Monday Musings

Last month, on April 15, CMS issued a proposed rule [CMS-1622-P] outlining 2016 Medicare payment rates for skilled nursing facilities (SNFs).  The policies set out in the rule would continue the shift in Medicare payments from “volume to value” that is being implemented in the rest of the healthcare system. Remember the “Triple Aim” — building a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people.

The Improving Medicare Post-Acute Care Transformation Act of (IMPACT Act), passed on October 6, 2014, requires standardizing data reporting across four post-acute care settings: home health agencies, inpatient rehabilitation facilities, long-term care hospitals and skilled nursing facilities. Starting in 2018, SNFs that fail to implement the SNF Quality Reporting Program and submit the required quality data to CMS will have their annual updates reduced by two percentage points.

CMS is proposing to adopt   measures for the SNF quality program: (1) skin integrity; (2) incidence of major falls; and (3) functional status/cognitive function. CMS intends to propose additional quality and resource use measures in future rule making.

The “skin integrity” measure is a measure that I’m not a big fan of: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay) (NQF #0678; Measure Steward: CMS). I’m not happy with this measure because a pressure ulcer is considered to have “worsened” if it is reclassified from “unstageable” to a specific Stage. (Don’t get me started on the fact that there is a staging system in which one of the stages is “we don’t know what stage it is”). Since we know that the only reason an ulcer is considered unstageable is that you can’t decide whether it is Stage 3 or a Stage 4 due to slough or necrotic tissue, it is hardly a “worsening” ulcer when the ulcer becomes clean enough to make that determination. It’s actually probably an improving ulcer. I am also not happy with this measure because in effect, it means that the ONLY measure we have across all these settings of care that is directed at the problem of pressure ulcers involves COUNTING THEM. It does not involve any action aimed at prevention or treatment. Even more ironic, this measure is classified as an “outcome measure,” presumably because it targets “worsening.” Since we all know that pressure ulcers do not “progress through the stages”, we know that you can’t detect “worsening” by a change in stage. While a patient might get NEW pressure ulcers (and this IS important), I can tell you that 30% of OUTPATIENTS with pressure ulcers get new ulcers while they are being cared for at outpatient wound centers. In any case, no wound care practitioner would consider this an “outcome” measure. The outcome we should be looking for is resolution (closure).

I’d also like to point out that the ONLY post-acute setting that the IMPACT legislation does NOT cover is the hospital based outpatient department. In other words (other than a doctor’s office), the only post-acute setting NOT required to report this skin integrity measure is, ironically, the hospital based Outpatient Wound Center. I am not sure if this is good or bad.

What I think everyone should notice is that:

  1. If you thought that quality based reimbursement was something that only doctors had to worry about (because I’ve written so much about PQRS), then think again—it’s effecting all of post-acute care.
  2. Skin issues matter to CMS and the first area they are trying to target for “quality measurement” is that of pressure ulcers.

We need MUCH better quality measures directed at the treatment and/or prevention of pressure ulcers that make sense across all sites of care. We can’t fix the problems caused by an inaccurate “staging” (sic) system but maybe we can find better things to measure about them.