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EXECUTIVE SUMMARY

In New Mexico Medicaid pays for about 1.4 M Nursing Facility (Facility) bed days per year. Medicaid is the primary payer for more than 90% of Long-Term Care (LTC) facility days and has approximately 76 licensed nursing facilities in New Mexico. In the Centennial Care 2.0 contract with the three Managed Care Organizations (MCOs), the Human Services Department (HSD) required the MCOs to have Value Based Purchasing (VBP) contracts with nursing facilities. In effort to successfully initiate a program to implement the VBP requirements for the Medicaid Centennial Care 2.0 contract, HSD under the guidance of Dr. David Scrase initiated the New Mexico Medicaid: Value Based Purchasing and Nursing Facilities project. The project includes a four-pronged approach that includes a Community Advisory Board (CAB), MCO VBP workgroup, Provider Advisory Group (PAG) and Project ECHO. The project goal is to improve quality of care, reduce avoidable hospitalizations, and optimize health for all New Mexico Medicaid members receiving services in nursing facilities by 2023. This is being offered as a voluntary opportunity for all nursing facilities in New Mexico that are contracted with MCOs for Medicaid.

STAKEHOLDERS

• New Mexico Healthcare Association (NMHCA) Provider Advisory Group

• Centennial Care 2.0 MCOs - Blue Cross Blue Shield (BCBS), Presbyterian Health Plan (PHP) and Western Sky Community Care (WSCC)

• Human Services Department (HSD)

• Project ECHO

GOALS

The goals for the NF VBP program are:

1. Better value for Medicaid funds spent on care

2. Create an incentive for nursing home providers to improve or maintain high quality

3. Increase access to services for Medicaid beneficiaries

PRINCIPLES

A set of principles will guide the NF VBP program and data modeling. These principles will help ensure the decisions are based on a robust framework rather than opinion and beliefs. The following principles have emerged from input and support of all stakeholders:

1. All providers have the opportunity to “win”, and there are early wins, i.e. the bucket of monies is distributed based on performance relative to a standard;

2. Payouts based on Medicaid bed days (volume in each Facility) and payments will be made quarterly;

3. Program will be transparent and simple to understand in order to influence behavior and outcomes;

4. Program will utilize evidence based benchmarks (tied to clinical outcomes and evidence) and not create any new metrics;

5. Program will include a method for assigning a value to a metric for a provider if the QM is not available through the ;

6. Program will have a mid-course review after CY 2021. During this midcourse review the WORKGROUP will look at the effectiveness of the program and make any changes necessary.

DEFINITIONS

DATA VENDOR: This refers to the company engaged by the MCOs to calculate the amount of the VBP payment to each of the eligible FACILITY

FACILITY: Participating Nursing Facility

FACILITY MEDICAID BED DAYS: The sum of the number of days for an individual facility that each bed was occupied by a patient who was covered by Medicaid under Title XIX of the Social Security Act and enrolled with an MCO

FOUNDATIONAL PAYMENTS FOR INFRASTRUCTURE AND OPERATIONS: Quarterly payment of $3,750 made to each FACILITY based on the successful submission of data to the Data Vendor

HIGH-ACUITY: High-acuity residents will be identified through the MDS data set, Section I as per federal MDS guidelines, with Neurological or Psychiatric/Mood disorders – Cerebral palsy, Multiple Sclerosis, ALS (G12.21), Lewy-Body dementia, dementia with behavioral disturbance (F03.91 and F02.81), Parkinsons, Psychotic disorder, Manic depression (bipolar disease), Schizophrenia, PTSD, Huntingtons, Tourettes, or TBI

HIGH-ACUITY ADD ON: Additional payment made to a FACILITY based on their High-Acuity Medicaid Bed Days

HIGH-ACUITY MEDICAID BED DAYS: The sum of the number of days that each bed was occupied by a patient who fits the definition of High-acuity

MEDICAID BED DAYS: The sum of the number of days for an individual facility that each bed was occupied by a patient who was covered by Medicaid under Title XIX of the Social Security Act and enrolled with an MCO

NOTIFICATION DATE: Date in which the FACILITY receives the prior quarter’s performance from the DATA VENDOR

PER DIEM RATE: Calculated Rate based on the total amount of monies allocated to the VBP program divided by sum of Medicaid Bed Days.

PERFORMANCE TIER: Based on the summation of points earned by the FACILITY’S Quality Measures

QUARTER: Refers to a calendar year QUARTER, e.g. January 1 through March 31 would be the 1st QUARTER.

QUALITY MEASURE: Metrics selected to analyze FACILITY improvement in quality based on established Center for Medicare and Medicaid Services (CMS) metrics.

SECONDARY PAYMENT: Payment made to eligible facilities based on selected programs or behaviors.

TIER PERCENTAGE: Allocation percentage of the Per Diem Rate based on a FACILITY’S Performance Tier

VBP POOL: Total amount of monies available for the VBP program for the given year.

YEAR: The VBP program will be evaluated based on calendar year January 1 through December 31.

WORKGROUP: The workgroup shall be composed of one representative from each MCO and representative(s) from the NMHCA.

COMPONENTS OF NF VBP

The NF VBP program has four components, which include:

1. Funding mechanism

a. Funding mechanism refers to how the incentive payment in the VBP is funded (e.g. new funds, savings, withhold of existing funds.)

2. Measure Selection

a. Four measures selected jointly between MCOs and NMHCA

3. Assessing performance on measures

a. Refers to quality measure thresholds that will yield points used to determine the incentive payment

4. Linking performance to payment

a. Refers to the mechanism for which the Facility’s performance on the quality measures will be translated into an incentive payment.

MINIMUM REQUREMENTS

To be eligible for the Nursing Facility VBP Program, the FACILITY must meet the following minimum requirements:

• Medicaid Certified facility

• Contracted with at least 1 Medicaid MCO

• Submit Minimum Data Set (MDS) data to Data Vendor

• Facility must have a minimum of 365 Medicaid bed days within the previous 12 months or calendar year

• Data use agreements signed with Data Vendor and MCOs

ADDITIONAL COMMITMENTS

Within six months of implementation, the FACILITY must participate and/or contract with the following entities. Failure to do so within the stated time frame will result in suspension of FOUNDATIONAL PAYMENTS FOR INFRASTRUCTURE AND OPERATIONS to the FACILITY until participation and/or contracting is completed:

• Participate in required number of Medicaid Quality Improvement and Hospitalization Avoidance (MQIHA) Project ECHO sessions as determined by the Nursing Facility Value Based Purchasing ECHO Workgroup

• Data use agreement signed with Collective Medical Technologies (CMT) for Post-Acute EDie

• Zoom capabilities for Project ECHO sessions

• Participate in Post-Acute EDie with CMT

ENROLLMENT

Initial enrollment into the VBP program will be open October 1, 2019 to December 31, 2019. Program inception will be for a 2-year (calendar) period from January 1, 2020 through December 31, 2021. Beginning in 2020, a non-participating FACILITY must notify the MCO(s) by July 1st of interest to contract and have a completed contract with the MCO(s) by September 30th of that year to enter the program in the following calendar year.

A FACILITY can disenroll from the program by sending written notice to the MCO(s) which it is contracted with by September 30th of the respective enrollment year. The FACILITY will no longer be a part of the program at 11:59pm on December 31st of the enrollment year in which they provided notice.

MEASURE SCORING

The goal is to keep it simple and limit the measures to long stay (LS) measures that facilities are familiar with and can focus on improvements. NF VBP Program will be based on four QUALITY MEASURES. The quality measures will be selected and agreed upon by both the Nursing Facility VBP workgroup including the PAG, MCOs and Project ECHO. Additional measure(s) will be used as a test target and will not count towards the quality measurement. The quality measures will not change during the evaluation periods of CY 2020 through CY 2021. At the end of CY 2021 the workgroup will determine if the current measures will continue or will be replaced.

Quality Measures for CY 2020 through CY 2021

|Name |Identifier |

|Tier 2 |200 to 259 points |

|Tier 3 |140 to 199 points |

|Tier 4 |100 to 139 points |

|Tier 5 |99 points or less |

PAYMENT MECHANICS

The payment methodology has four payment mechanisms associated with the VBP program. The goal of these four payment mechanisms is to provide the facilities with the ability to implement the necessary changes to improve their scores, reward the facilities for improvement, and promote behavior beneficial for the residents, the FACILITY and the MCOs.

1. FOUNDATIONAL PAYMENTS FOR INFRASTRUCTURE AND OPERATIONS of $3,750 a quarter ($15,000 a year) is consistent among all participating facilities and is dependent upon the successful submission of data to the data vendor.

2. A SECONDARY PAYMENT will have a fixed amount allocated to it. This annual payment is to incentivize facilities to utilize technology to deliver better cost effective services and outcomes for Medicaid members. The secondary payment criteria is set for each YEAR and the change and facilities requirements will be communicated to the facilities no later than 90 days before the end of the YEAR. The first year of the SECONDARY PAYMENT will be Telemedicine. Facilities that utilize Telemedicine at a minimum of four times in the calendar year will be eligible for the SECONDARY PAYMENT.

|YEAR |Behavior/Outcome |

|CY 2020 |Telemedicine |

|CY 2021 |TBD |

The payment amount is determined by taking the allocated amount and dividing it by the facilities who have achieved the requirement. The SECONDARY PAYMENT is capped at $50,000 per year per FACILITY. If the allocation is not exhausted the remaining monies will be allocated to the HIGH-ACUITY ADD ON pool.

(Secondary Payment Allocation) / (Count of Eligible Facilities)

3. A PER DIEM RATE will be established by dividing the (VBP POOL – FOUNDATIONAL PAYMENTS FOR INFRASTRUCTURE AND OPERATIONS – SECONDARY PAYMENT) / Total MEDICAID BED DAYS for participating facilities. Medicaid Bed Days will be calculated based on MCO enrollment data received from HSD at the end of each quarter, which will be considered the final enrollment count for that quarter. Each FACILITY is eligible to receive the full per diem rate per their Medicaid Bed Days. Payment calculation shall be:

(FACILITY MEDICAID BED DAYS) x (PER DIEM RATE) x (TIER PERCENTAGE)

a. A TIER PERCENTAGE would be applied to the PER DIEM RATE. The tier percentage is based on the PERFORMANCE TIER a Facility achieves based on their quality measures. The associated percentage will be multiplied by the PER DIEM RATE.

| |Tier 1 |Tier 2 |Tier 3 |Tier 4 |Tier 5 |

|2nd year |100% |85% |75% |50% |10% |

|3rd year |100% |85% |75% |50% |0% |

|4th year |100% |85% |75% |50% |0% |

|5th year |100% |85% |75% |50% |0% |

4. A HIGH-ACUITY ADD ON payment will be made to facilities based on their HIGH-ACUITY MEDICAID BED DAYS. HIGH-ACUITY PER DIEM shall be calculated by taking the remaining monies for the period and dividing that by the sum of HIGH-ACUITY MEDICAID BED DAYS for the facilities that have HIGH-ACUITY MEDICAID BED DAYS. This HIGH-ACUITY PER DIEM is then multiplied by the FACILITY’S HIGH-ACUITY MEDICAID BED DAYS to arrive at the HIGH-ACUITY ADD ON payment.

(Remaining Monies) / (Sum of High-Acuity Medicaid Bed Days) = High-Acuity Per Diem

(High-Acuity Per Diem) x (High-Acuity Medicaid Bed Days for Facility) = High-Acuity Add On Payment

Total Payment for each Facility for each quarter =

(Foundational Payment) + (Per Diem Rate) + (High-Acuity Add On Payment) + (Secondary Payment, as applicable)

Each MCO will pay their portion of the Total Payment to each Facility based on the MCO’s percentage of Medicaid Bed Days in each Facility

CALCULATION REVIEW

Facilities that feel their performance was negatively and significantly impacted by factors outside of the control of the FACILITY during the QUARTER can request a Calculation Review using the following procedure:

1. A form for submitting a Calculation Review will be created (Note: All requests for Calculation Review must be submitted to the WORKGROUP with “Nursing Facility VBP Calculation Review” in the subject line within 15 business days of notification date.) The Calculation Review request will be reviewed, and a final decision will be made.

2. The following identifying data will be captured on the Calculation Review request form:

a. Facility Name

b. CMS Provider ID #

c. Physical Address with County

d. Administrator’s Name

e. Administrator’s Email

f. Phone #:

g. Date of Submission

3. The following data will be captured on the Calculation Review request form -

Calculation Review Request QPS Measure: Select one (per request):

a. LS Antipsychotic

b. LS UTI

c. LS PU Development

d. LS Hospitalization

4. The FACILITY must provide the rationale for the Calculation Review Request:  

a. Data: Provider can request a review of the results if it believes the MDS data or PointRight Hospitalization data is not correctly reported.

b. Population:  The provider may present evidence that due to unique circumstances such as special populations or services (i.e., memory impaired units or facilities that specialize in the treatment of complex wounds); the results of a particular measure cannot be benchmarked to the national average.

5. Supporting Documentation: Provide evidence of supporting documentation for the reason for the Calculation Review request by attaching it to the form. Do not include member specific information. Facilities must have clear documentation, be thorough, and have clear analysis in how they came to the conclusion of the request.

6. Calculation Reviews will be considered by the WORKGROUP. A formal meeting to review the Calculation Review request will be held within thirty (30) days of receipt of the Calculation Review request. The WORKGROUP will attempt to achieve consensus, but lacking a consensus, a majority will prevail. The MCO Program Directors will be responsible for oversight of the Calculation Review process, including notification to the provider.

7. Due to the program payment methodology with fixed quarterly payouts, if the Calculation Review is not filed within 15 business days of notification date, late Calculation Reviews will not be accepted.

8. All decisions in the Calculation Review process will be applied prospectively.

TIMELINE

|Period |Milestones |

|CY 2019 Q3 |Measures finalized in September |

| |Targets finalized in September for measurement starting January 2020 |

|CY 2019 Q4 |MCOs contracting with Data Vendor |

| |No payments to facilities |

|CY 2020 Q1 |Contracting with Data Vendor and MCOs’ Payment to Data Vendor (monthly invoices) ongoing |

| |No payments to facilities |

|CY 2020 Q2 |Reporting by facilities to Data Vendor for month 30 days after month end |

| |Data report by Data Vendor to facilities in April |

| |facilities have 30 days to clean up data |

| |Final January – March MDS sent to Data Vendor by April 30 |

| |Modify MCO payment in April for payments to facilities based on bed days by MCO per diem payment |

| |Payment made to facilities for successful submission and clean-up of 1/1/20 – 3/31/20 data |

|CY 2020 Q3 |Reporting by facilities to Data Vendor for month 30 days after month end |

| |Payment made to facilities in July 2020 based on Quality measures and the successful submission of 4/1/20 – 6/30/20 data |

|CY 2020 Q4 |Reporting by facilities to Data Vendor for month 30 days after month end |

| |Build payment rate to facilities based upon measured improvement (move away from successful submission of data) |

| |Payment made to facilities in October 2020 based on Quality measures and the successful submission of 7/1/20 – 9/30/20 data |

|CY 2021 Q1 |Reporting by facilities to Data Vendor for month 30 days after month end |

| |Payment made to facilities based on Quality Measures for 10/10/20 to 12/31/20 data |

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