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State Trends in Nursing Home Pay for Performance. Washington Health Care Association Annual Convention 2010 Spokane, WA. Leslie Hendrickson Hendrickson Development Goals Depends on Point of View.

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State Trends in Nursing Home Pay for Performance

Washington Health Care Association

Annual Convention 2010 Spokane, WA.

Leslie Hendrickson

Hendrickson Development

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Goals Depends on Point of View

  • Individual -- Want to learn something interesting about Pay for Performance.

  • Building -- Want to understand what changes I should encourage in my building.

  • State -- Identify issues to consider in encouraging state to adopt a P4P program. State organizing and lobbying effort.

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Takeaways Individual Level

  • Fifteen states, eight stable ones, three are project based.

  • Culture change hard to get at in uniform way. Easier measures are CMS MDS quality of care measures, survey results, staffing data and occupancy from cost reports.

  • Medicare may or may not use pay for performance. Will use it, if use of P4P reduces hospital expenditures.

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Takeaways Building Level

  • Staff retention key variable in all states.

  • Medicaid occupancy frequently used.

  • Emphasis on quality of life, culture change, self-direction and their reporting is increasing.

  • Colorado using very interesting measures:

    dining, bathing, consistent staffing, staff input in care planning, community involvement and volunteers, neighborhoods.

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Takeaways State Level

  • 2008 Task Force Recommendations

  • How P4P is funded is major determinant of success. If it comes out of current rate don’t bother, e.g. Ohio difficulties. If it is new $ on top of current rate, then worthwhile to do. See 2008 Tim Graves Texas comments.

  • Project based approaches Minnesota, Vermont, Utah good way to go.

  • Voluntary or collect data on all homes.

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CMS Value Based Purchasing

  • A three-year demonstration beginning in summer 2009.

  • As of March 1, 2010 Demonstration states: Arizona 38 homes, New York 78 homes, and Wisconsin 61 homes.

  • Nursing homes within these states were solicited to participate in the demonstration.

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CMS Value Based Purchasing

  • Aim 1: To examine the organizational characteristics and patient demographic and clinical characteristics of treatment and control group nursing homes.

  • Aim 2: To analyze the organizational and patient demographic and clinical characteristics of nursing homes eligible for performance payments, the amount of performance payments received, and subsequent impacts on nursing homes’ quality improvement and financial status.

  • Aim 3: To examine the impact of the demonstration on incidence of avoidable hospitalization and quality of care levels in participating nursing homes.

  • Aim 4: To assess the impact of the demonstration on nursing home management, organization, delivery of services and financial status.

  • Aim 5: To assess the impact of the demonstration, Medicare and Medicaid program expenditures and savings, and evaluate the cost-effectiveness of the demonstration.

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CMS Evaluation Activities

Longitudinal Nursing Home Interviews

Evaluation Findings: Structure, Process, Cost and Quality Outcomes

Nursing Home Site Visits



Merged Data Set Analysis (MDS, OSCAR, Medicare/Medicaid Claims, etc.)

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How CMS will Measure Cost Effectiveness

  • CMS will compare risk-adjusted Medicare Part A and B expenditures between the demonstration and comparison groups in each State. CMS will calculate the difference between the demonstration group’s actual Medicare expenditures and the “target” expenditures (i.e., what we would expect Medicare expenditures for beneficiaries in demonstration homes to be in the absence of the demonstration).

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How CMS will Measure Cost Effectiveness #2

  • The target expenditures will be calculated using base year expenditures for the demonstration group and the rate of change in expenditures for the comparison group since the base year.

  • Stingy savings, basically must be in the 80th percentile and above to qualify for payment from the state savings pool.

  • Unlike state efforts this is not culture change.

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New Federal Requirements in H.R. 3590

  • H.R. 3590 can get text at

  • Nursing Home Transparency Title I Part 1 Sections 6101 through 6107.

  • Sec. 6101. Required disclosure of ownership and additional disclosable parties information.

  • Sec. 6102. Accountability requirements for skilled nursing facilities and nursing facilities.

  • Sec. 6103. Nursing home compare Medicare website.

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New Federal Requirements in H.R. 3590 #2

  • Sec. 6104. Reporting of expenditures.

  • Sec. 6105. Standardized complaint form.

  • Sec. 6106. Ensuring staffing accountability.

  • Sec. 6107. GAO study and report on Five-Star Quality Rating System.

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Where is Medicare Going? Title III Section 3006 of H.R. 3590

  • Next step P4P step is in sight.

  • Requires Federal Health and Human Services to develop a pay for performance plan.

  • Report plan to Congress by October 1, 2011.

  • “The ongoing development, selection, and modification to the extent feasible and practicable, of all dimensions of quality and efficiency in skilled nursing facilities.”

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Section 6102 of H.R. 3590

  • Not later than December 31, 2011, the Secretary shall establish and implement a quality assurance and performance improvement program shall establish standards relating to quality assurance and performance improvement with respect to facilities and provide technical assistance to facilities on the development of best practices in order to meet such standards.

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Medicaid and Pay for Performance

  • Best stats are from Kuhmerker 2007 Commonwealth Fund study

  • 50% of states used P4P, 85% will by 2012.

  • 70% of uses are in managed care and primary care case management (PCCM)

  • Used in pay for participation in health information technology (HIT) programs

  • Unlike CMS, state focus is often on improving quality, not reducing cost

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Pay for Performance Themes

  • Staffing

    • Retention, Turnover, and Consistency

  • Quality of Care

    • Survey Data

    • Nursing Home Compare Data

  • Culture Change

  • Medicaid Occupancy

  • Surveys of staff, residents and families

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Summary CommentsRoughly Fifteen States

  • Arizona, funding on hold

  • California largest P4P in country but doesn’t know it. (labor driven operating allocation)

  • Colorado, stable, new $

  • Georgia, stable, new $

  • Iowa- stable, $ in base

  • Kansas stable, new $

  • Maryland, supposed to be new $, but isn’t, being phased in.

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Summary CommentsRoughly Fifteen States # 2

  • Massachusetts in limbo now,

  • Minnesota, stable, $ in base, project based

  • Ohio, not new $, cap limits receipt of incentive

  • Oklahoma, stable

  • Texas, out for bid, 72,000 interviews required

  • Utah stable, two programs one reimburses costs, other is project based

  • Vermont stable, phased in, project based

  • Virginia – discussed in 2007, dead now

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Colorado 2010 P4P Application

  • Really interesting. Well worth looking at


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2009 P4P Studies

  • 2009 State of Colorado Nursing Facility Pay-for-Performance Application Review (For Applications Submitted 1/31/09) at

  • Spring 2009 Pay-for-Performance in Nursing Homes HCFA article at

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2009 P4P Studies Slide #3

  • 2009 Oklahoma Focus On Excellence Independent Evaluation Easiest way to get this is to Google it. Hard to find on Oklahoma and Pacific Health Group site.

  • 2009 article in Medical Care Review “State Adoption of Nursing Home Pay-for-Performance”. Ask Rachel Werner lead author

    for copy at

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2008 P4P Studies #1

  • Bailit 2008 study of P4P for TX at

  • Testimony of Tim Graves on Behalf of The Texas Health Care Association House Human Services Committee May 1, 2008 at

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Voluntary or Mandatory





Ohio –calculated for everybody

  • Kansas

  • Oklahoma-survey part is voluntary

  • Minnesota

  • Colorado

  • Utah

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Three States use Project Funding

  • Vermont’s Gold Star Program

  • Minnesota’s

  • Utah

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Vermont Gold Star Employer Improvement Program

  • Homes get Gold Stars

  • The best practices were identified in seven different areas: staff recruitment, orientation, staffing levels and work hours, professional development and advancement, supervision training and practices, team approaches and staff recognition and support. Uses workbook with application instruction.

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Vermont Gold Star Employer Improvement Program Slide #2

  • To win a Gold Star, nursing homes must conduct a self-assessment, select a best practice area and develop a work plan. After one year, a council review team reviews the nursing facility’s progress through site visits and telephone interviews. The council awards Gold Star Employer Recognition based on achievement of designated goals or achievement of unanticipated goals that have measurable quality outcome improvements.

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Vermont Quality Incentive Awards#3

  • Five of the state’s forty homes can get award of up to $25,000 each year.

  • 1. The most recent health survey report resulted in a score of five or less, no deficiency with a scope and severity greater than AD@ level, with no more than two AD@ level deficiencies in the general categories of Quality of Care, Quality of Life, or Resident Rights.

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Vermont Quality Incentive Awards #4

  • 2. No substantiated complaints in previous 12 months related to quality of care, quality of life, or residents= rights.

  • 3. Designated Gold Star Provider.

  • 4. Resident satisfaction survey results above the statewide average

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Minnesota Performance-based Incentive Payments

  • Each Fall the State issues an RFP. Homes can get up to a 5% increase in per diem.

  • Improve the quality of care and quality of life in a measurable way.

  • Deliver good quality care more efficiently.

  • Rebalance long-term care and make more efficient and effective use of resources.

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Minnesota Slide Quality Add-on Program

Minnesota had quality “add-ons” in 2006 and 2007 which made payments based on 24 risk- adjusted quality indicators, for example:

  • Prevalence of Indwelling Catheters

  • Prevalence of Urinary Tract Infection

  • Prevalence of Infections

  • Prevalence of Residents who Have Fallen

  • Prevalence of Burns, Skin Tears or Cuts

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Minnesota Quality Add-on Program #2

  • Quality Indicators were complicated used risk adjustments/weights. Four other measures.

  • Direct care staff turnover;

  • Direct care staff retention;

  • Temporary staff usage; and

  • State inspection findings.

  • In 2007 did resident quality of life surveys.

  • Were not funded after 2007. It was a choice of funding the Add Ons or funding the COLA.

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Utah Quality Incentives

  • $1,000,000 paid out of provider tax.

  • If you spend the money you get some back.

  • In 2010 can get additional funds for nine costs: for example, nurse call systems, patient lift systems, electronic records, HVAC, van and van equipment, resident enhancing activities, dining improvements.


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  • Arizona has 134 licensed nursing homes contracted with the AHCCCS program.

  • Pay $50,000 to the top 40% based on one or two performance measures such as pressure ulcers or use of restraints.

  • Total $2.7 million plus $500,000 additional administrative costs--$3.2 million.

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GeorgiaNursing Home Quality Initiative

  • First Phase

  • Nursing Home Quality Initiative in 2003. Training needs identified and paid for from Civil Monetary Penalties (CMP).

  • Next phase started in 2007.

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Georgia’s Quality Incentive Rate System

  • % of high risk long-stay residents pressure sores;

  • % of long-stay residents physically restrained;

  • % of long-stay residents moderate to severe pain;

  • % of short-stay residents moderate to severe pain;

  • % of residents who received influenza vaccine; and

  • % of low risk long-stay residents pressure sores.

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Georgia’s Quality Incentive Rate System #2

  • Exceeding the threshold of 85 percent or higher of “good” or “excellent” ratings on the family satisfaction question “would you recommend this facility?”

  • Participation in the employee satisfaction survey.

  • Above the state average on either RN/LPN stability or certified nursing assistant stability.

  • In 2007, 78% of homes received payments

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IowaSignificant Change in 2009

  • Added Culture Change as reported in “self certification” form showing measures of Person Directed Care.

    • Added three Nationally Reported Quality

      Measures of quality of care:

    • High-Risk Pressure Ulcer

    • Physical Restraints

    • Chronic Care Pain

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Iowa Nursing Facility Pay-for-Performance Program

  • Quality of life.

    • Person-Directed Care, Resident Satisfaction

  • Quality of care.

    • Survey, Staffing, Nationally Reported Quality Measures

    • Access. Efficiency.

  • Most providers are only eligible for 1-3% increase. It is hard to get the full 5%. $1.40 a day to $1.50 a day is average add on that homes get.

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Kansas Changes in 2009

  • Deemphasized focus on efficiency

  • Added culture change but doesn’t pay much for it

  • Eliminated

    • Operating expenses

    • Staff retention but still keeps heavy emphasis on number of staff per se and staff turnover

    • Total occupancy

    • Survey outcomes now used as “gate keeper” rather than measure

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  • Initiated by the state

  • Is on hold because of budget problems

  • The last published document on Massachusetts P4P was the MassHealth Nursing Facility Bulletin 129 December 2008.


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Ohio Quality Incentive Program

  • Deficiency free on the most survey results.

  • Resident and family satisfaction surveys are above the statewide average.

  • Number of hours nurses are employed is above the statewide average;

  • Employee retention rate is above the average

  • Occupancy rate, Medicaid utilization and case mix are above the statewide average.

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Ohio 2009 Results and Context #3

  • 3,409 total points divided into amount of money allocated for P4P came out to .80 per day per point.

  • P4P not paid for out of provider tax although Ohio has a provider tax.

  • State in multi-year transition from cost-based reimbursement to price-based reimbursement with rate reductions.

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OklahomaFocus on Excellence

  • Well documented effort because of Pacific Health Group study.

  • Focus on Excellence has two components – an incentive payment methodology and a five star rating system published on a website.

  • Significant disadvantage is that money for FOE comes out of existing reimbursement and is not new dollars. Homes facing 6.9% reduction in remainder of FY 10 and 10% in FY 2011.

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Oklahoma #2

  • 1. Quality of Life.

  • 2. Resident/Family Satisfaction.

  • 3. Employee Satisfaction.

  • 4. System-wide Culture Change.

  • 5. Certified Nursing Assistant/Nursing Assistant Turnover and Retention.

  • 6. Nurse Turnover and Retention.

  • 7. State Survey Compliance.

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Oklahoma #3

  • 8. Clinical Measures. Residents without: falls,

    acquired catheters, acquired physical restraints, unplanned weight loss/gain, and acquired pressure ulcers.

  • 9. Nursing Staffing per Patient Day;

  • 10. Overall Occupancy (used on website only); and SoonerCare (Medicaid) Occupancy and Medicare Utilization (used in incentive payment methodology only)

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  • Georgia and Oklahoma using My Innerview to collect family and resident interview. Oklahoma pays $646,000 a year to My InnnerView.

  • Minnesota and Ohio used Vital Research to do resident interviews.

  • In last two months, both Colorado and Texas issued RFPs for contractors.