Excerpt from article written by

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.

“Actions providers take now will make or break their Five-Star Quality Rating experience in July.

That’s because the Centers for Medicare & Medicaid Services has changed quality measures in a way that will affect all nursing homes. CMS held a SNF Open Door Forum conference call on March 3 to explain the potential impact on long-term care providers.

Changes will be seen on the Nursing Home Compare website and in the SNF Five-Star Quality Rating System. Beginning in April, CMS will add six new Quality (QMs) to the Nursing Home Compare website. Three of these measures are to be calculated from claims data, while the other three will be based on MDS 3.0 data.

These outcome measures capture four additional elements for the short-stay Medicare beneficiary, and two for the long-stay care recipient.

Regulations in 2014 made the development of readmission measures a high priority for CMS.  The claims-based measures look at 30-day all-cause readmissions, 100-day community discharge without readmission, and 30-day outpatient emergency department visits. Each of these metrics identifies Medicare beneficiaries who return to a higher cost center for care after admission at a SNF.

The claims-based measures use Medicare fee-for-service claims only. The measures are risk adjusted using items from a rolling 12 months period of time from the claims, as well as the Medicare enrollment database and the MDS, updated twice annually. While the technical user’s manual is not yet available, an “Improvements” resource document by Abt Associates is available on the CMS web site here.”

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It’s fruitless to use logic or common sense to understand or even defend CMS’ QM’s.  The presumption of guilt permeates everything they mandate.  The measures presume providers guilty of poor quality based on how they fill out a form, provide faulty data and kiss up to the surveyors and arbitrarily and capriciously assign their stars based on a presumption of guilt.  Then the penalties begin … if under their presumptive measure of quality you get lower than 3 stars you lose … reputation … network agreements … money… your business.

And the presumption of guilt justifies CMS to either penalize or use the phony negative incentives … 2% for keeping patients in the SNF regardless of condition (no ER visits or re-hospitalizations allowed) … three of these stars get you more business regardless of guilt or proof.  All of this under the presumption that measuring input justifies penalizing output … outcome is not how many mistakes a provider makes but how many patients they restore.

Thus the presumption of guilt allows CMS to dictate how much they pay or not pay using reimbursement to penalize presumed poor quality without one QM measuring or paying for true outcome … what about how many patients are restored to their highest level of functioning and are discharged back to the community not the ER or hospital?  Of course this isn’t going to happen because we don’t have due process nor accountability for our Big Brother dictates of presumptive guilt and presumptive quality.