Engaging Value Based Purchasing – The PDPM and Quality Measurement

We are about to embark on an adventure, the likes of which we have not seen in long-term care. The Patient-Driven Payment Model will forever shift the way we engage with our residents, especially as it applies to how we get paid from the traditional Medicare Part A program. In all likelihood, though it’s in the the future, PDPM will impact how we are paid from state Medicaid programs, as well as Medicare Advantage.

Indeed, the spotlight for the last year has been on what is changing with regard to SNF reimbursement residents for under Part A. But in our lust for success under this new payment model we have lost sight of a critical component of the PDPM that must be embraced if we are to achieve the value inherent in this new payment system.

Value-based purchasing is a term we have grown accustomed to. We probably don’t think too much about it, given the way that we are currently reimbursed with RUG IV/66. An inherent flaw in this system is that it rewards the case mix and maximized RUG scores. It does not, as a payment methodology, take into account the variety of characteristics that uniquely define the care we are providing for each unique resident. RUG IV/66 also does not highlight the quality component that must be accounted for in order for a payment system to be equitably driven.

In recent days, the Centers for Medicare & Medicaid Services has made some telling statements connecting the PDPM to quality as an inherent part of the system, not just an add-on. Here is some of what CMS has said:

PDPM redefines the relationship between payment and quality measures, realigning payment incentives and quality incentives.”

“Value-driven care is, by definition, a balance between care quality and care cost: High – value, efficient providers are those who are able to deliver high quality care for low cost.”

“CMS measures the quality of care provided to SNF patients/residents in a variety of ways: SNF Quality Reporting Program, SNF Value Based Purchasing, Nursing Home Compare Star Ratings.”

“PDPM provides a more holistic approach to payment classifications, which CMS believes achieves the goal of elevating the patient’s voice.”

Do you hear what I hear? CMS has been clear that a major aspect to the design of the PDPM is payment that is quality informed. That cannot be overstated. Payment incentive and quality incentive realignment! It is important that we as a SNF culture understand this and engage it with the full vigor that we have so far put toward understanding it as a reimbursement model. 

This is not a novel concept. CMS has been preparing us for this since the implementation of the Quality Indicators (I’m showing my age here), now called Quality Measures. There has always been a quality component. Now it is an inseparable part of the payment system. With the advent of Nursing Home Compare, Five-Star, MDS 3.0, the IMPACT ACT, PAMA and now the PDPM, we have come full circle.  

Here’s how. SNF providers are faced with the ongoing 2% sequestration adjustment, 2% adjustments related to VBP/Rehospitalizations and 2% adjustments associated with QRP reporting. The 5-star system and Nursing Home Compare are fluid targets and have significant impact on referral sources and payer contracts. Starting last fall providers began reporting 4 new outcomes based QRP measures informed by section GG. These along with the other QRP MDS based measures and claims based measures are and will be publicly reported. 

To manage all of that we need to know that 40 separate Quality Measures are being reported somewhere, 33 MDS based measures and 7 claims-based measures. 30 Quality measures are currently being reported on Nursing Home Compare (NHC) (23 MDS based and 7 claims based). 21 measures are reported on the CASPER report. 11 measures are currently reported for Quality Reporting Program (QRP) purposes. Don’t forget that QIES/CASPER and Nursing Home Compare are the two primary sources for all of this reporting.

Then, consider that there are no less than 6 manuals that providers should have access to that define how each of these measures are calculated. Of the 40 reported measures, 25 MDS based measures are defined in the QM User’s Manual versions 11 and 12. Four claims-based measures are defined in a separate manual. Nine MDS-based QRP measures are defined in QRP manual v2.0. Two separate manuals are required to define the final three claims-based QRP measures. Then, as if that weren’t enough, in order to calculate your 5-Star rating, 17 Quality Measures are used including 12 MDS based (1 QRP) and 5 claims based (1 QRP). Finally, the 5-star rating system requires a separate technical manual. Oh, and by the way, for NQF2510, our current rehospitalization measure that affects 2% of our rates each year, has a separate manual as well. 

Getting a grasp of the current quality measurement milieu is not for the faint of heart. Understanding the current measures and how they intersect PDPM is challenging. In a recent QRP training that CMS did in Kansas City, several frustrations were lobbed at CMS representatives related to the complex nature of the QM system with which providers currently must contend. A daunting task awaits those who will adjust to quality and payment realignment. Yet, it is CMS’ expectation and our payment, in large measure, depends on it.

But how do we not miss the forest for the trees? What steps can we take to wrap our arms around this behemoth? 

Occasionally in business, the question is asked: “How do you eat an elephant?” The response? “One bite at a time.”

May I suggest four “bite” size steps that might be a way for you and your teams to approach this sanely and with some confidence that you will experience positive outcomes.

First, MDS accuracy cannot be overstated. The breadth of the reach of this document is mind boggling. Providers must understand that completing the MDS accurately is non-negotiable. This means that IDTs tasked with completing it must have the most recent version and should read it regularly.

The advance copy of the PDPM RAI Manual released by CMS in May is 1,299 pages long. You should have already gotten started. Keep in mind that the MDS/RAI is not a passive process. Every part of the RAI process must be used as a filter that helps to identify quality pathways. The reduced PDPM MDS schedule should offer assessors some additional margin to consider the quality measure impact as the assessment is being completed.

Second, gaining confidence in understanding the QM/QRP Technical Specifications must be a priority. As noted previously there are six total manuals/documents that will need to be accessed in order to do this. QM manuals may be accessed here and QRP manuals may be accessed here. Providers would do well to download a copy of each of the relevant manuals and keep current copies in a notebook for ready access. Working through each of the 40 reported QM technical specifications over time will yield positive benefits.

Third, facilities should have access to their most recent quality measurement reports. These include a CASPER report with resident roster, 5-star preview reports with resident rosters, and QRP reports indicating both compliance and performance, along with resident listings. Keeping these together in a hard copy notebook is a good idea. All of your most recent QM and QRP reports can be downloaded from the QIES CASPER site. Remember Nursing Home Compare as well. You can print your long and short stay measures from that site as well and it’s good to know what the public sees.

Fourth, with the prior three steps in place, your teams can now engage in Focused Quality Stewardship. This means the MDS, the quality measurement technical specs and your facility-specific reporting can now be looked at as a roadmap for diving into quality areas that you identify as needing attention. Completing the MDS with an eye to quality measurement. Review your reports regularly, i.e. resident by resident as you enter new assessment windows. This will let you identify patterns and areas where quality needs attention. Then your QAPI and PI programs can take over to address specific issues. 

I know it’s a lot, but it’s necessary. One of my favorite quotes is by poet Henry David Thoreau. He wrote, “Our least deed, like the young of the land crab, wends its way to the sea of cause and effect as soon as born, and makes a drop there to eternity.”

I can’t help but think that this applies here. As we embrace the quality aspects of the PDPM by engaging quality measurement, we will make a lasting “drop” into the sea of reimbursement. This impact on resident care will form concentric beneficial circles. They will ripple out to endorse what value-based purchasing was intended to be all along.