1. Quality Nursing Home Care: Getting Our Money’s Worth
November 4, 2016
Cheryl Hennen, MN State Long-Term Care Ombudsman
Laura Katz Olson, Professor of Political Science, Lehigh University
Cynthia Rudder, Consultant, Consumer Voice

2. Relating Nursing Home Reimbursement to Quality
Cynthia Rudder, Ph.D.
November 4, 2016
The Consumer Voice Annual Conference

3. HOW TO MAKE A DIFFERENCE?
Understand your state’s system of reimbursement
Fight for more transparency in how public monies are used and distributed in nursing homes.
Review nursing home cost reports

4. INTRODUCTION: CASE-MIX MEDICAID AND REIMBURSEMENT FOR NURSING HOMES
Case Mix reimbursement systems measure the intensity of care and services required for each resident (including staffing needs) and translate those measures into groupings (categories)   Those groupings are used in the calculation of facility payment.  
The MDS is used in states’ Medicaid reimbursement methodology. The MDS is used to classify residents into Resource Utilization Groups (RUGs) that in turn generate a case mix score. 

5. WHY ARE STATES USING CASE MIX?
To improve access to care (for heavy care residents) by varying the reimbursement rate with the resident’s condition.
To improve efficiency and contain costs by paying prospectively.
To enhance quality of care by linking reimbursement to the acuity of care.

6. CASE MIX DISINCENTIVES FOR QUALITY
Facilities are paid higher rates for heavier care residents. There is a possibility that lighter care residents, those in the lower paying categories, who still need nursing home care, will not get the care they need.
Residents who improve are reclassified into a lower paying category; there is little financial incentive for facilities to help residents improve.

7. CASE MIX DISINCENTIVES FOR QUALITY
Residents who deteriorate move to a higher paying category; there may be a financial disincentive to give care.
Profits can be made by spending less than the prospective rate. Facilities may not be spending what they need to in order to care for the residents they admit. They may not be more efficient, they may simply be withholding care.

8. SELECTED PRINCIPLES OF CASE MIX THAT CAN AFFECT QUALITY
Ceiling
Floor - Base
Cost Categories and What they Include
Direct care
Indirect care
Capital costs
Noncomparable

9. IDEAS TO LINK QUALITY TO NURSING HOME REIMBURSEMENT BY LESSENING THE DISINCENTIVES
Require facility to spend any savings they have incurred as a result of spending less than the cap or ceiling on direct care.
Do not permit spending less than the prospective rate in the direct cost category by either limiting caps (ceilings) or eliminating them altogether.

10. IDEAS TO LINK QUALITY TO NURSING HOME REIMBURSEMENT BY LESSENING THE DISINCENTIVES
Profits made by spending below a floor on direct care must be spent on direct care or be returned to the state. – Louisiana and Mississippi did this.

11. IDEAS TO LINK QUALITY TO NURSING HOME REIMBURSEMENT BY LESSENING THE DISINCENTIVES
Keep the higher rate for a specific period of time when a resident improves. Maryland did this.
Require proof that the deterioration to a higher paying category was not the fault of the facility before upping the rate.

12. OTHER IDEAS FOR LINKING QUALITY AND REIMBURSEMENT
Link surveillance to the reimbursement system.
Maine reduced a facility’s rate to 90 percent of the rate until deficiencies are corrected.
Encourage spending in direct care by having high ceilings or no ceilings.
Maine increased the direct cost component of the rate if a facility did not meet staffing requirements.

13. OTHER IDEAS FOR LINKING QUALITY AND REIMBURSEMENT
Pay for quality care not just access – Pay for Performance
Examples of states that either are doing or did do in the past:
Georgia – gives add-ons to the rate for a lower rate of: high risk long-stay residents who have pressure sores; long-stay residents who are physically restrained; long-stay residents who have moderate to severe pain; short-stay residents who have moderate to severe pain; In addition, it looks at staff retention; resident satisfaction surveys.

14. OTHER IDEAS FOR LINKING QUALITY AND REIMBURSEMENT
Indiana – uses a report card to increase reimbursement.
Iowa – performance on surveys, nursing hours, resident satisfaction, staff retention, low use of agency staff and resident advocacy committee resolution rates.
Kansas – add-on for staff turnover, staff retention, survey findings.
Ohio – family and resident satisfaction, nursing hours, and inspection results.
Utah – adds funds for quality improvement plans that include the involvement of residents and families, resident satisfaction, a plan for culture change, employee satisfaction plan.

15. OTHER IDEAS FOR LINKING QUALITY AND REIMBURSEMENT
Put a cap or ceiling on the use of agency staff. Delaware did this.
Put a cap on administrative costs. Maine and Pennsylvania did this.
Add funds to increase direct worker wages.
Add funds for administrators who have more experience and higher levels of education. South Dakota did this.

16. COST REPORTS
1994 – study of NYS’s Nursing Home Industry Profit, Losses, Expenditures and Quality*
NYS spent the most at that time in the country on Medicaid NH residents *

17. COST REPORTS
For profit facilities, many of whom made a profit on Medicaid:
Spent 12 percent less per bed than the not for profits
Lowest number of staff per bed; spent less on staff
For profit facilities with high case mix spent less on full time direct care staff
Little money was spent on activities and social work

18. Cost Reports:
Reviewing cost reports can raise interesting questions – need to ask questions
Use of contract staff
Numbers of staff
Salaries
Expenditures
Revenues

19. Cost Reports:
We need to fight for better access to cost reports in a consumer friendly format
GAO just released in September, 2016 a report on expenditures
Direct and indirect care costs were lower as a percentage of revenue at for profits and at chains
For profits had lower staffing ratios
Recommended that CMS improve the public’s ability to locate and use expenditure data and to ensure its accuracy

20. Cost Reports
NYS: can receive the cost reports under FOIL in whatever format wanted and is free
CT: has cost reports on-line:
q=583778
CMS: Under FOIA, and on the website, but not in consumer friendly format.

21. PAY FOR PERFORMANCE: THINGS TO THINK ABOUT
Additional funds or use the reimbursement pool of money?
A few criteria or a lot of criteria
How much should each be counted?
Family and resident satisfaction?
Staffing

22. Pay for Performance Agency use Turnover
Clinical – ulcers, falls, psychotropic drugs, etc.
Depression, control of bowel and bladder, lose weight, pain, ADLs. UTI
Improvement
Who should not be eligible?

23. NEW YORK STATE’S NURSING HOME QUALITY INITIATIVE
2016 – funds come out of pool of reimbursement funds – not extra money
Quality Component: 70 points
Percent of Long Stay High Risk Residents With Pressure Ulcers
Percent of Long Stay Residents Who Received the Pneumococcal Vaccine

24. NEW YORK STATE’S NURSING HOME QUALITY INITIATIVE
Percent of Long Stay Residents Who Received the Seasonal Influenza Vaccine
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
Percent of Long Stay Residents Who have Depressive Symptoms
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowels or Bladder

25. NEW YORK STATE’S NURSING HOME QUALITY INITIATIVE
Percent of Long Stay Residents Who Lose Too Much Weight
Percent of Long Stay Antipsychotic Use in Persons with Dementia

26. NEW YORK STATE’S NURSING HOME QUALITY INITIATIVE
Percent of Long Stay Residents Who Self- Report Moderate to Severe Pain
Percent of Long Stay Residents Whose Need for Help with Daily Activities Has Increased
Percent of Long Stay Residents with a Urinary Tract Infection

27. NEW YORK STATE’S NURSING HOME QUALITY INITIATIVE
Percent of Employees Vaccinated for Influenza
Rate of Staffing Hours per Day (new proposed NYS measure)
Percent of Contract/Agency Staff Used

28. NEW YORK STATE’S NURSING HOME QUALITY INITIATIVE
Compliance Component: 20 points
NYS Regionally Adjusted Five-Star Quality Rating for Health Inspections
Timely Submission of Nursing Home Certified Cost Reports
Timely Submission of Employee Influenza Immunization Data
Efficiency Component: 10 points
Number of Potentially Avoidable Hospitalizations per 10,000 Long Stay Days*

29. CONCLUSION:FOLLOW THE MONEY!
BECOME INVOLVED IN HOW YOUR STATE DISTRIBUTES MEDICAID MONEY TO NURSING HOMES! – Review webinars and papers on how to become involved and learn about case-mix reimbursement: bursement.shtml FIGHT FOR FINANCIAL TRANSPARENCY IN A CONUMER FRIENDLY FORMAT!

30. Office of Ombudsman for Long-Term Care MN
2016 Consumer Voice Conference
Quality Nursing Home Care: Getting our Money’s Worth
November 4, 2016
Enhancing the quality of life and the quality of care of older adults
A Service of the Minnesota Board on Aging

34. Philosophy and Mission
The ombudsman works to enhance the quality of life and services for long-term care consumers through advocacy, education and empowerment. We promote person-directed living which respects individual values and preferences and preserves individual rights.

35. Ombudsman Duties 1. Education and Information
Regarding health, safety, welfare & rights of clients
Promote consumer self-advocacy & empowerment
Promote citizen participation
Resources to resident & family councils
2. Advocate on Behalf of Clients
Individual client problem-solving through mediation, education and negotiation
3. Systems Advocacy
Recommend changes to systems; advocate for policy and regulation change

36. Asking residents about their Quality Of Life is unique
Minnesota is only one of a few states that use professional interviewers to get QOL information
The myth persists that satisfaction = QOL or that families can answer or that a few Qs can capture people’s feelings
“We consider this Resident Satisfaction Quality of Life Survey to be an important and useful tool to quantify some of the most important ‘resident empowerment’ messages we impart every day in our efforts to improve both quality of care and quality of life for those whom we serve.” Quote from Regional Ombudsman

37. Long Term Care Facility Quality Of Life Survey.
Residents participate in face-to-face interviews.
The primary representative for each current resident receives the corresponding family quality of life survey in the mail.
The purpose of the survey is:
1) To increase long term care facility awareness of resident and family perspectives of their services;
2) To aid long term care facilities in making quality improvement plans

38. Quality Goals for Minnesota
Provide higher quality care within the long-term care community
Motivate and inspire facilities to invest in better care.
Equip facilities with organizational tools and expertise to improve their quality

39. Why Pay for Performance
Research shows paying for achievement and improvement may be the most powerful way to motivate providers to change their practices
MN is unique in paying providers to invest in the Quality Improvement process; choosing what needs to be the focus (root cause analysis) ,develop and implement action plan to achieve goals
Requires focus on sustainability.

40. Strategies used to improve Quality of Care
MN Nursing Home Report Card: designed to promote a high standard of quality in all nursing homes across the state. By publishing information about quality of care in nursing homes.
Value-based Reimbursement System: effective January 1, 2016, a quality component is built into the operating payment rate by placing limits on care-related costs using a facility’s quality score. A facility with a higher quality score is subject to higher limits.
Quality Improvement Incentive Program: facility chooses a single quality indicator and work to improve that measure. Facilities rate increase is based on the amount of improvement relative to the previous year.

41. MN Performance based incentive Payment Program (PIPP)
70% of NF have participated in PIPP
83% have applied for PIPP at least once
Through Round 9 – October 1, 2015
214 projects funded

42. Advocacy/Consumer Experience
Ombudsman experiences/ impressions
Implications: positives, is there room for improvement
Consumer response - what have we learned