The Centers for Medicare & Medicaid Services’ (CMS) comment period on the SNF proposed rule ended with only 74 comments posted from skilled nursing stakeholders Monday. For perspective, last year’s comment period garnered about 4,700 comments.
The drastic decline in comments reflects a sense of appeasement with the new rulings. Providers in 2022 faced a potential downward adjustment to rates by 4.6% to achieve budget neutrality. But this year, it seems, providers are generally pleased with the 3.7% rate increase to Medicare Part A, or approximately $1.2 billion for 2024.
That said, it’s not enough to tackle rising costs in the coming year, nursing home advocates and associations have said.
The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) submitted two comment letters to CMS regarding the proposed rule, one in May discussing how the payment rule is calculated, and how that calculation wasn’t able to adequately adjust for sudden changes within the long-term care community.
AHCA/NCAL used an independently developed Milliman report to deepen this argument.
“Addressing the shortcomings of the SNF PPS is particularly relevant given the overwhelming impact caused by the COVID-19 pandemic and recent inflationary pressures to ensure that payment rates support SNF patients’ needs,” AHCA said in a blog post reviewing its comments.
Commenters reviewed proposals for the SNF Quality Reporting Program (QRP) and SNF Value-Based Purchasing (VBP) Program for the following year as well, raising concerns about certain measures related to staffing turnover and vaccination.
AHCA/NCAL’s second comment letter, a whopping 80-page document sent to CMS on June 1, focuses on proposed QRP and VBP measures, as well as consolidated billing, technical updates to the Patient Driven Payment Model (PDPM) ICD-10 mappings.
3.7% is nice, but doesn’t reflect reality
Comments from associations like LeadingAge said the proposed rule doesn’t address the reality of operator environments – as costs are expected to rise in the coming year, a paltry raise will ultimately limit access to care.
Katie Smith Sloan, president and CEO of LeadingAge, added that members will need to continue purchasing personal protective equipment and Covid testing supplies to comply with Centers for Disease Control & Prevention (CDC) recommendations, along with budgeting for compliance with new or enhanced requirements related to emergency preparedness.
“These increases are essentially unfunded mandates that our mission-driven, nonprofit providers have no choice but to manage – on top of anticipated cost increases from soon-to-come federal staffing requirements,” Smith Sloan said in an email to Skilled Nursing News.
Labor costs alone have ballooned, noted Smith Sloan, and there “simply aren’t enough applicants.” As labor shortages jeopardize operations, staffing mandates will at the same time force providers to set funds aside for recruitment and retention for compliance.
VBP measures don’t align with program intent
Coupled with the raise, other measures that were finalized included the proposed value-based care measures connected to quality, staffing turnover, resident falls and discharges.
Two measures finalized by CMS in the 2023 SNF PPS Final Rule and due to be incorporated in 2026 include: SNF healthcare-associated infections requiring hospitalization (SNF HAI), and total nursing hours per resident day staffing.
A measure tracking discharge to community from post-acute care is set to take effect in 2027.
Proposed measures include replacing the SNF 30-day all-cause hospital readmission measure (SNFRM) with the SNF within-stay potentially preventable readmission measure (SNF WS PPR) by 2028.
Four other proposed measures included:
- The percentage of residents experiencing one or more falls with major injury and resulting in a long stay.
- Total nursing staff turnover
- Discharge function
- Number of hospitalizations per 1,000 long-stay resident days
Proposals would also establish case minimum and measure minimum policies, incorporate a health equity adjustment (HEA), add scoring methodology for proposed measures, and update the SNF VBP validation process.
In its comments to CMS, LeadingAge took issue with the turnover measure, specifically with how it was calculated.
The focus on turnover also places “inappropriate blame” on providers who are doing their best to ensure quality care at the right staffing levels, according to Smith Sloan.
Staff preferences have changed, running counter to traditional health care staffing models with preferences for flexible hours and work-from-home options.
Also, providers turning to staffing agencies to fill openings could result in high turnover rates.
“For those two reasons, we do not support the inclusion of a nurse staffing turnover measure in SNF VBP,” Smith Sloan said.
Meanwhile, AHCA/NCAL did not support any of the four proposed VBP measures.
“In their own way, each of the measures does not align with the intent of the Medicare SNF VBP program to tie Medicare payments to health care outcomes of Medicare beneficiaries,” the association said in its June 1 commentary.
The staffing turnover measure, for one, doesn’t link payment to quality outcomes, AHCA/NCAL said. It’s a facility-wide measure incorporating managed care and other elderly residents, when CMS has indicated on prior measures that only fee-for-service Medicare beneficiaries should be included in VBP.
“Third, this measure has not been endorsed by a consensus-based entity and thus only has conditional support from the Measure Applications Partnership (MAP),” according to the AHCA/NCAL submitted comment. “Ignoring [consensus-based entities] undermines the potential success of SNF VBP to align payment with clinical outcomes.”
Some QRP measures stuck in the past
LeadingAge also opposed two other proposed measures on quality reporting – Covid-19 vaccination coverage measures including a modification to vaccination among health care personnel, and a new measure calculating the percent of patients who are up to date on vaccinations, to be implemented in 2026.
“Continuing to include the staff vaccination measure, despite CMS’ rescinding the staff Covid-19 vaccine mandate and adding the resident vaccination measure penalizes providers for allowing residents and staff to exercise personal choice and manipulates information that is already available to the public in a more meaningful manner,” said Smith Sloan.
AHCA/NCAL said it conditionally supports the modification, but asked that CMS reduce reporting burdens on providers, better informing consumers that the vaccine is not mandatory for health care providers which could impact reported vaccination rates.
In terms of adopting the percent of patients who are up-to-date, AHCA/NCAL conditionally supported that as well, but requested that CMS immediately discontinue the regulatory requirement to submit the same information to the CDC.
Another QRP measure develops a meaningful pain management measure or measures to support short and long-term stay populations, with yet another measure that calculates discharge scores based on type of chronic condition.
While AHCA/NCAL said it looks forward to seeing this implemented through the Minimum Data Set (MDS), the association doesn’t support developing condition-specific subgroup measures on discharge; AHCA/NCAL cited concerns about facility-specific sample limitations and measure stability.
Other significant QRP proposals include, but are not limited to, eliminating the requirement for facilities facing civil monetary penalties to actively waive their right to a hearing in writing, instead treating the failure to submit a timely hearing request as a constructive waiver which would result in the usual 35% penalty reduction.
Companies featured in this article:
