Minnesota Efforts to Promote Nursing Home Quality


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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Robert L. Kane, MD

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Minnesota Efforts to Promote Nursing Home Quality

  1. 1. Minnesota Efforts to Promote Nursing Home Quality Robert L. Kane, MD University of Minnesota School of Public Health NASHP Meeting October 15, 2007
  2. 2. Project Team <ul><li>Robert Kane (UM) </li></ul><ul><li>Greg Arling (UI) </li></ul><ul><li>Bob Held (DHS) </li></ul><ul><li>Valerie Cooke (DHS) </li></ul><ul><li>Christine Mueller (UM) </li></ul>
  3. 3. A Variety of Strategies Have Been Tried <ul><li>Pay-for-Performance </li></ul><ul><li>Quality Bonus </li></ul><ul><li>NH Report Cards </li></ul><ul><li>Quality Incentive Payments </li></ul>
  4. 4. Pay-for-Performance <ul><li>Payment based on quality score </li></ul><ul><li>Payment applied to CMI </li></ul><ul><li>NHs tiered by quality score </li></ul><ul><li>Average costs per tier </li></ul><ul><li>NH keeps larger portion or actual costs according to quality </li></ul>
  5. 5. Quality Profile Elements <ul><li>Available Now </li></ul><ul><li>Survey deficiencies </li></ul><ul><li>Staff/resident ratio </li></ul><ul><li>Staff retention </li></ul><ul><li>Use of pool staff </li></ul><ul><li>Quality indicators </li></ul><ul><li>% single rooms </li></ul><ul><li>Quality of Life/Resident Satisfaction </li></ul><ul><li>Under Development </li></ul><ul><li>Family Satisfaction </li></ul><ul><li>Short Stay </li></ul><ul><li>Community Discharge </li></ul><ul><li>Environmental Assessment –ability to support independence, dignity and rehabilitation </li></ul><ul><li>Dementia Care </li></ul>
  6. 6. Quality Score <ul><li>On a 100 point scale, maximum points assigned to each quality measure are: </li></ul><ul><ul><li>Direct Care Hours 10 </li></ul></ul><ul><ul><li>Staff Retention 20 </li></ul></ul><ul><ul><li>Use of Pool Staff 5 </li></ul></ul><ul><ul><li>Quality Indicators from MDS 35 </li></ul></ul><ul><ul><li>Quality of Life/Satisfaction 20 </li></ul></ul><ul><ul><li>Survey Deficiencies 10 </li></ul></ul>
  7. 7. Relation of Case Mix Component + Support Services Cost PPD and Quality Score
  8. 8. Characteristics: <ul><li>Nursing facility specific rates </li></ul><ul><li>Rates are a function of a pre-determined price, quality and actual costs </li></ul><ul><li>Acuity-based rates </li></ul><ul><li>Annually re-based </li></ul><ul><li>Prospective rate system </li></ul><ul><li>Phase-in over 4 year period </li></ul>
  9. 9. Quality Tiers <ul><li>Ten tiers </li></ul><ul><li>Ten point increments </li></ul><ul><li>Tier 1 - lowest quality scores </li></ul><ul><li>Tier 10 – highest </li></ul>
  10. 10. Calculate Target Rates for Operating Components <ul><li>Costs per patient day for each provider are arrayed for each category </li></ul><ul><li>Lowest populated quality tier target rate is 10th percentile of costs </li></ul><ul><li>Highest is 90th percentile of costs </li></ul><ul><li>Adjusted to achieve budget neutrality </li></ul>
  11. 11. Quality Incentive Payment <ul><li>Use quality score to adjust difference between target rate and specific facility cost </li></ul><ul><ul><li>Facilities with costs above or below the target rate receive a portion of the difference, depending on quality score </li></ul></ul><ul><ul><li>The closer the facility’s costs are to their target rate, the higher percentage of the difference the facility is paid </li></ul></ul>
  12. 12. The matrix
  13. 13. Who are the Winners <ul><li>Consumers </li></ul><ul><li>Workers </li></ul><ul><li>Facilities with high quality </li></ul><ul><li>Facilities that are efficient </li></ul><ul><li>Facilities that have better physical plants </li></ul><ul><li>Facilities that have the ability to adapt to a system that demands quality and efficiency </li></ul>
  14. 14. Not passed by legislature <ul><li>Too complicated </li></ul><ul><li>Some constituents lost money </li></ul><ul><li>NH opposition </li></ul><ul><li>No consumer advocacy </li></ul>
  15. 15. Quality Add-on <ul><li>NHs paid an additional percentage of payments based on quality scores </li></ul><ul><li>Year 1: 5 indicators: turnover (15%), retention (25%), pool use (10%), MDH survey (10%) and QIs (40%). </li></ul><ul><li>Could earn up to 2.4% of their operating rate </li></ul><ul><ul><li>set up to be an average 1% quality add-on industry wide. </li></ul></ul><ul><ul><li>Additional 1.3% as COLA. </li></ul></ul><ul><li>Year 2: quality of life (20%) and direct care hours per day(10%), retention (20%), QIs (35%), pool (5%) and MDH survey (10%) </li></ul><ul><li>Could earn up to 0.3% as a quality add-on. </li></ul><ul><ul><li>designed to be .13% on average industry wide. The remaining 1.87% was given as a COLA. </li></ul></ul>
  16. 16. NH Report Cards <ul><li>Information for consumers </li></ul><ul><li>Individualized information </li></ul><ul><li>Based on available data </li></ul>
  17. 17. Components <ul><ul><li>Nursing Hours </li></ul></ul><ul><ul><li>Staff Turnover </li></ul></ul><ul><ul><li>Use of Pool Staff </li></ul></ul><ul><ul><li>Proportion of Single Rooms </li></ul></ul><ul><ul><li>Quality Indicators from MDS </li></ul></ul><ul><ul><li>Survey Deficiencies </li></ul></ul><ul><ul><li>Quality of life </li></ul></ul><ul><ul><ul><li>From survey of a sample of residents in each NH </li></ul></ul></ul>
  18. 18. Report Card Logistics <ul><li>User indicated zip code location and three most important variables </li></ul><ul><li>received information on NHs order by preferences </li></ul><ul><li>QOL, citations most valued </li></ul>
  19. 19. Performance-Incentive Payment Goals <ul><li>Improve the quality of care and quality of life of nursing home residents in a measurable way. </li></ul><ul><li>Deliver good quality care more efficiently </li></ul><ul><li>Rebalance long-term care and make more efficient and effective use of resources. </li></ul>
  20. 20. Quality Incentives- Round 1 <ul><li>$1.2M state share and with fed match and private pay amounts to about $3.5M in incentive payments </li></ul><ul><li>155 applications, 20 projects funded - 1 collaborative of 13 facilities so 32 facilities in total received incentive payments. </li></ul><ul><li>Most incentives 5% of operating rate </li></ul><ul><li>Need to show evaluation plan </li></ul>
  21. 21. Quality Incentives – Round 2 <ul><li>Consortia encouraged </li></ul><ul><li>Evaluation should fit the QIs in use </li></ul><ul><li>Intent to study projects to determine the financial impact to the Medicaid budget. </li></ul><ul><li>$6.7M state share and with fed match and private pay amounts to about $20M in incentive payments </li></ul>
  22. 22. MN 2007 NH Rebasing Law <ul><li>NHs will receive cost payments for care related costs up to 120% of group medians </li></ul><ul><li>6 groups formed from geography and NH type </li></ul><ul><li>8 year phase in with hold harmless </li></ul><ul><li>Then, care related payments based on limits from 105% to 125% based on quality scores </li></ul>
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