Call us toll free 1-877-TMI-8171

Let’s look into the magic crystal ball.


As we reach the end of 2017, we asked our team to look into the magic crystal ball and give us their predictions and prognostications for the coming year. Some things that our team agreed would happen – the Winter Olympics will take place in South Korea; the Lions will continue to be mediocre; and health care costs will continue to rise! In senior living and senior care, there will be a continued push to improve outcomes and reduce costs. Partnerships and referral networks will become increasingly vital as senior communities, home health providers, hospitals, and physician practices work to improve the care continuum.

Here are our top 5 forecasts for the coming year:


1. Prepare to get the RUGs pulled out.


In mid-December 2017, the Medicare Payment Advisory Commission (MedPAC) met to discuss post-acute payment and reviewed year-by-year SNF margins. While the Medicare margin decreased from 12.6% in 2015 to 11.4% in 2016, MedPAC said that the level of Medicare payments is still too high and SNF PPS needs to be revised.


MedPAC recommended to Congress that a proposed framework for a new Medicare payment system for SNFs, called Resident Classification System, Version I (RCS-I) should be implemented in FY 2019.


This likely means that some form of a PPS overhaul is going to hit us on 10/01/18, so how can SNFs and therapy providers prepare?


  • We know that there will be a shift toward less therapy provided, and fewer assessments will be required. Despite the drop in therapy, the importance of efficient and competent care management will be magnified.
  • SNFs and therapy providers should make sure they have efficient systems for tracking therapy that include RCS-I’s new case-mix components.
  • Therapy providers should prepare to establish clinical protocols for the various classifications and include a mix of treatment modes (individual, concurrent, and group).
  • And because SNFs will see a decline in therapy reimbursements, more than ever they will need to prove their worth to their referral networks. Therapy partners can help by providing easy-to-understand data that shows they provide successful person-centered care with optimal outcomes.


2. Have we hit quality measure overload?!


With MDS 3.0 Quality Measures + Quality Reporting Program (QRP) Measures + SNF VBP Measures + Five-Star + Nursing Home Compare, there are now 50+ QMs. Yes, it’s prudent to measure, rank, reward, and penalize those who provide care to Medicare patients, but with so many overlapping QMs, have we gone too far?! Plus, we still aren’t accounting for two leading cost drivers – patient non-compliance and the provision of care for those beneficiaries who are most sick, frail and helpless. The non-compliant and the most debilitated/dependent folks are the most costly to care for, and all of these QMs do nothing to identify or address how to tackle these matters.


What can SNFs do to manage this quality measure overload?


  • Connect with groups/associations that advocate for the industry – like Leading Age, NADONA, HCAM, APTA, AOTA, ASHA.
  • Establish and maintain lines of communication with their fiscal intermediaries (FIs) and Medicare advantage administrators (MAAs) and seek out “Provider Education and Training.” FIs and MAAs are funded by CMS to conduct provider training, but SNFs may not be getting the education that CMS expects them to get..
  • Learn the terminology. For example – What’s a stay vs an episode? A ‘stay’ consists of all the days a patient spends midnights at the SNF. An ‘episode’ can be one ‘stay’, or, if the patient discharges (home, or to the hospital) and returns in the 30 day window, they may have multiple ‘stays’ in one ‘episode.’
  • Learn about CMS’ “Measures Under Consideration” List for 2018, and participate in the public process. For example, one of the proposed measures, the “CoreQ: Short Stay Discharge Measure,” will include a four-item patient questionnaire intended to gauge the individual’s satisfaction with their stay.
  • Educate, communicate, and collaborate with their therapy provider. Readily share information, so your therapy provider can help! For example, establish a transparent, pro-active, and collaborative system to manage ADRs.



3. VBP penalties and rewards are coming.


On 10/01/18 the “Value Based Purchasing Program” will begin impacting all traditional Medicare Part A payments made to SNFs under SNF PPS. If you are a Skilled Nursing Facility provider, you’ve already been participating in the VBP – you just might not realize it! Since 2016, CMS has been collecting data on “30-Day All Cause Readmission Measure” or SNFRM. Hospital readmissions are identified through Medicare hospital claims, not thru SNF claims, so no readmission data has been collected directly from SNFs, and there are no additional reporting requirements for the measure.


This data will be used (beginning 10/1/18) to percentile rank SNFs. Those in the bottom 40% will have 2% of their PPS payments held back and put in escrow. CMS will then channel ~50% of the funds withheld from those on the “naughty list” and send it to those on the “nice list,” otherwise known as the “top performers.”

4. Will the therapy cap get repealed?


Congress took its holiday recess without addressing the Medicare therapy cap, which is disappointing since a bipartisan agreement was reached in October 2017 to permanently end the hard cap.  What does this mean? Beginning on January 1, 2018, the $2,010 hard cap on physical therapy and speech-language pathology services combined will be instituted, and the exceptions process that currently permits medically necessary services above the cap through use of the KX modifier will no longer apply. As APTA President Sharon Dunn, PT, PhD. explained, “Congress’ inaction creates the worst-case scenario for patients and providers. Medicare patients will start the new year unsure if they will receive medically necessary care. This inaction by Congress means arbitrary barriers, stress for patients and their families, and disruptions for providers.”


When Congress returns from its recess on January 19, 2018, there’s a chance the cap could be short lived. When we turn to the magic eight ball, it told us “Reply hazy try again,” so we shall report back in January.


5. CMS will reconsider re-admissions and other quality metrics.


Several studies, including this one by Harvard & UCLA supports the possibility that the Hospital Readmissions Reduction Program has had the unintended consequence of increased mortality in patients hospitalized with heart failure. This brings up pertinent questions about person-centered care:


  • If we encourage patients not to return to the hospital, then what discharge infrastructure needs to be put in place, so that lives are not at risk?
  • When does reducing length of stay become counterproductive?
  • What length of stay is too short and puts the patient in jeopardy – of unnecessary pain, a longer healing time, decline in function, and/or a return to the hospital or worse?
  • And when will the “powers that be” realize that when patients are discharged as quickly as possible, it is inevitable that some will return to the hospital and/or experience other medical complications?


We predict that in 2018 more research and conversations will take place to find good middle ground between person-centered care, patient satisfaction, and quality improvement. We will keep asking the question – how do we optimize length of stay to achieve best outcomes? We also predict that the healthcare industry will strive to “find a floor” (or baseline) for re-admissions and lengths of stay.


Therapy Management, Inc. works with senior communities to provide the full spectrum of wellness and therapy services. We empower our clients with innovative programs, outcomes reports, competitive data, and marketing support, so they can stand out in their marketplace. Call us at 248-349-9595.