Medicare Update

OIG Presents Ways to Improve Quality of Nursing Home Care

On May 15, 2008, Lewis Morris, Chief Counsel to the Inspector General, presented testimony entitled "In the Hands of Strangers: Are Nursing Home Safeguards Working?" before the House Energy and Commerce Committee's Subcommittee on Oversight and Investigations.

In his testimony, the Chief Counsel describes the studies, enforcement actions, initiatives and government-industry collaboration that the Department of Health and Human Services' Office of Inspector General (OIG) has undertaken to identify ways to improve the quality of nursing home care. The Chief Counsel also offers some suggestions for consideration, including:

• Improve screening of all nursing home staff by creating a nationwide centralized database that includes information from OIG's exclusions database, state nurse aide registries, and disciplinary actions by state licensing boards. 
• Create a demonstration project to establish mandatory compliance programs for selected nursing homes.
• Enhance the quality-of-care data made available to the nursing home industry and the public.

On May 9, 2008, the U.S. Government Accountability Office (GAO) also released a report entitled "Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses." According to the report, during fiscal years 2002 through 2007, about 15 percent of federal comparative surveys nationwide identified state surveys that failed to cite at least 1 deficiency at the most serious levels of nursing home noncompliance - actual harm and immediate jeopardy.  In the report, the GAO recommends that the Centers for Medicare & Medicaid Services (CMS):

• Require regional offices to determine if there was understatement when state surveyors cite a deficiency at a lower scope and severity level than federal surveyors and to track this information.
• Establish quality controls to improve the accuracy and reliability of information entered into the federal monitoring survey database.
• Routinely examine comparative survey data and hold regional offices accountable for implementing CMS guidance that is intended to ensure that comparative surveys more accurately capture the conditions at the time of the state survey.
• Regularly analyze and compare federal comparative and observational survey results.

The GAO reports that it provided a draft of the report to CMS through the Department of Health and Human Services (HHS) and that HHS endorsed and indicated that it would implement the GAO recommendations.

CMS to Hold Skilled Nursing Facility/Long-Term Care Open Door Forum

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will hold the next Skilled Nursing Facility/Long-Term Care Open Door Forum at 2:00 p.m. (EDT) on May 22, 2008.

To participate by telephone, one must dial 1-800-837-1935 and reference conference ID 41865584.  To participate in person, one must RSVP by 2:00 p.m. (EDT) on May 20, 2008 to SNF_LTCODF-L@cms.hhs.gov, and include your name, organization, phone number, and “SNF/LTC” in the subject line.  The Open Door Forum will take place at the Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. CMS asks that attendees arrive no later than 1:30 p.m.   

Beginning May 26, 2008, CMS will also make an audio recording of the Open Door Forum available.  To access the audio recording, one must dial 1-800-642-1687 and enter the conference ID.  The recording will expire after 3 business days.

CMS Proposes 2009 Skilled Nursing Facility Prospective Payment Rule

On May 1, 2008, the Centers for Medicare & Medicaid Services (CMS) issued a Press Release announcing the release of a display copy of a Proposed Rule that would update the skilled nursing facility (SNF) prospective payment system for fiscal year (FY) 2009.

According to the Press Release, the Proposed Rule would recalibrate the case mix weights to reestablish budget neutrality on a prospective basis and recalibrate refinements that accounted for the use of non-therapy ancillary services. For FY 2009, CMS projects that the impact of the proposed recalibration would be a negative $770 million.  However, CMS expects for the negative $770 million to be offset by a FY 2009 market basket adjustment factor of 3.1 percent (or $710 million).  Therefore, the Proposed Rule would result in a negative annual update for SNFs of approximately $60 million in FY 2009.

In the Proposed Rule, CMS also addresses its ongoing analysis of nursing home staff time measurement data collected in the Staff Time and Resource Intensity Verification (Strive) project.  CMS also proposes technical corrections in the regulatory text with respect to Medicare bad debt payments to SNFs. 

The Proposed Rule is scheduled to appear in the Federal Register on May 7, 2008. CMS is expected to accept comments on the Proposed Rule until June 30, 2008.  The Proposed Rule explains how to submit comments to CMS.

CMS Updates Nursing Home Compare and Releases Quality Action Plan

On April 24, 2008, the Centers for Medicare & Medicaid Services (CMS) issued a Press Release announcing that the Nursing Home Compare website now provides information regarding whether a nursing home is or has been on CMS' special focus facility (SFF) list. 

According to CMS, the SFF initiative was created because a number of facilities were consistently providing poor quality of care, yet were periodically instituting enough improvement to pass one survey only to fail the next.  As of April 2008, CMS reports that there are 134 SFFs out of approximately 16,000 active nursing homes.  Once a nursing home is selected as a SFF, a state survey agency will conduct twice the number of standard surveys and apply progressive enforcement until the nursing home:

• significantly improves and graduates from the SFF initiative;
• is granted additional time due to promising developments; or
• is terminated from the Medicare and/or Medicaid programs.

In conjunction with the Nursing Home Compare changes, CMS has also released a 2008 Action Plan for Further Improvement of Nursing Home Quality (Action Plan).  CMS reports that the Action Plan consists of 5 inter-related and coordinated approaches to improving quality.  In brief, those approaches include:

• Consumer Awareness & Assistance. CMS intends to provide an increasing array of information about long-term care that will be written in an easy-to-understand format and be available at www.medicare.gov.
• Survey, Standards & Enforcement Processes.  During 2008, CMS intends to undertake initiatives to improve the effectiveness of annual nursing home surveys and investigations prompted by complaints. CMS also plans to work with the states to improve current enforcement efforts.
• Quality Improvement. CMS will focus on a number of key quality areas, including reductions in the use of physical restraints, reductions in the prevalence of preventable pressure sores, and greater emphasis on developing individualized care plans.
  
• Quality Through Partnerships. CMS intends to continue and strengthen its partnerships with non-governmental organizations that are committed to quality improvement in nursing homes.
• Value-Based Purchasing. CMS intends for the Nursing Home Value-Based Purchasing Demonstration to augment and reinforce other quality efforts.

OIG Publishes Draft Supplemental Compliance Program Guidance for Nursing Facilities

On April 15, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) released Draft OIG Supplemental Compliance Program Guidance (CPG) For Nursing Facilities.  The draft supplemental CPG for nursing facilities is intended to supplement the OIG's original CPG for nursing facilities, which was published in the Federal Register on March 16, 2000.  In fact, the OIG reports that the 2 documents "collectively offer a set of guidelines that nursing facilities should consider when developing and implementing a new compliance program or evaluating an existing one." The Draft OIG Supplemental Compliance Program Guidance (CPG) For Nursing Facilities is expected to appear as a Proposed Notice in the Federal Register on April 16, 2008.

MedPAC Releases Medicare Payment Policy Report for 2009

On February 29, 2008, the Medicare Payment Advisory Commission (MedPAC) issued a News Release announcing the release of its Report to Congress: Medicare Payment Policy for 2009 (Report).  In the Report, MedPAC makes updates and policy recommendations for certain Medicare fee-for-service payment systems for 2009.  In brief, MedPAC recommends the following updates:

• Hospital Inpatient & Outpatient Services. MedPAC recommends that Congress increase payment rates in 2009 by the projected rate of increase in the hospital market basket index, concurrent with implementation of a quality incentive payment program.  The Centers for Medicare & Medicaid Services' (CMS) current projection of the market basket increase for fiscal year 2009 is 3.0 percent.  MedPAC also recommends that Congress reduce the indirect medical education adjustment by 1 percent to 4.5 percent per 10 percent increment in the resident-to-bed ratio. 
• Physician Services. MedPAC recommends that Congress increase the physician fee schedule conversion factor by the projected change in input prices less MedPAC's adjustment for productivity growth.  With the current estimate of input cost changes in 2009 of 2.6 percent and MedPAC's productivity adjustment of 1.5 percent, MedPAC's recommended 2009 update would be 1.1 percent.  MedPAC also recommends that Congress enact legislation requiring that CMS establish a process for measuring and reporting physician resource use on a confidential basis for a period of 2 years.
• Outpatient Dialysis Services. MedPAC recommends that Congress update the composite rate in calendar year 2009 by the projected rate of increase in the end-stage renal disease market basket index (2.5 percent) less MedPAC's adjustment for productivity growth (1.5 percent).  This would update the composite rate by 1 percent.  MedPAC also recommends that Congress implement a quality incentive program for physicians and facilities that treat dialysis patients.
  
• Skilled Nursing Facility Services. MedPAC recommends that Congress eliminate the update to payment rates for skilled nursing facility (SNF) services for fiscal year 2009 and that Congress establish a quality incentive payment policy for SNFs.  Further, to improve quality measurement for SNFs, MedPAC recommends that CMS:
  • add the risk-adjusted rates of potentially avoidable rehospitalizations and community discharge to its publicly reported post-acute care quality measures;
  • revise the pain, pressure ulcer, and delirium measures currently reported on CMS' Nursing Home Compare website; and
  • require SNFs to conduct patient assessments at admission and discharge.
• Home Health Services. MedPAC recommends that Congress eliminate the update to payment rates for home health care services for calendar year 2009. 
• Inpatient Rehabilitation Facility Services. MedPAC recommends that the update to the payment rates for inpatient rehabilitation facility services be eliminated for fiscal year 2009.
• Long-Term Care Hospital Services.  MedPAC recommends that the payment rates for long-term care hospital (LTCH) services be updated by the market basket index less MedPAC's adjustment for productivity growth (1.5 percent).  MedPAC reports that, under current market basket assumptions, this recommendation would update LTCH payment rates by 1.6 percent.

MedPAC is an independent Congressional agency established by the Balanced Budget Act of 1997 to advise Congress on issues affecting the Medicare program.  MedPAC meets publicly to discuss policy issues and formulate its recommendations to Congress.  Two reports, issued in March and June each year, are the primary outlets for MedPAC's recommendations.

Senator Grassley Introduces Nursing Home Transparency and Improvement Act of 2008

On February 14, 2008, Senator Charles Grassley and Senator Herb Kohl introduced the Nursing Home Transparency and Improvement Act of 2008 (S.2641).  According to a related Press Release, S.2641 aims to bring more transparency to consumers regarding nursing home quality, improve enforcement, and strengthen nursing home staff training requirements.

Among other things, S.2641 would reportedly require that "special focus facility" designations be placed on the Nursing Home Compare website.  S.2641 would also require that CMS develop a standardized complaint form and require more uniform reporting of nursing staff levels so that comparisons can be made across nursing homes.  S.2641 would also strengthen the available penalties.  For instance, S.2641 would reportedly allow the Secretary to impose civil monetary penalties of up to $100,000 for a deficiency resulting in death, $3,000-$25,000 for deficiencies at the level of actual harm or immediate jeopardy, and not more than $3,000 for other deficiencies.  Finally, S.2641 would attempt to improve staff training by including dementia management and abuse prevention training as part of pre-employment training. 

Additional information on S.2641 can be found in a related Press Release. 

CMS to Hold Skilled Nursing Facility/Long-Term Care Open Door Forum

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will hold the next Skilled Nursing Facility/Long-Term Care Open Door Forum at 3:30 p.m. (EST) on February 27, 2008.

To participate by telephone, one must dial 1-800-837-1935 and reference conference ID 18796437.  To participate in person, one must RSVP by 2:00 p.m. (EST) on February 25, 2008 to SNF_LTCODF-L@cms.hhs.gov, and include your name, organization, phone number, and “SNF/LTC” in the subject line.  The Open Door Forum will take place at the Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. CMS asks that attendees arrive no later than 3:00 p.m. (EST).   

Beginning 2 hours after the Open Door Forum, CMS will also make an audio recording of the Open Door Forum available.  To access the audio recording, one must dial 1-800-642-1687 and enter the conference ID.  The recording will expire after 3 business days.

CMS Releases List of Special Focus Facility Nursing Homes

On February 12, 2008, the Centers for Medicare & Medicaid Services (CMS) issued a Press Release announcing that it has posted a broader list of the nursing homes identified as part of the Special Focus Facility (SFF) initiative. 

In November 2007, CMS released a list of 54 SFF nursing homes that had failed to improve significantly after being given an opportunity to do so. The broader list reportedly includes all nursing homes in the SFF initiative and identifies the facilities by category, including:

• New Additions:  Nursing homes added within approximately the past 6 months.
• Not Improved:  Nursing homes that have failed to improve significantly in at least 1 survey after being named as a SFF nursing home.
• Improving: Nursing homes that have significantly improved on the most recent survey, including no findings of harm to any resident and no systematic potential for harm.
• Recently Graduated: Nursing homes that have sustained significant improvement for about 12 months, indicating an upward trend in quality improvement compared to the nursing home's prior history of care.
• No Longer in Medicare & Medicaid: Nursing homes that were either terminated by CMS from participation in Medicare within the past few years or voluntarily chose not to continue participation.

According to the Press Release, CMS intends to add cross links between the individual nursing home pages on the nursing home compare website with the full SFF list in April 2008.  In August 2008, CMS also expects to provide more information on methods by which SFFs may access additional technical assistance to improve their quality of care.

In 1998, CMS created the SFF initiative in response to the number of facilities that were consistently providing poor quality of care and periodically instituting enough improvement to pass one survey, only to fail the next. 

CMS reports that there are currently about 131 active facilities identified as SFFs.  According to CMS, about 50 percent of the nursing homes identified as SFFs significantly improve their quality of care within 24-30 months.  However, CMS reports that about 16 percent are eventually terminated from the Medicare and Medicaid programs.

OIG Reports on Government-Long Term Care Industry Roundtable

On January 31, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) and the Health Care Compliance Association released a report arising from a recent government-industry roundtable called Driving for Quality in Long-Term Care: A Board of Directors Dashboard.  The roundtable was held on December 6, 2007 and provided the long-term care industry with an opportunity to inform the OIG of issues surrounding board of directors' oversight of quality of care.

The report includes written summaries of the discussions that took place in breakout groups designed around the following 3 perspectives on the oversight of quality of care: (i) organizational commitment to quality; (ii) processes related to monitoring and improving quality; and (iii) outcome measures related to quality. In the report, a fourth breakout group also considered the benefits of, and challenges to, developing a Quality of Care Dashboard (i.e., a management tool that may provide a way to access and oversee performance on quality of care issues).  In a related Press Release, the OIG indicates that it is considering additional opportunities for government-industry dialogue on quality of care issues.