Blog by Mark Prifogle, GrandView Pharmacy CEO

I have shared these documents with our team to help them better understand how our customers and skilled nursing facilities get reimbursed in Indiana. As a group, we must focus on how to use the best evidence-based approaches to ensure all 9 of these metrics perform at a stellar level. Pharmacy plays a significant role in each of them.

Value Based Purchasing (“VBP”) Update

The current policy on how the Value Based Add on has been calculated the last few years. They have a total of 100 Quality points. If they receive all of the Quality points, it increases their Indiana Medicaid daily rate per resident by $14.30 per resident, per day! So, in a 100 bed facility, if they achieve the maximum, it generates an additional $42,900 per facility, per month — or $514,800 per year!

This system was HEAVILY (75%) based on the Facility Report Card score, which is a calculation based on their survey performance by the State Department of Health. It also adds points for Nursing Hours and Staff Turnover in various areas. Click here to view the document.

Indiana Medicaid VBP Update (8.15.18)

This document outlines the new system our skilled facilities will be converting over to in October.

The new system will be quite different. It will weight the Long Stay Five Star QM/QIs at 60% and the Report Card Score at 25% (the report card score was frozen at 6/30/2017 for this rate calculation for a variety of reasons). The Balance will be 10% for All Facility W2 Turnover and an Advance Care Planning Certificate. The Advance Care Planning certificate is an online class one person from the facility has to take through a Relias portal once a year. This portion is essentially a “free” 5 points for participation. Click here to view the document.

Measures for Long-Stay residents (residents in the facility for greater than 100 days) that are derived from MDS assessments:
  1. Percentage of residents whose need for help with activities of daily living has increased
  2. Percentage of residents whose ability to move independently worsened
  3. Percentage of high risk residents with pressure ulcers (sores)
  4. Percentage of residents who have/had a catheter inserted and left in their bladder
  5. Percentage of residents who were physically restrained
  6. Percentage of residents with a urinary tract infection
  7. Percentage of residents who self-report moderate to severe pain
  8. Percentage of residents experiencing one or more falls with major injury
  9. Percentage of residents who received an antipsychotic medication

For those interested, I am also sharing a third document which shows how the 5-Star Ratings are calculated. Click here to view the document.

As you can see, pharmacy, especially consultant pharmacy, will play a much larger role in the way our skilled nursing facilities will get paid for their Medicaid services. By doing our part to ensure these 9 QM/QI % are optimally aligned, we have an opportunity to help each of our facilities generate hundreds of thousands of dollars in additional income!

As a trusted partner, we strive to help our customers, who are working in an extremely challenged environment – regulatory, census, staffing – perform better financially.

Special thanks to Zach Cattell and Lori Davenport of the Indiana Health Care Association for the content provided to make this blog possible.