When I read my first SNF PPS final rule about 25 years ago, I thought that the start dates for some of its initiatives were so far in the future that they were of no concern. As a young person, my long-range planning didn’t extend beyond that evening’s dinner or weekend activities.
Today, when I read the most current proposed SNF rule for fiscal year 2024, with program initiatives starting as far out as FY 2027, I think, “Surely I’ll be retired by then, or even worse!” But long periods of time pass as quickly as the setting sun, and even initiatives scheduled to begin years away require our attention now. Such is the case with the proposed new measures in the SNF Value-Based Purchasing program.
To cut to the chase, the money in the VBP program isn’t changing. We are still talking about 2% of your Medicare FFS Part A payments. And although this program is positioned as a carrot, it’s hard to see it as anything other than a stick.
The money (2%) is taken from you (called the “withhold”), and the Centers for Medicare & Medicaid Services skims some off the top for the Medicare Trust Fund. Currently, 60% of the total withhold is returned to the best-performing SNFs. Though the proposed rule discusses increasing the percentage returned to 66% in FY 2027. Again the carrot seems more like a stick.
The fundamentals are not new. However, change is happening. In the FY 2024 proposed rule, CMS references four measures that may be added to the program, and one measure to be replaced. While the total financial pot is not set to change, the proposed rule lays out a much broader set of measures to identify the best-performing facilities. And unlike my younger self, it is prudent to act now to ensure that you are classified among the best-performing SNFs and to secure future incentive payments.
The good news is that these measures are mostly known to you — they have been used in other programs such as Five-Star and QRP. Some of these measures are MDS based, while others are claims based. This table summarizes all the existing, approved, and to-be-approved measures that likely will comprise the SNF VBP program.
| Measure Long Name | Measure Short Name | What Data? | Measure Status | Financial Impact | Considers Data From(baseline period) | Considers Data From (performance period) | Other Comment |
| SNF 30-Day All Cause Readmission Measure | SNFRM | Medicare FFS claims | Adopted, implemented | Resuming FY 2024, sunsetting after FY 2027 | FY 2019 | FY 2022 | When VBP resumes in FY 2024, baseline will be FY 2019 data, performance FY 2022 data (related to COVID) |
| SNF Healthcare-Associated Infections Requiring Hospitalization Measure | SNF HAI Measure | Medicare FFS claims | Adopted, not implemented | FY 2026 | FY 2022 | FY 2024 | |
| Total Nurse Staffing Hours per Resident Day Measure | Total Nurse Staffing Measure | Payroll-Based Journal | Adopted, not implemented | FY 2026 | FY 2022 | FY 2024 | Current Five-Star measure |
| Total Nursing Staff Turnover Measure | Nursing Staff Turnover Measure | Payroll-Based Journal | Proposed | FY 2026 | FY 2022 | FY 2024 | Current Five-Star measure |
| Discharge to Community – Post Acute Care Measure for SNFs | DTC PAC SNF Measure | Medicare FFS claims | Adopted, not implemented | FY 2027 | FYs 2022 and 2023 | FYs 2024 and 2025 | Current QRP measure |
| Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay) Measure | Falls with Major Injury (Long-Stay) Measure | MDS 3.0 | Proposed | FY 2027 | FY 2023 | FY 2025 | Current Five-Star measure |
| Discharge Function Score for SNFs Measure | DC Function Measure | MDS 3.0 | Proposed | FY 2027 | FY 2023 | FY 2025 | Proposed QRP measure |
| Number of Hospitalizations per 1,000 Long Stay Resident Days Measure | Long Stay Hospitalization Measure | Medicare FFS claims | Proposed | FY 2027 | FY 2023 | FY 2025 | Current Five-Star measure |
| SNF Within-Stay Potentially Preventable Readmissions Measure | SNF WS PPR Measure | Medicare FFS claims | Proposed | FY 2028 | FYs 2023 and 2025 | FYs 2025 and 2026 | Replacement measure only considers resident while in SNF;the SNF WS PPR measure iscalculated using two consecutive years of Medicare FFS claims data |
The proposed rule also addresses health equity and the reduction of health outcome disparities in SNFs. Kiran Sreenivas, vice president of research at the American Health Care Association/National Center for Assisted Living, sums up this new addition nicely: “The proposed addition of the Health Equity Adjustment to the SNF VBP Program starts in FY ’27. This is an encouraging step to address disparities. It rewards facilities that admit at least 20% complex residents, which is defined as dually eligible for Medicare and Medicaid.” These SNFs must also provide high-quality care. Sreenivas notes that this “doesn’t reduce resources to SNFs since CMS will be increasing the payback percentage to 66% from the current 60%. That increase translates to approximately $27 million more available to providers to invest in quality improvement.”
If I were to advise my past self, I would tell him that the FY 2027 payout actually began last year. The data that will drive your future success with VBP is in the past and present. (Look at the baseline periods in the table above.) I would also tell him:
- Ensure the data integrity of your MDS measures. CMS promises additional scrutiny of these specific measures.
- Claims-based measures are nearly impossible to manage. Use a proxy measure. For example, the hospital utilization measures can be simply tracked with MDS, or your EHR, or even the back of an envelope!
- QRP, VBP, and the other dozens of quality measures are your tools as much as they are for CMS and consumers. Make them real. Build them into your QAPI and operations.
- Don’t believe them when they say peroxide will turn your hair blond. It won’t. It will be awful.
Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
