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Healthcare  360Evaluating  Your  Operations

From  Every  Angle

Presented  by:

Veronica  M.  BencivengaDirector

HMM  Consulting,  a  Division  of  HMM,  CPA’s  LLPOffice:  (631)  265-­6289Mobile:  (631)  880-­2882

vbencivenga@horanmm.comwww.horanmm.com

Intercounty  Health  Facilities  Association

December  1,  2016

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AGENDA

þ Speaking  “DATA”þ Evaluating  Your  Technology  Planþ External  Evaluation  -­ Current  Data  Initiatives

þ Industry  Developments  and  Trends

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Speaking  “DATA”

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• Medicaid  Managed  Care• Value  Based  Purchasing• Quality  Pools  (NHQI)• Bundling• Shared  Savings• DSRIPPayment  Reform    

• Patient  Centered  Care  Coordination• Clinical  Decision  Support• Early  Detection  of  Decline• Transitions  in  Care

Care  Delivery

• CMS  Five-­Star  • Nursing  Home  Quality  Measures• Payment  Analytics  (Pepper)

• Rehospitalizations

Performance  Monitoring  

Data  Landscape  Today

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Your  data  tells  people  about  you.    Managing  your  data  story  is  critical.    

• Five  Star  Rating• Quality  Measures• Length  of  Stay• Staffing/Turnover• Rehospitalization Rates• Patient  Satisfaction• Cost  Control

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Managing  Your  Data  Story

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Veronica’s  Data  Story

This  is  ME!• 10 -­ Years  at  HMM• 23 – Years  of  experience  in  

nursing  home  industry

• 132 -­ Client  engagements• 117 -­ Speaking  engagements• 20 – Average  hours  spent  

preparing  each  speaking  engagement

• 293 -­ Connections  on  LinkedIn  (Narrow  Network  J)

This  is  ME!• 18 -­ Years  happily  married• 3 -­ Children  (Michael-­13,    

Jack-­12,  Natalie-­10)

• 23 – Level  on  Pokemon Go  (Team  Valor-­Red)

• 260 – Hours  volunteered  in  2015  for  school,  church  or  community  activities

• 90,000 – Photos  stored  on  my  home  server

• 2 – Digital  SLR  cameras

4Hours  of  

Sleep

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Clinical  and  Financial  are  the  

SAME DATAQuality  =  Payment

Not  getting  paid  for  the  service,  getting  paid  for  the  outcome  

Clinical  and  Financial  are  ONE

The  new  language  of  healthcare• Metrics• Numerator• Denominator• Data  elements• Cut  points• Quintile• Statistics• Root  cause                                                                analysis 8

Quality  by  the  Numbers

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Quality  by  the  Numbers

Hospital Readmissions

Finance  speaks  DATA,  hence  can  help  with  learning  to  speak  QUALITY• Multi  purpose  data• Conditional  data  • Overlapping  data• Data  from  many  angles  • Different  timeframes • CMS  Quality  Measures

• SNF  Value  Based  Purchasing  (VBP)

• SNF  Quality  Reporting  Program  (SNF  QRP)

You  won’t  get  the  right  answer  if  you  don’t  ask  the  right  question.• Inclusions  and  Exclusions• Parameters

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Understanding  the  Reports

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Clinical  and  Financial  are  the  

SAME DATAQuality  =  Payment

Not  getting  paid  for  the  service,  getting  paid  for  the  outcome  

Clinical  and  Financial  are  ONE

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Information  at  risk  when  clinical  and  financial  software  not              bi-­directionally  integrated  or  using  a  single  database

• Which  system's  data  will  you  rely  on?    • Which  do  you  give  to  the  OMIG,  RAC,  other  auditors?    • How  do  you  avoid  data  DRIFT  

Information  at  Risk

Demographic Name,  DOB,  Social,  Medical  Record  #

Financial Payers  -­‐ different  payers  have  different  requirements  Authorizations  – All staff  need  access  to  this

Census Usually  admission  interface  only,  discharges  have  to  be  done  independently  in  both  systems

Contacts Emergency  and  ordering,  notes  by  social  workers,  etc.

Level  of  Care Clinical  determination,  changes  with  condition  of  patient

MDS Missing,  corrections,  in-­‐activations

Diagnosis Increasing  importance  on  accuracy  and  maintenance  for  payment  bundlesand  staffing  (PBJ)

Analytics/Stats Which  system's  data  will  you  rely  on?    Discrepancies  will  need  to  be  investigated

Data  at  Risk

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How  do  we  get  there?• Evaluate  all  information  streams• Identify  barriers• Capture  data  at  the  source  whenever  possible

• Leverage  technology

Real-­time  Data  

Examples:• Census• Insurance  verification,  Eligibility• Costing  of  a  potential  patient• Actual  staffing

You  can’t  keep  doing  things  the  same  old  way• Make  purposeful  changes• Educate– Leadership– Staff– Families– Business  Partners,  Vendors

• Manage  Expectations

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How  do  you  change  and  entire  organization?

Old New

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Evaluating  YourTechnology  Plan

• Every  company  is  a  technology  company  – Fortune  500  CEO  Survey  -­ Rapid  pace  of  technological  change  is  the  single  biggest  challenge  facing  their  companies

– Endless  streams  of  data  and  growing  intelligentalgorithms have  the  potential  to  transform  almost  every  aspect  of  nearly  every  business

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It’s  All  Connected

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• TODAY  Every  company  is  a  technology  company  capturing  and  sharing  data– Pizzerias,  law  enforcement,  clothing  companies,  MAPMyRUN,  religious  organizations…  and  yes  SNF’s)

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It’s  All  Connected

• Success  will  be  defined  by  your  ability  to  capture,  manage  interpret  and  share data    

• Software  and  hardware  are  your  foundation• Do  you  have  a  Technology  Plan?• Have  you  really looked  at  your  capital  budget  with  today’s  objectives  in  mind?

• Are  you  specifically  budgeting  for:  – Hardware  upgrades  and  replacement– Web  enabled  medical  devices  that  transfer  data  to  EMR– Advancing  adoption  of  your  EMR  through  advanced  training,  new  features

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Evaluating  your  Technology  Plan

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• Do  you  understand  your  EMR  vendor’s  product  road  map?

• Do  your  software  vendors  have  the  resources  to  not  only  keep  up  with  the  changes,  but  anticipate  what’s  coming  next?

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Evaluating  your  Technology  Plan

EMR  is  a  series  of  investments  whose  benefits  accumulate  over  time

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EMR  Adoption  – Use  More,  Get  More  ROI

• You  CAN’T do  it  all  at  once

• Make  a  plan  to  expand  EMR  use  including:– Impact  on  workflows– Training  time  and  training  resources

– Hardware

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Schedule  an  “Optimization  Session”• Review  software  configuration• Identify  re-­training  opportunities• Identify  features  you  are  paying  for  but  not  using

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EMR  Adoption  – Use  More,  Get  More  ROI

TIP:  For  VBP  and  Receivables  management,  most  SNF’s  need  to  reconfigure  their:• Census  workflow• Payor set-­ups• Levels  of  care

• Integrated  4.0  Interact  tools• Dashboards  and  Notifications  – Manage  by  Exception

• Analytics– Report  on  any  combination  of  measures• All,  Survey,  Nursing  Home  Compare,  Five-­Star

– Results  for  the  QM  Numerator,  Denominator  and  Percentage

– Compare  to  State  and  National  Averages

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Value  Added  EMR  Features  – Decision  Support

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Dashboards  allow  you  to  monitor  clinical  and  financial  metrics  in  real  time.

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A  picture  is  worth  a  1,000  words

Decision  Support  – Dashboards

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Alerts  and  Warnings  draw  attention  to  potential  issues  that  are  time  sensitive

BRINGS  THE  DATA  TO  YOU• Values  out  of  acceptable  parameters

• No  bowel  movement  in  3  days• Temp  out  of  range

• Unusual  patterns  • Duplicate  medications• Decreased  inputs  and  outputs

Decision  Support  – Managing  by  Exception

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• Availability• Mobility  • Displays• Larger,  portable  or  multiple

• Connected  Devices  – Nurse  Rosie  Connect

• Telemonitoring

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Hardware  and  Devices  – The  Right  Fit

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External  Evaluation-­Current  Data  

Initiatives

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Federal

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State

Payment Quality

Current  Quality  and  Payment  Initiatives

• Medicare  Advantage• Bundled  Payment  (Episodes)

• Bundled  Payments  for  Care  Improvement  (BPCI)

• Comprehensive  Care  for  Joint  Replacement  (CJR)

• Mandatory  Effective  April  1,  2016

• SNF  Value  Based  Purchasing  • 30-­Day  All-­Cause  Readmission  

Measure  (SNFRM)• NEW:  Effective  10/1/2016  

12/31/2016  for  Fiscal  Year  2018

• Five-­Star  Quality  Rating  System• Nursing  Home  Compare

• 5  new  measures  added  July  2016

• Staffing  Data  Submission  PBJ    • NEW:  Effective  7/1/2016

• SNF  Quality  Reporting  Program  (SNF  QRP)  

• NEW:  Effective  10/1/2016  12/31/2016  for  Fiscal  Year  2018

• Mandatory  Medicaid  Managed  Care  for  new  LTC  patients

• Roll  out  began  2/12015

• Delivery  System  Reform  Incentive  Payment  (DSRIP)• VBP  Road  Map

• Nursing  Home  Quality  Initiative  (NHQI)

• Effective  2013  with  ongoing  methodology  changes  

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• Improving  Medicare  Post  Acute  Transformation  Act  2014• Purpose  is  to  compare  outcomes  across  all  four  post  acute  care  settings  and  create  longitudinal  data• Skilled  Nursing  Facilities• Home  Health  Agencies• Inpatient  Rehabilitation  Facilities• Long  Term  Care  Hospitals

• Implements  collection  of  standardized  data using  assessments  currently  required  (SNF=MDS,  HHA=Oasis,  etc.)

• Requires  development  and  implementation  of  “cross  setting”  Quality  Measures  based  on  standardized  data

• Data  Collection  10/1/2016-­12/31/2016  will  be  used  for  rate  setting  FY  2018

IMPACT  Act  of  2014

For  the  first  time  since  PPS  started  in  1998  

your  Medicare  rates  will  be different  from  your  neighbor!

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Behavior  Management• Clinically  nuanced  insurance  coverage

– 2017-­2022  CMS  will  test  Value-­Based  Insurance  Design  (VBID)  in  Medicare  Advantage  and  measure  whether  structuring  patient  cost  sharing  and  other  health  plan  design  elements  encourages  enrollees  to  use  health  care  services  in  a  way  that  improved  their  health  and  reduces  costs.

• Health  score  (like  a  credit  score)

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What’s  Next?

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IndustryDevelopmentsand  Trends

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I  believe  this  is  a  result  of  a  disconnect  between  program  mandates  such  as…mandating  payment  rates  while  failing  to  provide  sufficient  revenue,  constant  regulatory  changes  that  add  additional  administrative  burdens  and  otherwise  failing  to  recognize  operational  challenges  these  changes  impose

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Sign  of  Things  to  Come

“

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"There  are  problems  with  the  state  not  reimbursing  plans  to  adequately  reflect  when  a  plan  has  a  large  number  of  very  high  cost  or  high  utilizing  patients,"  Gottfried  said.  "And  GuildNet is  caught  in  that  squeeze  as  a  lot  of  plans  and  providers  are."

~  Alan  Morse,  CEO  of  GuildNet

SNF’s  struggle  to  quantify  the  managed  care  cashflow crisis  due  to:

• Differences  in  recordkeeping• Where/how  managed  care  days  are  combined,  level  of  detail

• Differences  in  staff  skill  levels• Differing  contract  terms  for  same  plan  on  a  provider  by  provider  basis

Quantifying  the  “Managed  Care  Problem”

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Questions?

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Thank  You

Veronica  M.  BencivengaOffice  (631)  265-­6289Mobile  (631)  880-­2882VBencivenga@horanmm.comwww.horanmm.com

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HMM  ConsultingA  division  of  HMM,  CPAs  LLP

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CMS  Quality  Measures  -­ 33• 30  Main  measures

• 11  Short  Stay• 19  Long  Stay

• 3  additional  “Surveyor  Quality  Measures”

Surveyor  Measures  -­ 17• Available  to  State  surveyors  and  SNF’s  through  

CASPER• Subset-­17  of  the  33  measures

Nursing  Home  Compare  -­ 18• Publically  Available• Compares  SNF  to  State  and  National  averages• Subset-­18  of  the  30  main  measures

• 5  Short  Stay• 13  Long  Stay

CMS  Five-­Star  Rating  -­ 11• 3  components

• Quality  Measures  – Subset  11  of  the  18  in  Nursing  Home  Compare• 3  Short  Stay• 8  Long  Stay  

• Health  Inspection• Staffing  

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#3  – SNF  QRP• 30  Day  all-­cause  re-­hospitalizations

• New  effective  10/1/2016• IMPACT  Act  2014• Claims  Based

Hospital  Readmissions

#1  -­ Hospital• Hospital  Readmissions Reduction  Program

• Reported  through  SPARCS (indirect)

#2  – Five  Star• Percent  of  short  stay  residents  who  were  re-­hospitalized  after  a  nursing  home  admission• New  Quality  Measure  effective  7/27/2016

• Claims  Based

#4  – SNF  VBP• 30  Day  all-­cause  re-­hospitalizations

• Protecting  Access  to  Medicare  Act  of  2014  (PAMA)  

• Claims  Based• Year  1  – SNF  Readmisson Measure  (SNFRM)

• Year  2  – SNF  Potentially  Preventable  Readmission  Measure  (SNFPPR)