patient- and Caregiver-Centered
Care.
Measures.......................... Percent of Residents Who
Self-Report Moderate to Severe Pain
Application of the Change
in Self-Care Score for Medical
Rehabilitation Patients (NQF #2633)
Application of the Change
in Mobility Score for Medical
Rehabilitation Patients (NQF #2634)
Application of the
Discharge Self-Care Score for
Medical Rehabilitation Patients
(NQF #2635)
Application of the
Discharge Mobility Score for
Medical Rehabilitation Patients
(NQF #2636).
NQS Priority...................... Health and Well-Being.
Measure........................... Percent of Residents or
Patients Who Were Assessed and
Appropriately Given the Seasonal
Influenza Vaccine.
NQS Priority...................... Patient Safety.
Measure........................... Percent of SNF Residents
Who Newly Received an Antipsychotic
Medication.
------------------------------------------------------------------------
The comments we received on this topic, with their responses, appear
below.
Comment: We received several comments supporting the inclusion of
measures regarding the transfer of health information and care
preferences. One commenter encouraged the inclusion of measures that
capture the role of family caregivers in supporting care transitions,
quality outcomes, and individual care preferences. Another commenter
recommended pilot testing measures regarding transfer of health
information and preferences; while another suggested a measure that
would incentivize the adoption of health IT around the domain
requirement to support the electronic transmission of health
information and care preferences.
Response: We thank the commenters for their comments and agree that
the transfer of health information across PAC settings is important to
capture. As we move through the development of this measure concept, we
will consider the inclusion of the role of family caregivers in
supporting care transitions, quality outcomes, and individual care
preferences. In addition, we will take into consideration the
commenters' recommendations pertaining to the pilot testing for these
measure concepts.
Comment: We received comments that were broadly supportive of
patient- and caregiver-reported measures and agreed that they are
meaningful to patients and their families.
Response: We thank the commenters for their support of patient-
reported measures under consideration for future implementation in the
SNF QRP and agree with the importance of patient- and caregiver-
centered measures such as these.
Comment: Several commenters supported the potential future use of
the four self-reported function measures. One commenter supported risk
adjustment of these measures and the focus on patient-centered
outcomes. Another supported the use of the four self-reported function
measures applied from the IRF setting and emphasized the importance of
alignment across PAC settings and encouraged measure testing in the SNF
setting prior to implementation. Another commenter recommended that SNF
residents should be excluded from measures related to change in
function if there is no expectation of functional improvement.
Several commenters suggested the development of function measures
addressing cognition. One commenter remarked on the limited number of
items in the MDS related to communication, cognition, and swallowing
and noted that these three domains stand as major obstacles to validly
determine the status, needs, and outcomes of individuals with
neurological disorders. The commenter encouraged us to adopt a specific
screening tool, the Montreal Cognitive Assessment (MoCA), or similar
screening tools and assessment tools (that is, CARE-C) to best meet the
needs of Medicare beneficiaries and the intent of the IMPACT Act.
Another commenter recommended that we consider community-based
measures of function, examining patient outcomes after they are
discharged from a PAC setting. One commenter encouraged the development
of an outcome measure to meet the IMPACT Act domain of functional
status, suggesting the NH Compare measure, Percent of Residents Whose
Need for Help with Activities of Daily Living has Increased (Long
Stay).
Response: We thank the commenters for their support of the four
self-reported function measures under consideration for future
implementation in the SNF QRP. We also appreciate commenters'
suggestions regarding the development and specification of these
measures as well as additional measure concepts or areas related to
function that we should consider. We agree that the implementation of
outcome measures of function in the SNF QRP is a priority. We also
agree that future measure development should include other areas of
function, such as communication, cognition, and swallowing. We will
continue to engage stakeholders in future measure development. We will
take these suggested quality measure concepts and recommendations
regarding measure specifications into consideration in our ongoing
measure development and testing efforts.
[[Page 52041]]
Comment: We received several comments regarding pain management and
prevention. One commenter suggested that we consider HCAHPS measures
related to pain control, while another commenter suggested such a
measure should reflect a patient-centered approach to pain management
instead of level and frequency of pain symptoms. We also received a
comment encouraging the use of the CAHPS NH survey to examine resident
and family members' experience of care.
Response: We will take these suggested quality measure concepts and
recommendations regarding measure specifications into consideration in
our ongoing measure development and testing efforts.
Comment: We received several comments supporting a future seasonal
influenza vaccination measure. Several commenters encouraged us to
consider other immunization measures for the SNF QRP, including a
pneumococcal vaccine measure. One commenter encouraged consideration of
the cost of delivering these services as they may have financial
implications for SNFs.
Response: We thank the commenters for their support of a future
seasonal influenza vaccination measure. Cost burden for providers is
always a consideration as we develop and implement new measures. We
appreciate the commenters' feedback on potential measure development
areas related to immunization. We will take their recommendations into
consideration in our measure development and testing efforts, as well
as in our ongoing efforts to identify and propose appropriate measures
for the SNF QRP in the future.
Comment: We received several comments supporting the inclusion of
the antipsychotic quality measure (listed on the Nursing Home Compare
Web site) in the SNF QRP. One commenter supported the measure but
cautioned against adapting the pre-existing, non-NQF-endorsed
antipsychotic measures currently used in nursing homes, indicating that
these process measures do not provide a linkage to clinical outcomes or
intermediate outcomes. Commenters also emphasized the need for the
measures to account for situations where continued or newly prescribed
antipsychotics would be clinically appropriate.
Response: We appreciate commenters' feedback on this potential
measure development area. We will take their recommendations into
consideration in our measure development and testing efforts, as well
as in our ongoing efforts to identify and propose appropriate measures
for the SNF QRP in the future.
Comment: Commenters suggested additional measures and measure
concepts for us to consider for future implementation in the SNF QRP,
including workforce-related measures and measures assessing resident
experience of care, engagement, and shared decision-making. Several
commenters recommended that CMS consider incorporating various Nursing
Home Compare measures into the SNF QRP.
Response: We thank commenters for their suggestions regarding areas
for potential future measure development. We will take their
recommendations into consideration in our measure development and
testing efforts, as well as in our ongoing efforts to identify and
propose appropriate measures for the SNF QRP in the future.
i. Form, Manner, and Timing of Quality Data Submission
i. Participation/Timing for New SNFs
In the FY 2016 SNF PPS final rule (80 FR 46455), we established the
requirements associated with the timing of data submission, beginning
with the submission of data required for the FY 2018 payment
determination, for new SNFs. We finalized that a new SNF would be
required to begin reporting data on any quality measures finalized for
that program year by no later than the first day of the calendar
quarter subsequent to 30 days after the date on its CMS Certification
Number (CCN) notification letter. For example, for the FY 2018 payment
determinations, if a SNF received its CCN on August 28, 2016, and 30
days are added (August 28 + 30 days = September 27), the SNF would be
required to submit data for residents who are admitted beginning on
October 1, 2016. We did not propose any new policies related to the
participation and timing for new SNFs.
ii. Finalized Data Collection Timelines and Requirements for the FY
2018 Payment Determination and Subsequent Years
In the FY 2016 SNF PPS final rule (80 FR 46457), for the FY 2018
payment determination, we finalized that SNFs submit data on the three
finalized quality measures for residents who are admitted to the SNF on
and after October 1, 2016, and discharged from the SNF up to and
including December 31, 2016, using the data submission method and
schedule that we proposed in this section. We also finalized that we
would collect that single quarter of data for FY 2018 to remain
consistent with the usual October release schedule for the MDS, to give
SNFs a sufficient amount of time to update their systems so that they
can comply with the new data reporting requirements, and to give CMS a
sufficient amount of time to determine compliance for the FY 2018
program. The proposed use of one quarter of data for the initial year
of quality reporting is consistent with the approach we used to
implement a number of other QRPs, including the LTCH, IRF, and Hospice
QRPs.
We also finalized that, following the close of the reporting
quarter, October 1, 2016, through December 31, 2016, for the FY 2018
payment determination, SNFs would have an additional 5.5 months to
correct and/or submit their quality data and we finalized that the
final deadline for submitting data for the FY 2018 payment
determination would be May 15, 2017 (80 FR 46457). The statement that
SNFs would have an additional 5.5 months was incorrect in that the time
between the close of the quarter on December 31, 2016 and May 15, 2017
is 4.5 months, not 5.5 months. Therefore, we proposed that SNFs will
have 4.5 months, from January 1, 2017 through May 15, 2017, following
the data submission period of October 1, 2016 through December 31,
2016, in which to complete their data submissions and make corrections
to their data where necessary.
Table 14--Finalized Measures, Data Collection Source, Data Collection Period and Data Submission Deadlines
Affecting the FY 2018 Payment Determination
----------------------------------------------------------------------------------------------------------------
Data submission
Quality measure Data collection Data collection period deadline for FY 2018
source payment determination
----------------------------------------------------------------------------------------------------------------
NQF # 0678: Percent of Patients or MDS 10/01/16-12/31/16....... May 15, 2017.
Residents with Pressure Ulcers that
are New or Worsened.
NQF # 0674: Application of Percent of MDS 10/01/16-12/31/16....... May 15, 2017.
Residents Experiencing One or More
Falls with Major Injury (Long Stay).
[[Page 52042]]
NQF # 2631: Application of Percent of MDS 10/01/16-12/31/16....... May 15, 2017.
Long-Term Care Hospital Patients
with an Admission and Discharge
Functional Assessment and a Care
Plan that Addresses Function.
----------------------------------------------------------------------------------------------------------------
We invited public comments on our proposal to correct the time
frame for SNFs to correct and/or submit their quality data used for the
FY 2018 payment determination to consist of 4.5 months rather than the
5.5 months stated in the FY 2016 SNF PPS final rule (80 FR 46457). We
received no comments on this proposed correction.
Final decision: We are finalizing as proposed that for the FY 2018
payment determination, SNFs will have 4.5 months following the end of
the reporting quarter to complete their data submissions and make
corrections to their data where necessary.
iii. Data Collection Timelines and Requirements for the FY 2019 Payment
Determinations and Subsequent Years
In the FY 2016 SNF PPS final rule (80 FR 46457), we finalized that,
for the FY 2019 payment determination, we would collect data from the
2nd through 4th quarters of FY 2017 (that is, data for residents who
are admitted from January 1st and discharged up to and including
September 30th) to determine whether a SNF has met its quality
reporting requirements for that FY. In the FY 2016 SNF PPS final rule
we also finalized that beginning with the FY 2020 payment
determination, we would move to a full year of fiscal year (FY) data
collection. We intend to propose the FY 2019 payment determination
quality reporting data submission deadlines in future rulemaking.
In the FY 2016 SNF PPS final rule (80 FR 46457), we also finalized
that we would collect FY 2018 data in a manner that would remain
consistent with the usual October release schedule for the MDS.
However, to align with the data reporting cycles in other quality
reporting programs, in contrast to fiscal year data collection that we
finalized last year, we are now proposing to move to calendar year (CY)
reporting following the initial reporting of data from October 1, 2016,
through December 31, 2016, as finalized in the FY 2016 SNF PPS final
rule (80 FR 46457), for the FY 2018 payment determination.
More specifically, we proposed to follow a CY schedule for measure
and data submission requirements that includes quarterly deadlines
following each quarter of data submission, beginning with data
reporting for the FY 2019 payment determinations. Each quarterly
deadline will occur approximately 4.5 months after the end of a given
calendar quarter as outlined below in Table 15. This timeframe will
give SNFs enough time to submit corrections to the assessment data, as
discussed below. Thus, if finalized, the FY 2019 payment determination
would be based on 12 calendar months of data reporting beginning on
January 1, 2017, and ending on December 31, 2017 (that is, data from
January 1, 2017, up to and including December 31, 2017.) This approach
would enable CMS to move to a full 12 months of data reporting
immediately following the first 3 months of reporting (October 1, 2016
through December 31, 2016 for the FY 2018 payment determination) rather
than an interim year which uses only 9 months of data, and a subsequent
12 months of FY data reporting following the initial reporting for the
FY 2018 payment determination.
Our proposal to implement, for the FY 2019 payment determination
and all subsequent years for assessment-based data submitted via the
MDS, calendar year, quarterly data collection periods followed by data
submission deadlines is consistent with the approach taken by the LTCH
QRP and the IRF QRP, which are based on CY data and for which each data
collection quarterly period is followed by a 4.5 month time frame that
allows for the continued submission and correction of data until a
deadline has been reached for that quarter of data. At that point, the
data submitted becomes a frozen ``snapshot'' of data for both public
reporting purposes and for the purposes of determining compliance in
meeting the data reporting thresholds.
Table 15--Proposed Data Collection Period and Data Submission Deadlines Affecting the FY 2019 Payment
Determination and Subsequent Years
----------------------------------------------------------------------------------------------------------------
Quarterly review and
correction periods and
Data collection Data collection/ data submission
Quality measure source submission quarterly quarterly deadlines for
reporting period * FY 2019 payment
determination **
----------------------------------------------------------------------------------------------------------------
NQF # 0678: Percent of Patients or MDS CY 2017 Q1--1/1/2017-3/ CY 2017 Q1 Deadline:
Residents with Pressure Ulcers that 31/2017. August 15, 2017.
are New or Worsened.
NQF # 0674: Application of Percent of CY 2017 Q2--4/1/2017-6/ CY 2017 Q2 Deadline:
Residents Experiencing One or More 30/17. November 15, 2017.
Falls with Major Injury (Long Stay)
NQF #2631: Application of Percent of CY 2017 Q3--7/1/2017-9/ CY 2017 Q3 Deadline:
Long-Term Care Hospital Patients 30/2017. February 15, 2018.
with an Admission and Discharge CY 2017 Q4--10/1/2017-12/ CY 2017 Q4 Deadline:
Functional Assessment and a Care 31/2017. May 15, 2018.
Plan that Addresses Function
----------------------------------------------------------------------------------------------------------------
* Data collection/submission will follow a similar quarterly reporting period schedule for subsequent CYs.
** Data review and correction periods and data submission deadlines will follow a similar quarterly schedule for
subsequent CYs.
We invited public comments on our proposal to adopt calendar year
data collection time frames, following the initial 3-month reporting
period from October 1, 2016, to December 31, 2016, for all measures
finalized for adoption
[[Page 52043]]
into the SNF QRP. The comments we received on this topic, with their
responses, appear below.
Comment: We received several comments supporting our proposal to
move to a CY reporting schedule to align with the LTCH and IRF QRPs.
Response: We appreciate the commenters' support of our proposal to
move to a calendar year reporting schedule, which is consistent with
the approach we also use for the LTCH and IRF QRPs. We seek to align
requirements across QRPs whenever possible.
Comment: We received one comment supporting the continuation of the
October release schedule for updates to the MDS and the alignment of
data collection with that October release schedule.
Response: We appreciate the commenters' support of our alignment of
the beginning of the initial data collection period for new measures
with the October release schedule for the MDS and moving to CY
reporting following the initial data collection period.
Further, we proposed that beginning with FY 2019 payment
determination, assessment-based measures finalized for adoption into
the SNF QRP will follow a CY schedule of data reporting, quarterly
review and correction periods, and data submission deadlines as
provided in Tables 15 and 16 for all subsequent payment determination
years unless otherwise specified:
Table 16--Proposed Data Collection Period and Data Submission Deadlines
Affecting the FY 2019 Payment Determination and Subsequent Years
------------------------------------------------------------------------
Quarterly review and
correction periods
Data collection/ and data submission
CY data collection quarter submission quarterly deadlines for
reporting period payment
determination
------------------------------------------------------------------------
Quarter 1................... January 1-March 31.. April 1-August 15.
Quarter 2................... April 1-June 30..... July 1-November 15.
Quarter 3................... July 1-September 30. October 1-February
15.
Quarter 4................... October 1-December January 1-May 15.
31.
------------------------------------------------------------------------
We invited public comments on the proposed data collection period
and data submission deadlines for all assessment-based measures
finalized for adoption into the SNF QRP beginning with the FY 2019
payment determination, specifically, on our use of CY reporting with
data submission deadlines following a period of approximately 4.5
months after each quarterly data collection period to enable the
correction of such data, as outlined in Table 16. We received no
additional comments on this proposed general schedule.
Final decision: We are finalizing our proposed data collection
period and data submission deadlines for all assessment-based measures
finalized for adoption into the SNF QRP beginning with FY 2019 payment
determination, as outlined in Tables 15 and 16.
iv. Timeline and Data Submission Mechanisms for Claims-Based Measures
for the FY 2018 Payment Determination and Subsequent Years
The Medicare Spending per Beneficiary--PAC SNF QRP, Discharge to
Community--PAC SNF QRP, and Potentially Preventable Potentially
Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP
measures are Medicare FFS claims-based measures. Because claims-based
measures can be calculated based on data that are already reported to
the Medicare program for payment purposes, no additional information
collection will be required from SNFs. As discussed in section V.B.6.
of the FY 2017 SNF PPS proposed rule (81 FR 24257 through 24267), for
the Medicare Spending per Beneficiary--PAC SNF QRP Measure, the
Discharge to Community--PAC SNF QRP measure and the Potentially
Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP, we
proposed to use 1 year of claims data beginning with CY 2016 claims
data to inform confidential feedback reports for SNFs, and CY 2017
claims data for public reporting.
We invited public comments on this proposal. We did not receive any
comments specifically related to this proposal.
Final Decision: We are finalizing the timeline and data submission
mechanisms for claims-based measures proposed for the FY 2018 payment
determination and subsequent years as proposed in Tables 15 and 16.
v. Timeline and Data Submission Mechanisms for the FY 2020 Payment
Determination and Subsequent Years for New SNF QRP Assessment-Based
Quality Measure
We proposed that SNFs would submit data on the Drug Regimen Review
measure by completing data elements to be included in the MDS and then
submitting the MDS to CMS through the Quality Improvement and
Evaluation System (QIES), Assessment Submission and Processing System
(ASAP) system beginning October 1, 2018. For more information on SNF
QRP reporting through the QIES ASAP system, refer to the ``Related
Links'' section at the bottom of https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.html?redirect=/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp#TopOfPage.
We invited public comments on our proposed SNF QRP data collection
requirements for the Drug Regimen Review measure for the FY 2020
payment determination and subsequent years. We did not receive any
comments related to this topic.
For the FY 2020 payment determination, we proposed that SNFs submit
data on the proposed assessment-based quality measure for residents who
are admitted to the SNF on and after October 1, 2018, and discharged
from SNF Part A covered stays (that is, both residents discharged from
Part A covered stays and physically discharged) up to and including
December 31, 2018, using the data submission schedule that we proposed
in this section.
We proposed to collect a single quarter of data for the FY 2020
payment determination to remain consistent with the usual October
release schedule for the MDS, to give SNFs a sufficient amount of time
to update their systems so that they can comply with the new data
reporting requirements, and to give CMS a sufficient amount of time to
determine compliance for the FY 2020 program. The proposed use of one
quarter of data for the initial year of assessment data reporting in
the SNF QRP is consistent with the approach we used previously for the
SNF QRP and in other QRPs, including the LTCH, IRF, and Hospice QRPs in
which we have finalized the use of fewer than 12 months of data.
[[Page 52044]]
We also proposed that following the close of the reporting quarter,
October 1, 2018, through December 31, 2018, for the FY 2020 payment
determination, SNFs would have an additional 4.5 months to correct and/
or submit their quality data and that the final deadline for submitting
data for the FY 2020 payment determination would be May 15, 2019. We
further proposed that for the FY 2021 payment determination and
subsequent years, we will collect data using the CY reporting cycle as
previously proposed in section V.B.9.c. of the FY 2017 SNF PPS proposed
rule (81 FR 24271 through 24272).
Table 17--Proposed New SNF QRP Assessment-Based Quality Measures Data Collection Period and Data Submission
Deadlines Affecting the FY 2020 Payment Determination
----------------------------------------------------------------------------------------------------------------
Data collection/ Data submission
Quality measure Data collection submission reporting deadline for FY 2020
source period payment determination
----------------------------------------------------------------------------------------------------------------
Drug Regimen Review Conducted with MDS 10/01/18-12/31/18....... May 15, 2019.
Follow-Up for Identified Issues--PAC
SNF QRP.
----------------------------------------------------------------------------------------------------------------
We invited public comment on the proposed new SNF QRP assessment-
based quality measure data collection period and data submission
deadline affecting the FY 2020 payment determination. We did not
receive comments related to this topic.
Final Decision: We are finalizing as proposed the timeline and data
submission mechanism for the FY 2020 payment determination for the new
assessment-based quality as provided in Table 17.
For this measure, we also proposed to follow a CY schedule for
measure and data submission requirements that includes quarterly
deadlines following each quarter of data submission, beginning with
data reporting for the FY 2021 payment determinations. As previously
discussed, each quarterly deadline will occur approximately 4.5 months
after the end of a given calendar quarter as outlined in Table 18.
Thus, if finalized, the FY 2021 payment determination would be based on
12 calendar months of data reporting beginning January 1, 2019, and
ending December 31, 2019. Table 18 provides the data submission and
collection method, data collection period and data submission timelines
for the assessment-based quality measure affecting the FY 2021 payment
determination and subsequent years.
Table 18--Proposed New SNF QRP Assessment-Based Quality Measure Data Collection Period and Data Submission
Deadline Affecting FY 2021 Payment Determination and Subsequent Years
----------------------------------------------------------------------------------------------------------------
Data submission
Data collection Data collection/ quarterly deadlines
Quality measure source submission quarterly for FY 2021 payment
reporting period * determination **
----------------------------------------------------------------------------------------------------------------
Drug Regimen Review Conducted with MDS CY 19 Q1, 1/1/2019-3/31/ CY 2019 Q1 Deadline:
Follow-Up for Identified Issues--PAC 2019. August 15, 2019.
SNF QRP.
CY 19 Q2, 4/1/2019-6/30/ CY 2019 Q2 Deadline:
19. November 15, 2019.
CY 19 Q3, 7/1/2019-9/30/ CY 2019 Q3 Deadline:
2019. February 15, 2020.
CY 19 Q4, 10/1/2019-12/ CY 2019 Q4 Deadline:
31/2019. May 15, 2020.
----------------------------------------------------------------------------------------------------------------
* Data collection/submission will follow a similar quarterly reporting period schedule for subsequent CYs.
** Data review and correction periods and data submission deadlines will follow a similar quarterly schedule for
subsequent CYs.
We invited public comment on the SNF QRP assessment-based quality
measure data collection period and data submission deadline affecting
the FY 2021 payment determination and subsequent years for the new
assessment-based measure. We did not receive comments related to this
topic.
Final Decision: We are finalizing as proposed the timeline and data
submission mechanism for the FY 2021 payment determination and
subsequent years for the new SNF QRP assessment-based quality measure
as outlined in Table 18.
j. SNF QRP Data Completion Thresholds for the FY 2018 Payment
Determination and Subsequent Years
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46458)
for our finalized policies regarding data completion thresholds for the
FY 2018 payment determination and subsequent years. We finalized that,
beginning with the FY 2018 payment determination, SNFs must report all
of the data necessary to calculate the proposed quality measures on at
least 80 percent of the MDS assessments that they submit. We also
finalized that, for the FY 2018 SNF QRP, any SNF that does not meet the
proposed requirement that 80 percent of all MDS assessments submitted
contain 100 percent of all data items necessary to calculate the SNF
QRP measures would be subject to a reduction of 2 percentage points to
its FY 2018 market basket percentage. We finalized that a SNF has
reported all of the data necessary to calculate the measures if the
data actually can be used for purposes of calculating the quality
measures, as opposed to, for example, the use of a dash [-], to
indicate that the SNF was unable to perform a pressure ulcer
assessment. We wish to clarify that the provision we
[[Page 52045]]
finalized will affect FY 2018 payment determinations and subsequent
years and is dependent upon the successful achievement of the
completion threshold of the data used to calculate the measures we
finalize. We did not propose any changes to these policies. While we
did not solicit comments specifically regarding the data completion
threshold for the SNF QRP, we did receive one comment related to this
topic.
Comment: One commenter suggested that the 80 percent data
completion threshold finalized the SNF PPS FY 2016 final rule is set
too low and requested that, for the FY 2018 payment determination, the
data completion threshold be increased to at least ninety percent.
Response: We intend to reevaluate this threshold over time and will
propose to modify it, if warranted, based on our analysis.
k. SNF QRP Data Validation Requirements for the FY 2018 Payment
Determination and Subsequent Years
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46458
through 46459) for a summary of our approach to the development of data
validation process for the SNF QRP. At this time, we are continuing to
explore data validation methodology that will limit the amount of
burden and cost to SNFs, while allowing us to establish estimations of
the accuracy of SNF QRP data. We did not propose any further details
pertaining to the data validation process for the SNF QRP, but we plan
to do so in future rulemaking cycles. While we did not solicit comments
specifically regarding data validation requirements for the SNF QRP, we
received several comments related to this topic.
Comment: Several commenters agreed that validation of quality
measure data is important in IMPACT Act implementation. One commenter
recommended that we utilize pure data checks to identify both
inconsistencies between QRP measures and MDS items and that data from
these audits should be provided as part of SNF feedback reports to
improve data accuracy. This commenter also suggested that we audit
suspicious data patterns using trained MDS experts and present a list
of validation checks to providers and MDS vendors to help improve data
accuracy and expedite the process. Another commenter suggested revising
and testing revisions to the survey protocol to review resident
assessments and instituting penalties for violating resident assessment
requirements.
Response: We thank the commenters for their input on policies that
we should consider pertaining to data validation and accuracy analysis.
We appreciate the commenters' suggestions to ensure data accuracy such
as a combination of pure data checks to identify inconsistencies. We
encourage providers to engage in available opportunities to improve the
accuracy of their data. These suggestions will be taken into
consideration as we develop the data validation methodologies for the
SNF QRP.
l. SNF QRP Submission Exception and Extension Requirements for the FY
2018 Payment Determination and Subsequent Years
We refer readers to the FY 2016 SNF PPS final rule (80 FR 46459
through 46460) for our finalized policies regarding submission
exception and extension requirements for the FY 2018 payment
determination and subsequent years. We did not propose any changes to
these policies.
m. SNF QRP Reconsideration and Appeals Procedures for the FY 2018
Payment Determination and Subsequent Years
We refer the reader to the FY 2016 SNF PPS final rule (80 FR 46460
through 46461) for a summary of our finalized reconsideration and
appeals procedures for the SNF QRP for FY 2018 payment determination
and subsequent years. We did not propose any changes to these
procedures.
n. Public Display of Quality Measure Data for the SNF QRP & Procedures
for the Opportunity To Review and Correct Data and Information
Section 1899B(g) of the Act requires the Secretary to establish
procedures for public reporting of SNFs' performance, including the
performance of individual SNFs, on quality measures specified under
paragraph (c)(1) and resource use and other measures specified under
paragraph (d)(1) of the Act (collectively, IMPACT Act measures)
beginning not later than 2 years after the applicable specified
application date under section 1899B(a)(2)(E) of the Act. Under section
1899B(g)(2) of the Act, the procedures must ensure, including through a
process consistent with the process applied under section
1886(b)(3)(B)(viii)(VII) of the Act, which refers to public display and
review requirements in the Hospital Inpatient Quality Reporting Program
(HIQR), that each SNF has the opportunity to review and submit
corrections to its data and information that are to be made public
prior to the information being made public. In future rulemaking, we
intend to propose a policy to publicly display performance information
for individual SNFs on IMPACT Act measures, as required under the Act.
We proposed in the FY 2017 SNF PPS proposed rule to implement
procedures that would allow individual SNFs to review and correct their
data and information on IMPACT Act measures that are to be made public
before those measure data are made public.
For assessment-based measures, we proposed a process by which we
would provide each SNF with a confidential feedback report that would
allow the SNF to review its performance on such measures and, during a
review and correction period, to review and correct the data the SNF
submitted to CMS via the CMS Quality Improvement and Evaluation System
(QIES) Assessment Submission and Processing (ASAP) system for each such
measure. In addition, during the review and correction period, the SNF
would be able to request correction of any errors in the assessment-
based measure rate calculations.
We proposed that these confidential feedback reports would be
available to each SNF using the Certification and Survey Provider
Enhanced Reporting (CASPER) System. We refer to these reports as the
SNF Quality Measure (QM) Reports. We proposed to provide monthly
updates to the data contained in these reports that pertain to
assessment-based data, as the data become available. We proposed to
provide the reports so that providers would be able to view their data
and information at both the facility- and resident-level for quality
measures. The CASPER facility-level QM Reports may contain information
such as the numerator, denominator, facility rate, and national rate.
The CASPER patient-level QM Reports may contain individual patient
information which will provide information related to which patients
were included in the quality measures to identify any potential errors.
In addition, we would make other reports available in the CASPER
System, such as MDS data submission reports and provider validation
reports, which would disclose SNFs' data submission status, providing
details on all items submitted for a selected assessment and the status
of records submitted. Additional information regarding the content and
availability of these confidential feedback reports would be provided
on an ongoing basis at https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-
[[Page 52046]]
Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html.
As proposed in section III.D.2.i.ii. of the FY 2017 SNF PPS
Proposed Rule (81 FR 24270), SNFs would have approximately 4.5 months
after the reporting quarter to correct any errors that appear on the
CASPER-generated QM reports pertaining to their assessment-based data
used to calculate the assessment-based measures. During the time of
data submission for a given quarterly reporting period and up until the
quarterly submission deadline, SNFs could review and perform
corrections to errors in the assessment data used to calculate the
measures and could request correction of measure calculations. However,
once the quarterly submission deadline occurs, the data is ``frozen''
and calculated for public reporting; providers can no longer submit any
corrections. We would encourage SNFs to submit timely assessment data
during a given quarterly reporting period and review their data and
information early during the review and correction period so that they
can identify errors and resubmit data before the data submission
deadline.
As noted in this section, the data would be populated into the
confidential feedback reports, and we intend to update the reports
monthly with all data that have been submitted and are available. We
believe that a proposed data submission and review period, consisting
of the reporting quarter plus approximately 4.5 months, is sufficient
time for SNFs to submit, review and, where necessary, correct their
data and information. These proposed time frames and deadlines for
review and correction of assessment-based measures and data satisfy the
statutory requirement that SNFs be provided the opportunity to review
and correct their data and information that is to be made public and
are consistent with the informal process hospitals follow in the
Hospital Inpatient Quality Reporting (IQR) Program.
We proposed that, in addition to the data collection/submission
quarterly reporting periods that are followed by data review and
correction periods and submission deadlines, we would give SNFs a 30-
day preview period prior to public display during which SNFs may
preview the performance information on their measures that will be made
public. We proposed to provide a preview report also using the CASPER
System with which SNFs are familiar. The CASPER preview reports would
inform providers of their performance on each measure which will be
publicly reported. The CASPER preview reports for the reporting quarter
will be available after the 4.5-month review and correction period and
its data submission deadline, and the reports are refreshed on a
quarterly basis for those measures publicly reported quarterly and
annually for those measures publicly reported annually. We proposed to
give SNFs 30 days to review this information, beginning from the date
on which they can access the preview report. Corrections to the
underlying data would not be permitted during this time; however, SNFs
may contest incorrect measure calculations during the 30-day preview
period. We proposed that if CMS determines that the measure, as it is
displayed in the preview report, contains a calculation error, CMS
could suppress the data on the public reporting Web site, recalculate
the measure and publish it at the time of the next scheduled public
display date. This process would be consistent with that followed in
the Hospital IQR Program. If finalized, we intend to utilize a
subregulatory mechanism, such as our SNF QRP Web site, to explain the
process for how and when providers may ask for a correction to their
measure calculations.
We invited public comment on these proposals. The comments we
received on this topic, with their responses, appear below.
Comment: Several commenters, including MedPAC, supported public
reporting of the cross-setting quality measures.
Response: We appreciate the support from MedPAC and several other
commenters for public reporting of quality measures across post-acute
care settings. We will continue to move forward with cross-setting
measure development and public reporting of these measures to meet the
mandate of the IMPACT Act.
Comment: One commenter was concerned about measure methodology
associated with public reporting. The commenter stated that a year or
more between the report date and penalties would not be meaningful or
effective in changing behaviors.
Response: We appreciate the concern raised regarding the measure
methodology associated with public reporting and the time delay between
the performance period and public display of the quality measure
results. We assume commenter's use of the term ``measure methodology''
to refer to how the quality measure is calculated. We first want to
clarify that there are no penalties associated with quality measure
performance. The quality measures for public display reflect basic
fundamental processes or outcomes of providing good quality care. SNFs
should have internal processes established to monitor and improve their
care. Additionally, through the Certification and Survey Provider
Enhanced Reports (CASPER) system, providers are able to review their
data and performance results via reports that are available to them
well in advance of public display of the quality measures for the
purposes of ongoing quality improvement. We discuss such reports in
greater detail below and such reports will enable providers to review
their data on an ongoing basis so that they can utilize this
information to improve their quality of care.
Comment: One commenter was concerned that the review and correction
process may not provide SNFs enough information to validate measure
values.
Response: We appreciate the commenter's concern regarding the
review and correct process. In addition to the CASPER QM and Review and
Correct Reports as described earlier in the proposed rule, SNFs have
opportunities to review their information and validate their data for
measure calculation using other reports such as data submission reports
available through CASPER which gives providers information on fatal
errors and warning messages related to data submission. For example,
various data submission reports provide details regarding assessment
items submitted for a selected MDS 3.0 assessment and others summarize
errors encountered in assessments submitted during a specified period.
We believe these CASPER reports will provide SNFs with sufficient
information to validate measure values.
In addition to assessment-based measures, we have also proposed
claims-based measures for the SNF QRP. Section 1899B(g)(2) of the Act
requires prepublication provider review and correction procedures that
are consistent with those followed in the Hospital IQR Program. For
claims-based measures used in the Hospital IQR Program, we provide
hospitals 30 days to preview their claims-based measures and data in a
preview report containing aggregate hospital-level data. We proposed to
adopt a similar process for the SNF QRP.
Prior to the public display of our claims-based measures, in
alignment with the Hospital IQR, HAC and Hospital VBP Programs, we
proposed to make available through the CASPER system a confidential
preview report that will contain information pertaining to claims-based
measure rate calculations, for example, facility and national rates.
Such data and
[[Page 52047]]
information would be for feedback purposes only and could not be
corrected. This information would be accompanied by additional
confidential information based on the most recent administrative data
available at the time we extract the claims data for purposes of
calculating the rates. Because the claims-based measures are calculated
on an annual basis, these confidential CASPER QM reports for claims-
based measures would be refreshed annually. SNFs would have 30 days
from the date the preview report is made available in which to review
this information. The 30-day preview period is the only time when SNFs
would be able to see claims-based measures before they are publicly
displayed. SNFs will not be able to make corrections to underlying
claims data during this preview period, nor will they be able to add
new claims to the data extract. However, SNFs may request that we
correct our measure calculation if the SNF believes it is incorrect
during the 30 day preview period. We proposed that if we agree that the
measure, as it is displayed in the preview report, contains a
calculation error, we would suppress the data on the public reporting
Web site, recalculate the measure, and publish it at the time of the
next scheduled public display date. This process would be consistent
with that followed in the Hospital IQR Program. If finalized, we intend
to utilize a subregulatory mechanism, such as our SNF QRP Web site, to
explain the process for how and when providers may contest their
measure calculations.
The proposed claims-based measures--Medicare Spending per
Beneficiary--PAC SNF QRP Measure; Discharge to Community--PAC SNF QRP
and Potentially Preventable 30 Day Post-Discharge Readmission Measure
for SNF QRP--use Medicare administrative data from hospitalizations for
Medicare FFS beneficiaries. Public reporting of data will be based on
one CY of data. We proposed to create data extracts using claims data
for these claims based measures, at least 90 days after the last
discharge date in the applicable period (12 calendar months preceding),
which we will use for the calculations. For example, if the last
discharge date in the applicable period for a measure is December 31,
2017, for data collection January 1, 2017, through December 31, 2017,
we would create the data extract on approximately March 31, 2018, at
the earliest, and use that data to calculate the claims-based measures
for that applicable period. Since SNFs would not be able to submit
corrections to the underlying claims snapshot or add claims (for those
measures that use SNF claims) to this data set at the conclusion of the
at least 90-day period following the last date of discharge used in the
applicable period, at that time we would consider SNF claims data to be
complete for purposes of calculating the claims-based measures.
We proposed that beginning with data that will be publicly
displayed in 2018, claims-based measures will be calculated using
claims data with at least a 90 day run off period after the last
discharge date in the applicable period, at which time we would create
a data extract or snapshot of the available claims data to use for the
measure calculations. This timeframe allows us to balance the need to
provide timely program information to SNFs with the need to calculate
the claims-based measures using as complete a data set as possible. As
noted, under this proposed procedure, during the 30-day preview period,
SNFs would not be able to submit corrections to the underlying claims
data or add new claims to the data extract. This is for two reasons.
First, for certain measures, the claims data used to calculate the
measure is derived not from the SNF's claims, but from the claims of
another provider. For example, the measure Potentially Preventable 30-
Day Post-Discharge Readmission Measure for SNF QRP uses claims data
submitted by the hospital to which the patient was readmitted. The
claims are not those of the SNF and, therefore, the SNF could not make
corrections to them. Second, even where the claims used to calculate
the measures are those of the SNF, it would not be not possible to
correct the data after it is extracted for the measures calculation.
This is because it is necessary to take a static ``snapshot'' of the
claims to perform the necessary measure calculations.
We seek to have as complete a data set as possible. We recognize
that the proposed at least 90-day ``run-out'' period when we would take
the data extract to calculate the claims-based measures is less than
the Medicare program's current timely claims filing policy, under which
providers have up to one year from the date of discharge to submit
claims. We considered a number of factors in determining that the
proposed at least 90-day run-out period is appropriate to calculate the
claims-based measures. After the data extract is created, it takes
several months to incorporate other data needed for the calculations
(particularly in the case of risk-adjusted or episode-based measures).
We then need to generate and check the calculations. Because several
months lead time is necessary after acquiring the data to generate the
claims-based calculations, if we were to delay our data extraction
point to 12 months after the last date of the last discharge in the
applicable period, we would not be able to deliver the calculations to
SNFs sooner than 18 to 24 months after the last discharge. We believe
this would create an unacceptably long delay, both for SNFs and for us
to deliver timely calculations to SNFs for quality improvement.
We invited public comment on these proposals. The comments we
received on this topic, with their responses, appear below.
Comment: Several commenters recommended we provide real time
reporting for assessment-based measures and every six months reporting
for claims-based measures.
Response: SNFs will have an opportunity to review and utilize their
data using confidential reports provided through the Certification and
Survey Provider Enhanced Reports (CASPER) system as close to real time
as is feasible. We intend to provide SNF Review and Correct reports
that will allow providers to review information on assessment-based
measures and anticipate the reports will be updated at least monthly.
The decision to update claims-based measures on an annual basis was to
ensure that the amount of data received during the reporting period was
sufficient to generate reliable measure rates. However, we will look
into the feasibility of providing SNFs with information more
frequently.
Comment: One commenter was concerned with the 90-day run-out period
for the claims-based measures because claims not filed within this
period may negatively impact measure rates.
Response: We wish to clarify that we proposed for the claims-based
measures to be calculated using claims data with at least a 90 day run
off period after the last discharge date in the applicable period. We
established this as the minimum run off period so as to use the most
recently available data when calculating the claims-based measures. We
developed this proposal to balance the need to provide timely program
information to SNFs with the need to calculate the claims-based
measures using as complete a data set as possible.
Final Decision: After careful consideration of public comments, we
are finalizing these proposals as proposed.
o. Mechanism for Providing Feedback Reports to SNFs
Section 1899B(f) of the Act requires the Secretary to provide
confidential
[[Page 52048]]
feedback reports to post-acute care providers on their performance for
the measures specified under paragraphs (c)(1) and (d)(1), beginning 1
year after the specified application date that applies to such measures
and PAC providers. As discussed earlier, the reports we proposed to
provide to SNFs to review their data and information would be
confidential feedback reports that would enable SNFs to review their
performance on the measures required under the SNF QRP. We proposed
that these confidential feedback reports would be available to each SNF
using the CASPER System. Data contained within these CASPER reports
would be updated, as previously described, on a monthly basis as the
data become available except for claims-based measures which can only
be previewed on an annual basis.
We intend to provide detailed procedures to SNFs on how to obtain
their confidential feedback CASPER reports on the SNF QRP Web site at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html. We
proposed to use the CMS Quality Improvement and Evaluation System
(QIES) Assessment Submission and Processing (ASAP) system to provide
quality measure reports in a manner consistent with how providers
obtain such reports to date. The QIES ASAP system is a confidential and
secure system with access granted to providers, or their designees.
We sought public comment on this proposal to satisfy the
requirement to provide confidential feedback reports to SNFs. The
comments we received on this topic, with their responses, appear below.
Comment: One commenter supported our plan to make the feedback
reports available in QIES ASAP through CASPER.
Response: We appreciate the commenter's support for providing
feedback reports through CASPER.
Comment: Several commenters recommended that we conduct a ``dry
run'' in which providers receive confidential preview reports prior to
publicly reporting new SNF QRP measures so that providers can become
familiar with the methodology, understand the measure results, know how
well they are performing, and have an opportunity to give us feedback
on potential technical issues with the measures.
Response: We appreciate that implementation activities such as dry
runs are valuable prior to measure implementation to ensure the
usability of a measure and educate providers. We intend to offer SNFs
information and outreach training related to their measures so that
they become familiar with the measure's methodology and understand how
to interpret the confidential preview reports, which they will receive
prior to the public reporting of new SNF QRP measures. SNFs will also
receive additional confidential reports such as the SNF facility and
resident level QM Reports and Review and Correct reports which we are
developing. The Review and Correct Report will display all of the
reporting quarters so that SNFs can identify errors in their data prior
to and up until the submission deadline (freeze date) of a given
quarter. The Review and Correct Report will provide updates regarding
our data with a cumulative rate that will reflect publicly reported
performance. We believe that these various reports will provide an
indication on how well the SNF is performing as well as opportunities
to provide us feedback on technical issues with the measures. The SNF
Review and Correct Reports will be available beginning in the spring of
2017 and will be issued prior to the public reporting of SNF QRP
measures. We refer readers to the SNF QRP Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html for
further information, where we will address the process of accessing
reports. We will continue to engage stakeholders and ask for
recommendations to take into consideration for future public reporting
development for the SNF QRP.
Final Decision: After careful consideration of public comments, we
are finalizing our policies for providing confidential feedback reports
to SNFs as proposed.
3. SNF Payment Models Research
In the FY 2017 SNF PPS proposed rule (81 FR 24275 through 24276),
we provided an update on the progress we have made in the SNF Payment
Models Research project. Specifically, we discussed the two prior
Technical Expert Panels (TEPs) hosted by Acumen, LLC, the contractor
conducting this research. On June 15, 2016, during the comment period
associated with the FY 2017 SNF PPS proposed rule, Acumen hosted a
third TEP which brought together many of the concepts and developments
from the prior TEPs and analysis. We received a great deal of support
from TEP panelists, as well as some excellent feedback on ways to
improve the research going forward. As noted in the FY 2017 SNF PPS
proposed rule, materials associated with these TEPs are available on
the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html.
In the FY 2017 SNF PPS proposed rule, we requested comments on the
SNF PMR project. The comments we received on this topic, with
responses, appear below.
Comment: Many commenters supported the goals of the research
effort, specifically to develop a replacement for the existing SNF PPS
that reimburses providers based on resident characteristics and not
service provision. Some commenters stated that we should consider
adding certain elements into the new payment system, such as a high
cost outlier payment, separate payment for non-therapy ancillaries, and
shifting from a per diem payment to a stay-based or episode-based
payment schedule. One commenter stated that we should consider
incorporating an episode-based payment model specifically for speech-
language pathology services. A few commenters stated that the reformed
payment system should consider a resident's socioeconomic status.
Finally, some of these commenters asked that we try to align the new
PPS model with other existing or future post-acute care payment models.
Response: We appreciate the support for this project, and will
consider the suggestions made by commenters. However, we would note
that, in order to develop a revised payment model that is implementable
without requiring additional statutory authority, we have decided to
only pursue those options which would be authorized within existing
statutory constraints. Among other things, we believe this precludes
the possibility of an outlier policy or non-per diem payment.
Comment: A few commenters expressed concern regarding the timeline
for reform of the existing SNF PPS, with one commenter expressing
frustration that we have not yet implemented a revised SNF PPS. These
commenters stated that we should implement reform as soon as possible.
Response: We appreciate these commenters' concerns regarding the
timing for implementing reform, but would note that reform of a system
which covers such a wide range of services and such a diverse
population of beneficiaries requires time to be completed correctly. We
are moving as expeditiously as possible, ensuring that we allow
sufficient time for requesting and considering public comments.
[[Page 52049]]
Comment: A few commenters expressed concerns regarding the data
being used for the research. One commenter stated that we should not
use any data from the Staff Time and Resource Intensity Verification,
or STRIVE, project. A few commenters stated that SNF cost report data
may not represent a viable source of data upon which to base a revised
SNF PPS. One commenter expressed concern regarding the potential use of
ADL information collected on the MDS as a source of nursing resource
information, as the number of medications a resident is taking would
not be taken into account. Finally, a few commenters stated that we
should refrain from implementing a revised SNF PPS until new resident
data, such as that required by the IMPACT Act, is available for
analysis.
Response: We appreciate the concerns raised by these commenters and
will pass along these concerns to our contractor performing the
research so that it can take them into account as the research
continues to evolve.
Comment: One commenter provided comments on information the
commenter received participating in a TEP associated with the research
project. Specifically, the commenter expressed concern regarding the
possibility of combining physical and occupational therapy together
under a single rate component. The commenter also made reference to the
possibility of an additional TEP in Fall 2016.
Response: We appreciate this commenter's thoughts on the TEP
materials, as well as their participation on the panel itself. We will
pass these comments on to our contractor performing the research to
ensure that this, and other comments made by the commenter during the
panel, are taken into account. With regard to the possibility of
another TEP in Fall 2016, we have discussed plans with the contractor
to host an additional TEP in Fall 2016.
We appreciate all of the comments received on this topic and look
forward to providing additional details on the CMS Web site and in
future rulemaking. We invite the public to provide comments outside of
the rulemaking process by contacting us at
[email protected].
IV. Collection of Information Requirements
Section III.D.2.f. of this preamble sets out three claims-based
measures that we are adopting for the SNF QRP beginning with the FY
2018 payment year: (1) Medicare Spending per Beneficiary--PAC SNF QRP;
(2) Discharge to Community--PAC SNF QRP; and (3) Potentially
Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP.
Because they are claims-based, the measures can be calculated using
data that are already reported to the Medicare program for payment
purposes. Consequently, we believe there will be no additional burden
on SNFs in connection with the the reporting of data needed to
calculate these measures.
We did not receive any public comments on this topic in response to
the FY 2017 SNF PPS proposed rule.
For the FY 2020 payment determination and subsequent years, we are
adopting for the SNF QRP an assessment-based measure entitled Drug
Regimen Review Conducted with Follow-Up for Identified Issues--PAC SNF
QRP. The data for this measure will be collected and reported using the
MDS (version effective October 1, 2018). While the reporting of data on
quality measures is an information collection, we believe that the
burden associated with modifications to the MDS fall under the PRA
exception (provided in section 1899B(m) of the IMPACT Act of 2014)
because they are required to achieve the standardization of patient
assessment data. The requirement and burden will, however, be submitted
to OMB for review and approval when the modifications to the MDS or
other applicable PAC assessment instruments have achieved
standardization and are no longer exempt from the requirements under
section 1899B(m).
We estimate the additional elements for the new assessment measure
will take 7.5 minutes of nursing/clinical staff time to report data on
admission and 2.5 minutes of nursing/clinical staff time to report data
on discharge, for a total of 10 minutes. We estimate that the
additional MDS-RAI items will be completed by Registered Nurses (RN)
for approximately 75 percent of the time required and Pharmacists for
approximately 25 percent of the time required. Individual providers
determine the staffing resources necessary. We estimate 2,101,370
discharges from 16,484 SNFs annually, with an additional burden of 10
minutes. This would equate to 350,228 total hours or 21.25 hours per
SNF. We believe this work will be completed by RNs (75 percent) and
Pharmacists (25 percent). We obtained mean hourly wages for these staff
from the U.S. Bureau of Labor Statistics' (BLS) May 2015 National
Occupational Employment and Wage Estimates (http://www.bls.gov/oes/current/oes_nat.htm), to account for overhead and fringe benefits, we
have doubled the mean hourly wage. Per the National Occupational
Employment and Wage Estimates, the mean hourly wage for a RN (BLS
occupation code: 29-1141) is $34.14/hr. However, to account for
overhead and fringe benefits, we have double the mean hourly wage,
making it $68.28/hr for an RN. The mean hourly wage for a pharmacist
(BLS occupation code: 29-1051) is $57.34/hr. To account for overhead
and fringe benefits, we have double the mean hourly wage, making it
$114.68/hr for a pharmacist. Given these wages and time estimates, the
total cost related to the four measures is estimated at $1,697.17 per
SNF annually, or $27,976,212.64 [(262,671 hr x $68.28/hr) + (87,557 hr
x $114.68/hr)] for all SNFs annually. These values have been updated
from the FY 2017 SNF PPS proposed rule to reflect the more recent 2015
wage estimates. While we are setting out burden, the requirements and
associated estimates will not be submitted to OMB for approval under
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) since the
burden estimates are either claims-based or associated with the
exemption under section 1899B(m) of the IMPACT Act of 2014. We are
setting out the burden as a courtesy to advise interested parties of
the time and costs. These figures are not in the RIA section of this
rule.
We received the following comment in response to the FY 2017 SNF
PPS proposed rule.
Comment: One commenter agreed that standardization and associated
collection of this MDS-based measure is PRA exempt. However, the
commenter suggested that the estimate provided by CMS in the proposed
rule is insufficient.
Response: For burden associated with this FY 2017 SNF PPS final
rule, we considered the comment while planning to implement new items
on the MDS. The comment was general in that it did not identify the
estimate of concern nor did it identify what the correct estimate
should be. While considering the comment, we revised our hourly wage
estimate to account for more recent BLS wage data. Otherwise, our final
estimate is unchanged from what was proposed.
As described in further detail in section III.D.1.b. of this final
rule, we are adopting the SNFPPR measure for the SNF VBP Program. Like
the SNFRM (NQF #2510), which was adopted for the SNF VBP Program in the
FY 2016 SNF PPS final rule (80 FR 46419), the SNFPPR measure is also
claims-based. Because claims-based measures are calculated based on
claims that are already submitted to the Medicare program for payment
purposes, there is no additional burden associated with
[[Page 52050]]
data collection or submission for the SNFPPR measure. Thus there is no
additional reporting burden associated with the SNFPPR measure.
We did not receive any public comments on this topic in response to
the FY 2017 SNF PPS proposed rule.
Comments on any of the aforementioned collection of information
claims must be received by the OMB desk officer by August 29, 2016.
To be assured consideration, comments and recommendations must be
received via one of the following transmissions: OMB, Office of
Information and Regulatory Affairs, Attention: CMS Desk Officer, Fax
Number: (202) 395-5806 OR, Email: [email protected].
V. Economic Analyses
A. Regulatory Impact Analysis
1. Introduction
We have examined the impacts of this final rule as required by
Executive Order 12866 on Regulatory Planning and Review (September 30,
1993), Executive Order 13563 on Improving Regulation and Regulatory
Review (January 18, 2011), the Regulatory Flexibility Act (RFA,
September 19, 1980, Pub. L. 96-354), section 1102(b) of the Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA, March
22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August
4, 1999), and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). Executive
Order 13563 emphasizes the importance of quantifying both costs and
benefits, of reducing costs, of harmonizing rules, and of promoting
flexibility. This rule has been designated an economically significant
rule, under section 3(f)(1) of Executive Order 12866. Accordingly, we
have prepared a regulatory impact analysis (RIA) as further discussed
below, and the rule has been reviewed by OMB.
2. Statement of Need
This final rule updates the SNF prospective payment rates for FY
2017 as required under section 1888(e)(4)(E) of the Act. It also
responds to section 1888(e)(4)(H) of the Act, which requires the
Secretary to provide for publication in the Federal Register before the
August 1 that precedes the start of each FY, the unadjusted federal per
diem rates, the case-mix classification system, and the factors to be
applied in making the area wage adjustment. As these statutory
provisions prescribe a detailed methodology for calculating and
disseminating payment rates under the SNF PPS, we do not have the
discretion to adopt an alternative approach.
3. Overall Impacts
This final rule sets forth updates of the SNF PPS rates contained
in the SNF PPS final rule for FY 2016 (80 FR 46390). Based on the
above, we estimate that the aggregate impact would be an increase of
$920 million in payments to SNFs, resulting from the SNF market basket
update to the payment rates, as adjusted by the MFP adjustment. The
impact analysis of this final rule represents the projected effects of
the changes in the SNF PPS from FY 2016 to FY 2017. Although the best
data available are utilized, there is no attempt to predict behavioral
responses to these changes or to make adjustments for future changes in
such variables as days or case-mix.
Certain events may occur to limit the scope or accuracy of our
impact analysis, as this analysis is future-oriented and, thus, very
susceptible to forecasting errors due to certain events that may occur
within the assessed impact time period. Some examples of possible
events may include newly-legislated general Medicare program funding
changes by the Congress or changes specifically related to SNFs. In
addition, changes to the Medicare program may continue to be made as a
result of previously-enacted legislation or new statutory provisions.
Although these changes may not be specific to the SNF PPS, the nature
of the Medicare program is such that the changes may interact and,
thus, the complexity of the interaction of these changes could make it
difficult to predict accurately the full scope of the impact upon SNFs.
In accordance with sections 1888(e)(4)(E) and 1888(e)(5) of the
Act, we update the FY 2016 payment rates by a factor equal to the
market basket percentage change adjusted by the MFP adjustment to
determine the payment rates for FY 2017. As discussed previously, for
FY 2012 and each subsequent FY, as required by section 1888(e)(5)(B) of
the Act, as amended by section 3401(b) of the Affordable Care Act, the
market basket percentage is reduced by the MFP adjustment. The special
AIDS add-on established by section 511 of the MMA remains in effect
until such date as the Secretary certifies that there is an appropriate
adjustment in the case mix. We have not provided a separate impact
analysis for the MMA provision. Our latest estimates indicate that
there are fewer than 4,800 beneficiaries who qualify for the add-on
payment for residents with AIDS. The impact to Medicare is included in
the total column of Table 19. In updating the SNF PPS rates for FY
2017, we made a number of standard annual revisions and clarifications
mentioned elsewhere in this final rule (for example, the update to the
wage and market basket indexes used for adjusting the federal rates).
The annual update set forth in this final rule applies to SNF PPS
payments in FY 2017. Accordingly, the analysis that follows only
describes the impact of this single year. In accordance with the
requirements of the Act, we will publish a notice or rule for each
subsequent FY that will provide for an update to the SNF PPS payment
rates and include an associated impact analysis.
4. Detailed Economic Analysis
The FY 2017 SNF PPS payment impacts appear in Table 19. Using the
most recently available data, in this case FY 2015, we apply the
current FY 2016 wage index and labor-related share value to the number
of payment days to simulate FY 2016 payments. Then, using the same FY
2015 data, we apply the FY 2017 wage index and labor-related share
value to simulate FY 2017 payments. We tabulate the resulting payments
according to the classifications in Table 19 (for example, facility
type, geographic region, facility ownership), and compare the simulated
FY 2016 payments to the simulated FY 2017 payments to determine the
overall impact. In Section III.B.2 and III.B.4 of this final rule, we
discussed an error in calculating the FY 2017 wage index budget
neutrality factor in the FY 2017 SNF PPS proposed rule and how this
error affected the impact table in the FY 2017 SNF PPS proposed rule
(81 FR 24278). Specifically, we stated that in calculating the proposed
wage index budget neutrality factor, we inadvertently neglected to
update the wage index data used in the calculation with the most
recently available FY 2017 data. As we discussed in section III.B.2.
and III.B.4. of this final rule, this same error (the use of non-
updated wage index data) which resulted in an incorrect calculation of
the proposed wage index budget neutrality factor also resulted in
inaccurate wage index impacts in Table 19 of the FY 2017 SNF PPS
proposed rule. We have corrected this error, and Table 19 of this final
rule includes corrected impact values based
[[Page 52051]]
on updated FY 2017 wage index data. The breakdown of the various
categories of data in the table follows:
The first column shows the breakdown of all SNFs by urban
or rural status, hospital-based or freestanding status, census region,
and ownership.
The first row of figures describes the estimated effects
of the various changes on all facilities. The next six rows show the
effects on facilities split by hospital-based, freestanding, urban, and
rural categories. The next nineteen rows show the effects on facilities
by urban versus rural status by census region. The last three rows show
the effects on facilities by ownership (that is, government, profit,
and non-profit status).
The second column shows the number of facilities in the
impact database.
The third column shows the effect of the annual update to
the wage index. This represents the effect of using the most recent
wage data available. The total impact of this change is zero percent;
however, there are distributional effects of the change.
The fourth column shows the effect of all of the changes
on the FY 2017 payments. The update of 2.4 percent (consisting of the
market basket increase of 2.7 percentage points, reduced by the 0.3
percentage point MFP adjustment) is constant for all providers and,
though not shown individually, is included in the total column. It is
projected that aggregate payments will increase by 2.4 percent,
assuming facilities do not change their care delivery and billing
practices in response.
As illustrated in Table 19, the combined effects of all of the
changes vary by specific types of providers and by location. For
example, due to changes finalized in this rule, providers in the urban
Outlying region would experience a 1.7 percent increase in FY 2017
total payments.
Table 19--Projected Impact to the SNF PPS for FY 2017
----------------------------------------------------------------------------------------------------------------
Number of Update wage
facilities FY data Total change
2017 (percent) (percent)
----------------------------------------------------------------------------------------------------------------
Group:
Total....................................................... 15,445 0.0 2.4
Urban....................................................... 10,946 0.0 2.4
Rural....................................................... 4,499 0.3 2.7
Hospital based urban........................................ 467 -0.2 2.2
Freestanding urban.......................................... 10,479 0.0 2.4
Hospital based rural........................................ 320 0.5 2.9
Freestanding rural.......................................... 4,179 0.3 2.7
Urban by region:
New England................................................. 797 -0.8 1.6
Middle Atlantic............................................. 1,481 -0.1 2.3
South Atlantic.............................................. 1,862 -0.2 2.2
East North Central.......................................... 2,095 -0.1 2.3
East South Central.......................................... 547 -0.1 2.3
West North Central.......................................... 907 -0.2 2.2
West South Central.......................................... 1,323 0.3 2.7
Mountain.................................................... 509 -0.1 2.3
Pacific..................................................... 1,420 0.6 3.0
Outlying.................................................... 5 -0.6 1.7
Rural by region:
New England................................................. 139 0.1 2.5
Middle Atlantic............................................. 221 0.4 2.8
South Atlantic.............................................. 507 -0.2 2.2
East North Central.......................................... 933 0.2 2.6
East South Central.......................................... 530 0.4 2.8
West North Central.......................................... 1,087 0.5 2.9
West South Central.......................................... 745 0.6 3.0
Mountain.................................................... 233 0.7 3.2
Pacific..................................................... 104 -0.4 2.0
Ownership:
Government.................................................. 1,051 0.1 2.5
Profit...................................................... 10,766 0.0 2.4
Non-profit.................................................. 3,628 -0.1 2.3
----------------------------------------------------------------------------------------------------------------
Note: The Total column includes the 2.7 percent market basket increase, reduced by the 0.3 percentage point MFP
adjustment. Additionally, we found no SNFs in rural outlying areas.
5. Alternatives Considered
As described in this section, we estimate that the aggregate impact
for FY 2017 under the SNF PPS would be an increase of $920 million in
payments to SNFs, resulting from the SNF market basket update to the
payment rates, as adjusted by the MFP adjustment.
Section 1888(e) of the Act establishes the SNF PPS for the payment
of Medicare SNF services for cost reporting periods beginning on or
after July 1, 1998. This section of the statute prescribes a detailed
formula for calculating payment rates under the SNF PPS and does not
provide for the use of any alternative methodology. It specifies that
the base year cost data to be used for computing the SNF PPS payment
rates must be from FY 1995 (October 1, 1994, through September 30,
1995). In accordance with the statute, we also incorporated a number of
elements into the SNF PPS (for example, case-mix classification
methodology, a market basket index, a wage index, and the urban and
rural distinction used in the development or adjustment of the federal
rates). Further, section 1888(e)(4)(H) of the Act specifically requires
us to disseminate the payment rates for each new FY through the Federal
Register and to do so before the
[[Page 52052]]
August 1 that precedes the start of the new FY. Accordingly, we are not
pursuing alternatives for the payment methodology as discussed
previously.
6. Accounting Statement
As required by OMB Circular A-4 (available online at
www.whitehouse.gov/sites/default/files/omb/assets/regulatory_matters_pdf/a-4.pdf), in Table 20, we have prepared an
accounting statement showing the classification of the expenditures
associated with the provisions of this final rule. Table 20 provides
our best estimate of the possible changes in Medicare payments under
the SNF PPS as a result of the policies in this final rule, based on
the data for 15,427 SNFs in our database. All expenditures are
classified as transfers to Medicare providers (that is, SNFs).
Table 20--Accounting Statement: Classification of Estimated
Expenditures, From the 2016 SNF PPS Fiscal Year to the 2017 SNF PPS
Fiscal Year
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $920 million.*
From Whom To Whom?........................ Federal Government to SNF
Medicare Providers.
------------------------------------------------------------------------
* The net increase of $920 million in transfer payments is a result of
the MFP-adjusted market basket increase of $920 million.
7. Conclusion
This final rule sets forth updates of the SNF PPS rates contained
in the SNF PPS final rule for FY 2016 (80 FR 46390). Based on the
above, we estimate the overall estimated payments for SNFs in FY 2017
are projected to increase by $920 million, or 2.4 percent, compared
with those in FY 2016. We estimate that in FY 2017 under RUG-IV, SNFs
in urban and rural areas would experience, on average, a 2.4 and 2.7
percent increase, respectively, in estimated payments compared with FY
2016. Providers in the rural Mountain region would experience the
largest estimated increase in payments of approximately 3.2 percent.
Providers in the urban New England region would experience the smallest
estimated increase in payments of 1.6 percent.
8. Effects of the Requirements for the SNF VBP and SNF QRP Program
The requirements set forth for the SNF VBP and SNF QRP Program in
this final rule would not impact SNFs in FY 2017; therefore, we are not
including a regulatory impact analysis for the SNF VBP and SNF QRP
Program in this final rule.
B. Regulatory Flexibility Act Analysis
The RFA requires agencies to analyze options for regulatory relief
of small entities, if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities
include small businesses, non-profit organizations, and small
governmental jurisdictions. Most SNFs and most other providers and
suppliers are small entities, either by reason of their non-profit
status or by having revenues of $27.5 million or less in any 1 year. We
utilized the revenues of individual SNF providers (from recent Medicare
Cost Reports) to classify a small business, and not the revenue of a
larger firm with which they may be affiliated. As a result, we estimate
approximately 91 percent of SNFs are considered small businesses
according to the Small Business Administration's latest size standards
(NAICS 623110), with total revenues of $27.5 million or less in any 1
year. (For details, see the Small Business Administration's Web site at
http://www.sba.gov/category/navigation-structure/contracting/contracting-officials/eligibility-size-standards). In addition,
approximately 25 percent of SNFs classified as small entities are non-
profit organizations. Finally, individuals and states are not included
in the definition of a small entity.
This final rule sets forth updates of the SNF PPS rates contained
in the SNF PPS final rule for FY 2016 (80 FR 46390). Based on the
above, we estimate that the aggregate impact would be an increase of
$920 million in payments to SNFs, resulting from the SNF market basket
update to the payment rates, as adjusted by the MFP adjustment. While
it is projected in Table 19 that most providers would experience a net
increase in payments, we note that some individual providers within the
same region or group may experience different impacts on payments than
others due to the distributional impact of the FY 2017 wage indexes and
the degree of Medicare utilization.
Guidance issued by the Department of Health and Human Services on
the proper assessment of the impact on small entities in rulemakings
utilizes a cost or revenue impact of 3 to 5 percent as a significance
threshold under the RFA. According to MedPAC, Medicare covers
approximately 12 percent of total patient days in freestanding
facilities and 21 percent of facility revenue (Report to the Congress:
Medicare Payment Policy, March 2016, available at http://medpac.gov/documents/reports/chapter-7-skilled-nursing-facility-services-(march-
2016-report).pdf). As a result, for most facilities, when all payers
are included in the revenue stream, the overall impact on total
revenues should be substantially less than those impacts presented in
Table 19. As indicated in Table 19, the effect on facilities is
projected to be an aggregate positive impact of 2.4 percent. As the
overall impact on the industry as a whole, and thus on small entities
specifically, is less than the 3 to 5 percent threshold discussed
previously, the Secretary has determined that this final rule would not
have a significant impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of an MSA and has fewer
than 100 beds. This final rule would affect small rural hospitals that
(1) furnish SNF services under a swing-bed agreement or (2) have a
hospital-based SNF. We anticipate that the impact on small rural
hospitals would be similar to the impact on SNF providers overall.
Moreover, as noted in previous SNF PPS final rules (most recently the
one for FY 2016 (80 FR 46476)), the category of small rural hospitals
would be included within the analysis of the impact of this final rule
on small entities in general. As indicated in Table 19, the effect on
facilities is projected to be an aggregate positive impact of 2.4
percent. As the overall impact on the industry as a whole is less than
the 3 to 5 percent threshold discussed above, the Secretary has
determined that this final rule would not have a significant impact on
a substantial number of small rural hospitals.
C. Unfunded Mandates Reform Act Analysis
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2016, that
threshold is approximately $146 million. This final rule does not
include any mandate on state, local, or tribal governments in the
aggregate, or by the private sector, of $146 million.
[[Page 52053]]
D. Federalism Analysis
Executive Order 13132 establishes certain requirements that an
agency must meet when it issues a proposed rule (and subsequent final
rule) that imposes substantial direct requirement costs on state and
local governments, preempts state law, or otherwise has federalism
implications. This final rule would have no substantial direct effect
on state and local governments, preempt state law, or otherwise have
federalism implications.
E. Congressional Review Act
This final rule is subject to the Congressional Review Act
provisions of the Small Business Regulatory Enforcement Fairness Act of
1996 (5 U.S.C. 801 et seq.) and has been transmitted to the Congress
and the Comptroller General for review.
In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the Office of Management and Budget.
Dated: July 18, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: July 25, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-18113 Filed 7-29-16; 4:15 pm]
BILLING CODE 4120-01-P