Tag Archives: nursing

Why are U.S. nursing homes at high risk for COVID-19 contraction?

Emerging data from around the world suggest that nursing home residents are at exceptionally high risk for contracting COVID-19, with some areas reporting that close to half of regional deaths are either in nursing homes or in hospitals after admission from a nursing home. Less than 0.5% of Americans live in nursing homes, but the remarkable concentration of risk in such facilities may have profound implications on how we handle the pandemic.

In this article, Milliman’s Bruce Pyenson and Harvard’s David Grabowksi discuss why nursing homes have been hit so hard by COVID-19 and what can be done to fight the disease in these facilities.

A comparison of nursing home usage in states with and without Medicaid Managed LTSS

As states consider implementing managed long-term services and supports (MLTSS) programs and as managed care organizations consider participating in them, it is important to understand what level of savings from managed care may be achievable. This paper by Milliman’s Nick JohnsonAndrew Keeley, and Ali Khan examines Minimum Data Set frequency reports and U.S. Census Bureau American Community Survey population data to compare nursing home usage in states with MLTSS to states without MLTSS.

CMS final rule for skilled nursing facilities and value-based care: Is your organization ready?

On July 31, 2018, the Centers for Medicare and Medicaid Services (CMS) released a final rule that outlined the 2019 fiscal year payment updates and quality program changes for skilled nursing facilities (SNFs). This rule continues the drive for change from fee-for-service to value-based reimbursement and reduces the burden on providers consistent with the Patients Over Paperwork and Meaningful Measures initiatives. Below are the three changes introduced by the final rule and how each change affects SNFs. CMS estimates that the new rule will result in an additional $820 million in Medicare reimbursements to SNFs for the 2019 fiscal year due to the 2.4% increase in payment rates.

Changes to the case-mix classification system

The final rule creates a new Patient-Driven Payment Model (PDPM) for reimbursement that will replace the Resource Utilization Group, Version IV case-mix reimbursement model. This new model focuses on treatment of the whole patient rather than on volume of services. This will decrease paperwork and reduce the overall complexity compared to the old model.

The new PDPM goes into effect for fiscal year 2020, which begins on October 1, 2019, and focuses on clinically relevant factors to determine payment using diagnosis codes. The new model will encourage more contact between healthcare professionals and patients.

PDPM decreases the number of payment group combinations by 80%. It essentially focuses on payments based on the complexity of the patient needs and condition, instead of the volume of hours needed to provide care. Finally, CMS suggests that the new model will reduce the amount of documentation for patient assessments and significantly reduce reporting burdens, saving providers approximately $2 billion over 10 years.

To succeed with this new reimbursement model, SNFs will have to assess the types of patients they treat and may have to adjust treatment plans, including the level of care during stays, and realign their operations accordingly. SNFs will also have to assess their documentation procedures and ensure that patient characteristics and needs are accurately captured.

SNF Quality Reporting Program (QRP)

Also in the final rule, CMS removed measures that were not consistent with the Meaningful Measures initiative. The updated measure set focuses on making care safer, strengthening personal and family engagement, promoting coordination of care, promoting effective prevention and treatment, and making care affordable. There were no new measures suggested or initiated.

SNFs can also educate and engage healthcare professionals and review the new documentation formats for each quality measure. The success in meeting a measure is dependent on the engagement of staff and providers, so that the appropriate coding and documentation meet the quality measure specifications. SNFs can also begin looking at appropriate analytical data, which can help with specific performance needs.

SNF Value-Based Purchasing (VBP) program

The SNF VBP program will begin on October 1, 2018, and will add a positive or negative incentive payment for services rendered by facilities based on the result of their readmission measures. This final rule will reward providers that takes steps to limit 30-day readmissions of their patients to hospitals. SNFs can begin preparations for the VBP program by reviewing their financial, operational, and clinical policies and procedures.


There are several steps that SNFs need to begin to implement now to be ready for the October 1, 2018, implementation of the Value-Based Purchasing program. SNFs are an important part of many Value-Based Purchasing programs and are now being incentivized to provide quality of care to patients. They will be rewarded for looking at the needs of the patient instead of how much time a therapist or caregiver spends with a patient. This new program will allow patients and caregivers to pick facilities that cater to their personal needs for care or rehabilitation.

Measuring performance of skilled nursing facilities

The skilled nursing facility (SNF) industry is an important area for Medicare accountable care organizations (ACOs), Medicare Advantage health plans, and other Medicare programs. How can these organizations appropriately benchmark performance to provide efficient healthcare and reduce spending for SNF services?

Milliman’s Jill Herbold and Anders Larson offer some perspective in their report “Performance of skilled nursing facilities for the Medicare population.” The report highlights several utilization and expenditure metrics for measuring SNF performance. It also explores SNF performance levels across the United States and provides a quantitative assessment of the opportunities to reduce spending for SNF services.

Ambulatory care: Measuring quality and the impact of nursing

Jones-PattyThe shift of medical care from the inpatient to outpatient setting coupled with the emphasis on transformative designed patient-centered medical home models provides measurement challenges and opportunities. The challenges are how to effectively measure quality in this setting given the range of services that are provided—from routine preventive care to complex surgical and invasive procedures. The concurrent opportunity is to measure and promote the role of nurses in providing and leading the care and coordination services that are at the core of ensuring improved patient experiences and outcomes in the outpatient setting.

Table 1: Percentage Share of Inpatient vs. Outpatient Surgeries (1988-2008)[1]

Ambulatory Care  Measuring Quality and the Impact of Nursing

Table 2: Trends in Inpatient and Outpatient Utilization (1987-2007) [2]

Ambulatory Care  Measuring Quality and the Impact of Nursing 2

Professional nursing associations have taken notice of these trends and are accelerating the effort to improve the measurement of both quality and nursing impact in the ambulatory setting. In January of this year the American Nurse Association (ANA), American Nurses Credentialing Center (ANCC), and American Nurses Foundation (ANF) hosted the Ambulatory Measurement Summit. This meeting, and the work leading up to the summit, involved 40 nursing leaders representing stakeholders in national/specialty nursing organizations, payors with delivery systems, measure developers (including Milliman), delivery systems, and payors.

The charge to this group was to come to consensus on five existing measures that warranted further investigation and potential adaptation as an ambulatory nursing measure. Participating in this exercise with this impressive set of nursing leaders representing a wide range of interests, I was struck by several observations:

• There is a clear need to develop outpatient measures that go beyond preventive and chronic care and address other quality concerns. Ambulatory care (especially procedure-based care) involves complex services with risks and consequences that are not well addressed by today’s measures of processes such as immunization and screening rates.
• There is a continued opportunity to pilot new measures of coordination. There is clear recognition that the new value to consumers (and opportunity for nursing) will be the ability of the healthcare system to help them successfully move from one service to another and it will take innovative minds to design these measures.
• It is hard to measure the impact of nursing independent of other factors. As you examine specific measures it is difficult to claim nursing as the driver of performance in that measure but perhaps this serves to emphasize even more that healthcare involves teams and ultimately identify that nursing remains a key part of that team.

At the close of the summit the attendees reached consensus on five nationally endorsed measures, as having high relevance to nursing impact:

1. Medication reconciliation (NQF #0097)
2. Controlling high blood pressure (HEDIS measure)
3. Depression assessment conducted (NQF #0518)
4. Pain assessment and follow-up (NQF #0420)
5. All-cause readmissions (NQF #1768)

The next step will be for the ANA and the National Database of Nursing Quality Indicators® to undertake further review of the five consensus measures for possible refinement and testing for use within the ambulatory setting. We will watch this initiative closely as we refine Milliman’s measurement tools to fully reflect the changes underway in the healthcare system, as well as the role of stakeholders such as the nursing profession, and to improve the ability to measure the impact of these changes.

[1] Frakt, Austin (October 2010). Inpatient vs. outpatient surgeries. The Incidental Economist. http://theincidentaleconomist.com/wordpress/inpatient-vs-outpatient-surgeries
[2] Johnson, Tracy K. (May 2010). Ambulatory care stands out under reform. Healthcare Financial Management. http://www.hss-inc.com/healthcare-report/ambulatory-care-stands-out-under-reform.pdf

This article first appeared at Milliman MedInsight.

ACOs enhance career opportunities for nurses

Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) may provide nurses with greater career options. In this Nurse Zone article, Milliman’s Patty Jones discusses some new roles opening up for nurses skilled in care coordination and data analysis.

Here is an excerpt:

“Accountable care and a lot of the initiatives coming out of health reform provide some interesting and new opportunities for nurses,” said Patty Jones, RN, [MBA], a principal at Milliman, a consulting and actuarial firm in Seattle, adding that the positions will take advantage of skills nurses already have and necessitate some to develop new talents.

…“For an accountable care organization to be successful, they are tasked with coordinating the needs of a member or a patient over a series of services and different levels of care over the course of time,” said Jones, explaining that efforts will focus on case managing smoother transitions between settings and ensuring the patient takes prescribed medications and follows through with appointments to avoid re-hospitalizations.

“This is a natural place for nursing and nurse leaders to use skills in terms of care coordination and assist the patient to reach out and get attached to other levels of care,” Jones said.

Newer emerging roles, Jones said, involve patient education and engagement. But the teaching must take place within the framework of the patient’s readiness to learn and motivation for changing to a healthier state.

“It’s a coming together of the science and psychology of nursing,” Jones said.

A third area of opportunity for nurses involves resource management at the patient and organization level, not something all nurses are skilled at or interested in.

“There are real opportunities for clinical leaders, nurses included, to be part of the financial and resource management discussion,” Jones said.

Additionally, nurses will need a population view, similar to a public health approach, to identifying and closing gaps in preventive care. However, it will require an analytic mind and comfort with data.

For more perspective on how healthcare’s changing landscape is affecting nursing professionals, click here.