Quality Measures impact reimbursement via the Annual Percentage Update (APU) as part of the Quality Reporting Program. They also affect incentive payments as part of the Value Based Purchasing Program. Quality Measures can also impact Medicaid reimbursement in certain states.
For the Quality Reporting Program, as part of the IMPACT Act, if SNFs do not report the required quality measure data for this program timely, the SNF is subject to a 2% reduction in the Annual Payment Update (APU) for the applicable performance year. Timely submission for each calendar year (CY) quarter is 4.5 months following the end of the quarter; for example, the data collection submission deadline for January 1st through March 31st (Quarter 1) is August 15th. The applicable performance year is 2 years behind the affected Fiscal Year (FY) meaning data collection in CY 2024 will affect the APU for FY 2026.
As noted last month, the current measures for the Quality Reporting Program include:
Current data submission thresholds for the SNF QRP are as follows:
· MDS Assessment Data - 90% of data submitted to iQIES has to contain 100% of the required measures and standardized patient assessment data.
· NHSN Data – 100% of data submitted to the CDC’s NHSN must contain 100% of the required data for these measures.
The Value Based Purchasing Program currently has one measure – SNF 30-Day All-Cause Readmission Measure (SNFRM). The VBP impacts reimbursement with a +/- 2% withhold to fund incentive payments of which 60% is distributed back during the impacted FY based on Performance Scores. Performance Score is the higher of the Achievement Score (facility’s rate compared with national scores for all facilities during the baseline period) and the Improvement Score (facility’s performance versus baseline period). The bottom 40% receive less. Starting with FY 2026, several new measures will be added to the VBP including:
· Nursing Staff Turnover (reporting began with FY 2024; will affect payment starting with FY 2026)
· Discharge Function Score (begins with FY 2027)
· Long Stay Hospitalization Per 1,000 Resident Days (begins with FY 2027)
· Percent of Residents experiencing One or More Falls with Major Injury (begins with FY2027)
Starting with FY 2027, a Health Equity Adjustment will be applied with a 56.5% payback. Also, in FY 2028 the current SNFRM will be replaced with the SNF Within Stay Potentially Preventable Readmission (SNF WSPPR).
In addition to the possible loss of revenue related to these 2 programs, more than 24 states have, or are in the process of, incorporating quality measures into their Medicaid reimbursement. For example, in Ohio, a facility may receive a per day quality incentive payment based on quality points associated with the following quality measures:
· Percentage of residents experiencing one or more falls with major injury (5 points).
· Percentage of high-risk residents with pressure ulcers (5 points – frozen).
· Percentage of long stay residents who had a urinary tract infection (5 points).
· Percentage of long stay residents who had a catheter inserted and left in their bladder (5points).
· Percentage of long stay residents whose need for help with Activities of Daily Living has increased (7.5 points – frozen)
· Percentage of long-stay residents whose ability to move independently worsened (7.5 points – frozen).
· Percentage of long-stay residents who received an antipsychotic medication (7.5 points).
· Nurse Staffing Turnover (5 points)
· Occupancy (3 points).
*Total of 50.5 points. A higher score equals higher reimbursement.
Pennsylvania is currently in the process of adopting a quality measure incentive program for Medicaid payments.
Stay-tuned as we continue to explore the impact of quality measures…