Medicare Payment Policy

FIGURE
FIguRe
Percent
7-2
8–2
30
25
20
15
10
5
0
2000
Risk adjusted....
snF quality shows little
improvement over 10 years
Community discharge
(Increases indicate better quality)
Rehospitalization of patients with any of 5 conditions
(Decreases indicate better quality)
2002
2004
2006
2008
2010
Note: SNF (skilled nursing facility). Increases in rates of discharge to community
indicate improved quality. The five conditions include congestive heart
failure, respiratory infection, urinary tract infection, septicemia, and
electrolyte imbalance. Increases in rehospitalization rates for the five
conditions indicate worsening quality. Rates are calculated for all facilities
with 25 or more stays.
Source: Risk-adjusted rates for years 2003 to 2010 calculated by MedPAC
based on a risk-adjustment model developed by the Division of Health
Note: Note Care and Policy Source and Research, in InDesign. University of Colorado at Denver and Health
Sciences Center (Fish et al. 2011).
percent were discharged to SNFs in 2004; this share
increased to 38 percent in 2010 and remained at that share
in 2011.
Quality of care: A decade with little
improvement
The Commission tracks two indicators of SNF quality:
risk-adjusted rates of community discharge and
rehospitalization of patients with five potentially avoidable
conditions during the SNF stay. 14 In October 2010, CMS implemented a new patient
assessment tool for use by nursing homes and SNFs
(Minimum Data Set version 3.0). The change in
assessment tools required us to revise the methods we
use to risk adjust the quality measures the Commission
tracks. The revised Minimum Data Set has improved
patient tracking and provides more complete data than the
previous assessment data. The risk-adjustment methods
continue to include patient comorbidities and measures
of functional status but exclude service-use measures,
such as the provision of therapy or the patient’s use of a
feeding tube or catheter—conditions that providers could
influence.
Between 2000 and 2010,
the rates showed little change. This year, the Commission
developed a risk-adjustment measure of rehospitalization
of beneficiaries within 30 days of discharge from the SNF.
This performance measure would encourage facilities
to ensure safe and appropriate transitions to the next
health care setting (or home). Between 2010 and 2011,
performance for all three measures varied considerably
across facilities.
15 Because the comorbidity index includes
indicators for several mental illnesses, a separate measure
of cognitive status was not statistically significant and was
excluded from the final risk-adjustment model. 16 Notes about this graph:
• Data is in the datasheet. Make updates in the datasheet.
• I had to force return the items on the x-axis. They will reflow if I update the data.
• I had to manually draw tick marks and axis lines because they kept resetting when I changed any data
• Use direct selection tool to select items for modification. Otherwise if you use the black selection tool,
default when you change the data.
• Use paragraph styles (and object styles) to format.
While
the risk-adjusted rates for 2011 are close to those for 2010,
some discrepancies exist that partly reflect differences
in methods. Thus, changes between 2010 and 2011 need
to be interpreted with caution. However, going forward,
the new and more current methodology will be used and
will be comparable to that used for 2011. In that year,
the community discharge rate was 27.8 percent and the
168 Skilled nursing facility services: Assessing payment adequacy and updating payments
Rehospitalization and community discharge rates
are essentially unchanged from 2000
Between 2000 and 2010, rates of rehospitalization for
patients with any of five potentially avoidable conditions
and discharge Rehospitalization to the for community any of 5 conditions remained almost the same
(Figure 8-2). These rates differ slightly in level but not in
the trends Community previously discharge reported by the Commission. The
levels differ because the Commission adopted a new base
year for the measures (2011) so that the rates are more
directly comparable over time to the rates reported for
2011, as discussed below.
The persistent lack of improvement in rehospitalization
rates likely reflects the financial incentive to transfer
patients back to the hospital when they require expensive
ancillary services, poor communication (among staff and
between staff and physicians), and a lack of adequate
staffing at facilities (especially at night and on weekends).
Although all SNFs face the same incentives, there are
facilities with consistently low and high rehospitalization
rates. Last year, we found over 1,200 SNFs with
rehospitalization rates in the lowest (the best) quartile of
the distribution of rates for 3 years in a row; of them, over
300 were in the best 10th percentile each of the 3 years.
Conversely, over 900 facilities had rates in the top quartile
(the worst) 3 years in a row; of them, almost 200 were in
the worst 10th percentile each year.