CMS releases 2024 Skilled Nursing Facility Prospective Payment System proposed rule
It also includes proposals for the SNF Quality Reporting Program and the SNF Value-Based Purchasing Program.
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The Centers for Medicare and Medicaid Services has issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment System for fiscal year 2024.
It also includes proposals for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program for FY 2024 and future years.
The proposed rule would also eliminate the requirement for facilities to actively waive their right to a hearing in writing, and instead treat the failure to submit a timely hearing request as a constructive waiver.
The administration framed the proposed rule as part of a larger effort to improve the safety and quality of care in nursing homes. CMS said it was still committed to proposing minimum staffing standards for nursing facilities later this spring.
CMS indicates minimum staffing requirements will be forthcoming in future rulemaking. In the 2023 SNF PPS proposed rule, CMS solicited public comments on minimum staffing requirements. In August the agency launched a new mixed-methods study, collecting quantitative and qualitative evidence on staffing levels within nursing homes. CMS said it would continue to review the feedback and evidence from both the comment solicitation and mixed-methods study, "all of which will be used to inform proposals for minimum direct care staffing requirements in nursing homes in rulemaking this spring."
PROPOSED UPDATES TO SNF PAYMENT RATES
CMS estimates that the aggregate impact of the payment policies in the proposed rule would result in a net increase of 3.7%, or about $1.2 billion, in Medicare Part A payments to SNFs in FY 2024.
In 2019, CMS implemented a new case-mix classification system, the PDPM, in an ostensibly budget neutral manner, intending that the transition to PDPM from the prior case-mix classification model, the Resource Utilization Group, Version 4 (RUG-IV), would not result in an increase or decrease in aggregate SNF spending. But since PDPM implementation in FY 2020, CMS' initial data analysis showed an unintended increase in payments of about 5%, or $1.7 billion per year.
After considering the stakeholder feedback received on the FY 2023 SNF PPS proposed rule, CMS finalized a PDPM parity adjustment factor of 4.6% in the final rule with a two-year phase-in period, resulting in a 2.3% reduction in FY 2023 and a 2.3% reduction in FY 2024 to the SNF PPS payment rates.
PROPOSED CHANGES TO SNF QRP
CMS is proposing the adoption of the Discharge Function Score (DC Function) measure beginning with the FY 2025 SNF QRP. This measure assesses functional status by assessing the percentage of SNF residents who meet or exceed an expected discharge function score, and uses mobility and self-care items already collected on the Minimum Data Set (MDS).
Also being proposed is the adoption of the CoreQ: Short Stay Discharge (CoreQ: SS DC) measure beginning with the FY 2026 SNF QRP. This measure calculates the percentage of individuals discharged from an SNF, within 100 days of admission, who are satisfied with their SNF stay. The questionnaire that would be administered under the CoreQ: SS DC measure asks individuals to rate their overall satisfaction with their care using a five-point Likert scale. The areas of care include staff, the care received, recommending the facility to friends and family, and how well their discharge needs were met.
CMS is also proposing the adoption of the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) measure beginning with the FY 2026 SNF QRP. This measure reports the percentage of stays in which residents in an SNF are up to date with recommended COVID-19 vaccinations in accordance with the Centers for Disease Control and Prevention's most recent guidance. Data would be collected using a new standardized item on the MDS.
Another proposal is to modify the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP COVID-19 Vaccine) measure beginning with the FY 2025 SNF QRP. This measure tracks the percentage of healthcare personnel (HCP) working in SNFs who are considered up to date with recommended COVID-19 vaccination in accordance with the CDC's most recent guidance.
CMS is proposing to remove the Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Application of Functional Assessment/Care Plan) measure; the Application of the IRF Functional Outcome Measures: Change in Self-Care Score for Medical Rehabilitation Patients (Change in Self-Care Score) measure; and the Change in Mobility Score for Medical Rehabilitation Patients (Change in Mobility Score) measure beginning with the FY 2025 SNF QRP.
The agency is also considering increasing the SNF QRP Data Completion thresholds for the Minimum Data Set (MDS) Data Items beginning with the FY 2026 SNF QRP. CMS proposes SNFs must report 100% of the required quality measure data and standardized resident assessment data collected using the MDS on at least 90% of the assessments they submit to CMS. Any SNF that does not meet the proposed requirement that 90% of all MDS assessments submitted contain 100% of required data items, will be subject to a reduction of 2 percentage points to the applicable FY annual payment update beginning with FY 2026.
PROPOSED CHANGES TO SNF VBP PROGRAM
The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program rewards SNFs with incentive payments based on the quality of care they provide. All SNFs paid under Medicare's SNF PPS are included in the SNF VBP Program.
CMS is proposing the adoption of the Nursing Staff Turnover Measure for the SNF VBP program beginning with the FY 2026 program year and FY 2024 performance year. This is a structural measure that has been collected and publicly reported on Care Compare, and assesses the stability of the staffing within an SNF using nursing staff turnover. This is part of the administration's stated goal to ensure adequate staffing in long-term care settings. Facilities would begin reporting for this measure in FY 2024, with payment effects beginning in FY 2026.
Also being proposed is the adoption of the Discharge Function Score measure beginning with the FY 2027 program year and FY 2025 performance year. This measure is also being proposed for SNF QRP and assesses functional status by assessing the percentage of SNF residents who meet or exceed an expected discharge function score, and use mobility and self-care items already collected on the MDS.
Other proposals are: the adoption of the Long Stay Hospitalization Measure per 100 residents beginning with the FY 2027 program year and FY 2025 performance year; he adoption of the Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) beginning with the FY 2027 program year and FY 2025 performance year; and the replacement of the Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) with the Skilled Nursing Facility Within Stay Potentially Preventable Readmissions (SNF WS PPR) measure beginning with the FY 2028 program year and FY 2025 performance year.
In a bid to prioritize the achievement of health equity and the reduction of disparities in health outcomes in SNFs, CMS is proposing the adoption of a Health Equity Adjustment in the SNF VBP Program that rewards SNF that perform well, and whose resident population during the applicable performance period includes at least 20% of residents with dual eligibility status. This adjustment would begin with the FY 2027 program year and FY 2025 performance year. CMS is adjusting the scoring methodology to provide bonus points to high-performing facilities that provide care to a higher proportion of duals.
In addition, CMS is proposing to increase the payback percentage policy under the SNF VBP program from current 60% to a level such that the bonuses provided to the high performing, high duals SNFs do not come at the expense of the other SNFs. The estimates for FY 2027 program year is 66%.
The proposed rule also provides additional updates on the validation process being established for the quality measures and standardized assessment data for SNFs. CMS is proposing the addition of the audit portion of the validation process for MDS-based measures beginning with the FY 2027 program year and FY 2025 performance year.
Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com
