The FY 2022 SNF PPS Final Rule: Learn the Facts behind the headlines Part 3 – Quality Measurement and Resident Input: What does the future hold?

The other day my wife and I were eating out with at one our favorite local establishments and, as is the case in many restaurants today, they were understaffed, so much so that the cooks had to help serve. Rather than make patrons wait, the cook staff actually helped serve tables.

Now that may be impressive, but in the current pandemic influenced milieu that has not always been the case. Often, the wait is lengthy, and the service staff are not always pleasant.

But, in this case, both the wait staff and the cook staff, as harried as they were, seemed ok and were very pleasant. The food was fresh and carefully prepared. We were impressed and showed that with the amount we tipped. I also wrote a note on the receipt thanking them.

Our opinion of our experience was meted out not only in my response but in how I will recommend that establishment in the future. My experience was the litmus test. How we experience a situation often determines how we respond and our lasting impressions.

I couldn’t help thinking about this experience and what is about to change with regard to the SNF Value Based Purchasing program. We talked at length in a recent post about the coming changes.  In this post I want to dig in a bit about the two patient centered quality measures that CMS has indicated will become part of how SNFs will measured under the SNF VBP.

What does Value Based Purchasing really mean anyway? Have you thought about that lately? As you may be aware, every FY SNFs lose 2% of their federal rate. Most SNFs will only to be paid back a portion of that rate reduction based on how they performed relative to rehospitalizations several years prior. In recent legislation, CMS has been authorized to add up to 9 additional measures to this program leaving rehospitalizations as only one of several players.

The general consensus is that this is a good thing as a single measure has been criticized as lacking the breadth to truly gauge overall facility value, and CMS is moving ahead. While we don’t know all of the details, CMS has indicated that the FY 2023 proposed and final rulemaking process will give us more information on the impending changes.

For the time being we are left with the prospect that change is on the way. And, in the FY 0222 Final Rule gave us a table of possible quality measures that are being considered. What is unique about the list provided in the Final Rule is that for the first time CMS is considering expanding the concept of value based purchasing beyond Medicare Part A to all payer sources and the patient point of view will be taken into account relative to quality measurement/value-based purchasing.

Let’s consider the two of the measures being considered that are based solely on the resident and or family’s interpretation of the quality of care received. These are, the Patient Reported Outcomes Measurement Information System and the CoreQ Short Stay Discharge Measure. Let’s start with the CoreQ Sort Stay Discharge Measure. The measure specifications may be found here. It is measurement that has been determined through the meaningful measures framework to represent the patients experience of care.

Fundamentally, this measure calculates the percentage of individuals discharged in a six-month time period from a SNF, within 100 days of admission, who are satisfied.

This patient reported outcome measure is based on the CoreQ: Short Stay Discharge questionnaire that utilizes four items:

  1. In recommending this facility to your friends and family, how would you rate it overall (Poor, Average, Good, Very Good, or Excellent)
  2. Overall, how would you rate the staff (Poor, Average, Good, Very Good, or Excellent)
  3. How would you rate the care you receive (Poor, Average, Good, Very Good, or Excellent)
  4. How would you rate how well your discharge needs were met (Poor, Average, Good, Very Good, or Excellent)

The numerator is the sum of the individuals in the facility that have an average satisfaction score of greater than or equal to 3 for the four questions

The denominator includes all of the patients that are admitted to the SNF, regardless of payor source, for post-acute care, that are discharged within 100 days; who receive the survey and who respond to the CoreQ: Short Stay Discharge questionnaire within two months of receiving the questionnaire. People meeting denominator exclusions do not receive a questionnaire.

Considering the impact that questions like these can and will have on a program like the SNF VBP, providers should get prepared. Some states already use portions of the CoreQ questions as part of the quality add on structure for their Medicaid rates. In Tennessee question 1 is used specifically.

However, SNF providers have never been required to use patient experience as a litmus test for value as it related to Medicare Payment. How will we respond when the mirror of resident perception is leveled against the face of current SNF operations?

In what ways will we change to accommodate what is sure to be another wake up call. Concepts such as health literacy, trauma informed care, health equity and patient centered care planning etc., may begin to take a different shape as we begin to consider that how we will be paid, will in some measure, be based on our resident’s care experience.

The second patient reported measure that CMS is considering for use in the “new” VBP is Patient- Reported Outcomes Measurement Information System (PROMIS)- PROMIS Global Health Physical. PROMIS® (Patient-Reported Outcomes Measurement Information System) is a set of person-centered measures that evaluates and monitors physical, mental, and social health in adults and children. It can be used with the general population and with individuals living with chronic conditions. This system was developed and validated with state-of-the-science methods to be psychometrically sound and to transform how life domains are measured. It was designed to enhance communication between clinicians and patients in diverse research and clinical settings and created to be relevant across all conditions for the assessment of symptoms and functions. The Meaningful Measure being addressed by this measure is, “Functional Outcomes”.

If you visit the PROMIS website, you will find that there is a complex array of tools and surveys available. A quick search through the available physical health tools yields tools that assess physical function, mobility upper extremity, mobility aids and the list goes on. CMS has not yet been specific as to which tools they intend to utilize. However, the bottom line is that this will be another way to measure resident experience in the form of their perceived and reported outcomes.

So, get ready! Value Based Purchasing/Pay for Performance is not going away. In fact, soon providers will see a broader scope of quality measures affecting their annual value based purchasing adjustments, including measures that validate the resident reported experiences and outcomes. Now is the time to be sure that measuring resident satisfaction is a routine part of how we do business. Much has also been discussed about the $$ amount that should be attached to the VBP program. Chances are good that there will be much more opportunity with regard to these incentives. How we experience a situation often determines how we respond and our lasting impressions. We as providers need to consider this and rise to the task of ensuring that the spirit and reality of value-based purchasing becomes the reality of the care cultures we create.