Skilled Nursing Facility Value-Based Purchasing Program

 The Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)

What is the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)?


The SNF VBP Program focuses on better outcomes and rewards skilled nursing facilities with incentive payments for the quality of care they give to people with Medicare, in particular reducing hospital readmissions. The SNF VBP Program moves CMS toward paying providers based on the quality, rather than the quantity, of care they give patients.

When will SNFs receive SNF VBP incentive payments?

SNFs will receive incentive payments, on an annual basis, at the start of each new fiscal year. The first time SNFs will receive incentive payments is on October 1, 2018, which is the start of fiscal year (FY) 2019. These incentive payment amounts are based on SNFs’ performance on the Program’s hospital readmissions measure during performance period, January 1, 2017, through December 31, 2017, and the baseline period, January 1, 2015 through December 31, 2015.

How will the program work?


A healthcare law called the 2014 Protecting Access to Medicare Act (PAMA) started the SNF VBP Program. Every year, CMS publishes a regulation that outlines what is required for the SNF VBP program. The most recent regulation can be found here. Under the SNF VBP Program:

SNFs will be evaluated on a hospital readmissions measure after a patient is discharged and has a hospital admission within 30 days.

SNFs will receive a performance score based on their individual performance and a performance score based on their comparison to other SNFs in the country.
SNFs will receive confidential quarterly and annual reports about their performance on the program’s measure.
SNFs will receive payment incentives based on their performance.
Since October 2016, CMS has been providing SNFs with quarterly confidential feedback reports containing information regarding their performance on the readmission measure specified for the SNF VBP Program. These quarterly reports are disseminated to SNFs via the Quality Improvement and Evaluation System (QIES)/Certification and Survey Provider Enhanced Reports (CASPER) system.

Public reporting of SNF performance will occur on the Nursing Home Compare website. In October 2017, performance data from the baseline year of the SNF VBP program was made available here. This includes SNFs’ performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015. Performance period data from CY 2017 will also be available on the Nursing Home Compare website. As a result of Phase Two review and corrections, an updated ranking file can be found here.

Performance data from the baseline year of the SNF VBP program are now available here. This includes SNFs’ performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015.

What types of SNFs are included in the SNF VBP Program?

All SNFs paid under the SNF Prospective Payment System (PPS) are included in the SNF VBP Program and are eligible for payment incentives based on their performance on the program’s measure. The types of SNFs in the Program include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities.

What measures will be used in the SNF VBP Program?
Skilled Nursing Facility 30-Day All-Cause Readmission Measure

The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) is used in the SNF VBP Program. The SNFRM estimates the risk-standardized rate of unplanned readmissions within 30 days for:

People with fee-for-service Medicare who were inpatients at PPS, critical access, or psychiatric hospitals.
Any cause or condition.
We finalized the SNFRM in the SNF PPS Final Rule for FY 2016. This fact sheet contains important information you should know about SNFRM.

This technical report and technical report supplement provide additional detail on the SNFRM.

Additional reliability testing for the SNFRM can be found in this memo.

What are the baseline and performance periods affecting FY 2019 payment for the SNF VBP Program?

For each year that the SNF VBP Program affects payment determination, SNFs are scored based on their performance during the applicable baseline period and performance period.

The baseline period affecting payment determination in FY 2019 is calendar year (CY) 2015 (January 1, 2015 through December 31, 2015).

The performance period affecting payment determination in FY 2019 is CY 2017 (January 1, 2017 through December 31, 2017).

How will SNFs' performance be scored under the SNF VBP Program?

SNFs will earn a SNF VBP Performance score (0 to 100) and ranking which is calculated based on that SNF’s performance on the measure specified for the Program during the performance period and the baseline period. The SNF VBP performance score is equal to the higher of the achievement score and improvement score.

SNFs will be awarded points for achievement on a 0-100-point scale and improvement on a 0-90-point scale, based on how their performance compares to national benchmarks and thresholds.
For more in-depth information on SNF VBP performance scoring, we refer you to the FY 2018 SNF PPS final rule and the FY 2019 SNF PPS final rule.

This report provides the analyses that were performed when proposing and finalizing the Program’s exchange function used to translate SNF performance scores into incentive payments.




**Please note that this mailbox is not secured to receive protected health information or patient-level data with direct identifiers.**


Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program: Frequently Asked Questions

What is the Skilled Nursing Facility Value-Based Purchasing Program?


The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program awards incentive payments to SNFs based on their performance on the Program’s measure of readmissions. SNF VBP payment incentives will be included on Medicare Part A claims paid under the SNF Prospective Payment System (PPS) as a single line item on each claim paid durinf the Fiscal Year (FY); no separate payment will be made. SNF VBP incentive payments do not any other type of claims (such as Medicare Advantage claims, Medicaid claims, or Medicaid managed claims). Beginning on October 1, 2018, which is the start of FY 2019, the Program will begin awarding incentive payments to SNFs based on performance on the SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510).

What SNFs are included in the SNF VBP Program?
All SNFs paid under the SNF PPS will receive incentive payments under the SNF VBP Program as directed by the Social Security Act. The types of SNFs that are paid under the SNF PPS include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities. The SNF VBP Program is not optional and does not require any action by SNFs to participate.

What measure is currently being used in the SNF VBP Program?


The SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510) is the messure currently used in the Program. The SNFRM evaluates the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions of Medicare beneficiaries. This measure assesses SNF patients hospital readmissions within 30 days of being discharged from a prior hospital stay.


What is the difference between a planned readmission and an unplanned readmission?
The SNFRM uses a readmission algorithm to identify planned readmisions. When the SNFRM measure was developed, a specific list of procedures or admitting diagnoses were identfied as being a planned readmission, based on input from technical experts. If a readmission does not meet the established criteria for a planned readmission according to this algorithm, it wil be considered an unplanned readmission. In addition, if a planned procedure occurs in combination with a diagnosis that disqualifies a readmission from being considered planned, the readmission with be considered unplanned.

When does the SNFRM 30-day readmissions period begin and end?
The SNFRM's 30-day readmission perion during which an unplanned readmission may be counted, referred to as the risk window, begins when a patient is discharged from an inpatient hospitalization and is subsequently admitted to a SNF within one day. The risk window ends 30 days from its start or when a patient is readmitted to a hospital, whichenve occurs first. For example, if a patient is discharged from a hospital to a SNF on 9/1/17, then readmitted to the hospital on 9/10/17, the 30-days risk window started on 9/1/17 and ended on 9/10/17 when the patient is readmitted to the hospital. A new 30-day risk window begin if the patient is subsequently discharged from the hospital and admitted back to the SNF.

Does the SNFRM count multiple hospital readmissions during a single 30-day readmission risk
window?


No. The SNFRM only assesses whether there is an unplanned readmission during a single 30-day readmission risk window. In the case of multiple readmissions, the 30-day risk window ends after the first readmission.

Are the measures in the SNF VBP Program the same as the measures in the SNF Quality Reporting Program (QRP) and on the Nursing Home Compare website?

No. The SNF VBP Program uses the SNFRM, which calculates the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions within 30-days of a SNF patient’s discharge from a prior hospital stay. Congress directed CMS in statute to use the SNFRM in the SNF VBP program.

How are performance scores calculated?
SNF VBP performance scores are calculated by first inverting the risk-standardized readmission rate (RSRR), so that higher rates are equal to better performance. Next, the SNF’s RSRR is compared to the performance standards published in each final rule and awarded between 0 and 100 points. SNFs are scored on improvement, compared to their baseline performance
rate, and achievement, compared to the national performance rate during the baseline period. The higher of the improvement and achievement scores will be a SNF’s performance score.

Will SNFs be able to calculate their achievement and improvement points?
A SNF can calculate its achievement and improvement points using the formulas provided in
the FY 2017 final rule with the following data:
• The SNF’s performance period rate on the SNFRM
• The SNF’s baseline period rate on the SNFRM
• The applicable achievement threshold and benchmark for the Program year
The higher of a SNF’s achievement and improvement scores will equal their performance score.

How are incentive payments determined?


Each SNF’s incentive payment will depend on its performance score, which will be placed in the logistic exchange function to determine the corresponding incentive multiplier. The highest scoring facilities will receive the highest payment incentives, and the lowest scoring facilities will receive the lowest payment incentives, as required by statute. In 2017, CMS notified SNFs and stakeholders in the Federal Register via rulemaking that we would redistribute 60 percent of withheld funds to SNFs based on their performance score. After calculation of performance scores for all SNFs, the following steps will be used to calculate incentive payments:

1. Estimate the 60 percent of Medicare fee-for-service payments to SNFs to be redistributed to SNFs (the “incentive pool”).

2. Assign payment incentive multipliers to each SNF VBP Performance Score using the logistic exchange function so that the total amount of incentive payments matches the 60 percent incentive pool.

How will SNFs be notified of their performance in the Program?


CMS provides confidential feedback reports to SNFs on a quarterly and annual basis. Quarterly supplemental workbooks containing patient-level data are provided for quality improvement purposes. SNFs will also receive two annual reports; one report containing a full performance period and their measure score, and the second report containing the SNF performance score, rank, and payment incentive to be applied to Medicare claims in the upcoming fiscal year. SNFs can access all reports through Quality Improvement Evaluation System (QIES) Certification and Survey Provider Enhanced Reporting (CASPER) system.

What is Phase One of the Review and Corrections process?

Phase One is an opportunity for SNFs to review and submit corrections to the facility-level information that will be made publicly available. Requests will only be accepted until March 31 following delivery of the confidential report containing facility-level information and must be submitted to the SNFVBPinquiries@cms.hhs.gov mailbox. CMS will review the request and notify the SNF of any changes that may result.

SNFs will need the following information to submit a Phase One Review and Corrections request to the SNFVBPinquiries@cms.hhs.gov mailbox:

1. The SNF’s CMS Certification Number (CCN)
2. The SNF’s Name
3. The correction requested and the reason for requesting the correction. SNFs must also submit evidence, if available, supporting the request.

CMS advises SNFs not to send protected health information (PHI) or patient-level data with direct identifiers with review and corrections requests; the SNF VBP mailbox is not secured to receive this information. For specific questions, SNFs may use the identification number in their workbook as this is a randomly assigned number and not considered PHI.

How can I correct an error in my patient-level data?

If a SNF identifies an error in information not covered under Phase One or Phase Two of the SNF VBP Review and Corrections process, CMS advises SNFs to follow the established claims process to update the information or contact the readmitting hospital to make corrections.

CMS encourages SNFs to work with hospitals as a part of its care coordination efforts to make any corrections to claims information and submit to their Medicare Administrative Contractor (MAC) in a timely manner. If an error is identified that may result in a correction to SNF VBP measure rates, the SNF must demonstrate that claims have been corrected and reprocessed by the MAC in relevant fields impacting SNF VBP performance, prior to CMS considering recalculation of SNF VBP measure data before the Phase One Review and Corrections deadline.

What is Phase Two of the Review and Corrections process?

Phase Two is an opportunity for SNFs to review and submit correction requests to their performance scores and rank only, found in the annual performance score report. CMS will not consider any patient level information or RSRR measure rate correction requests during Phase Two of the Review and Corrections process, since these correction requests are classified as being out of scope for review. Phase Two requests will only be accepted for 30 calendar days following the annual performance score reports being made available. A SNF must submit correction requests to the SNFVBPinquiries@cms.hhs.gov mailbox. CMS will review the request and notify the SNF of any changes that may result.

SNFs will need the following information to submit a Phase Two Review and Corrections request to the SNFVBPinquiries@cms.hhs.gov mailbox:
1. The SNF’s CMS Certification Number (CCN)
2. The SNF’s Name
3. The correction requested and the reason for requesting the correction. SNFs must also submit evidence, if available, supporting the request.

CMS advises SNFs not to send protected health information or patient-level data with direct identifiers with review and corrections requests since the SNF VBP mailbox is not secured to receive this information.

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