Providing patients or members with the highest-quality care while ensuring you have a handle on your high-cost drivers and liability risks is key to delivering the best in outcomes and realizing the benefits of value-based payment. To do this, Health Systems, ACOs, and REITs have the difficult task of collecting and interpreting the right data sets, and in the post-acute care (PAC) space, anecdotal or non-standardized data is common. It’s important to be aware of all the data available for designing a successful post-acute strategy.
Let’s look at two types of data available from skilled nursing facilities (SNFs), the pros and cons of the different data sets, and how to use each for maximum impact on care and cost.
Two Data Sets Tell Different Stories
There are two common data sources for SNF quality measures publicly available from the Centers for Medicare and Medicaid Services (CMS). The first is claims data. Coming from a Health System or ACO world, we might guess this data set comes from the SNFs billing claims as the name suggests. Rather, claims data refers to data used to measure SNFs’ performance in the quality measures for 30-day rehospitalization, emergency department visits, and successful discharge to the community. Claims data is hospital claims for those Medicare beneficiaries that receive PAC services following an inpatient stay.
Confusing? Yes, but this data can also be helpful because the claim follows the beneficiary. For example, for a patient discharged from a SNF who then promptly returns to the hospital, you can see the “bigger picture” care journey. Unfortunately, this data set is also limited as it only looks at Medicare Fee-for-Service claims submitted to CMS. If a SNF in your network has, for example, a high number of Medicare Advantage patients, you will be left with an incomplete picture.
The second data set is based on data from the Minimum Data Set (MDS), and it reflects the clinical outcomes that occurred during the patient’s SNF stay. The MDS is a standardized, structured assessment that is completed according to a mandated schedule for every patient/resident in a SNF, and it captures information on diagnoses, functional status, therapies, treatments, medications, cognition, mood, and behavior.
MDS data is essential to use because, among other reasons, it is part of public reporting; it drives the 23 MDS-based quality measures that are currently publicly available. It is also updated more frequently than the claims data set.
While a limitation of this data set is that it doesn’t “follow the patient” between care settings, it does capture clinical outcomes that otherwise would not appear in a claim for Medicare FFS. For example, a SNF would bill Medicare for a PAC patient receiving skilled nursing and therapy under the Patient-Driven Payment Model (PDPM) classification, with the diagnoses on the claim to support that PDPM Clinical category classification. However, if the patient also has clinical issues such as pain or behavioral changes that do not impact PDPM classification, this would not appear on the claim, but it would appear on the MDS. Although PDPM is part of Medicare’s shift towards value-based models from the previous fee-for-service model, the existing claims-based quality measures lack the clinical richness of MDS-based measures.
Combined, Both Claims Data and the MDS Show the Full Story
Claims data can help you judge the effectiveness of care transitions, with MDS data filling in more detail about rehospitalization rates. Meanwhile, MDS data gives you greater insight into your areas of high cost and liability risk. For Health Systems and ACOs focused on value-based payment, the ideal plan is to rely on both data sets to understand the full story of post-acute and long-stay resident care.
Another way of stating it is that claims based data gives you a retrospective view – think of it as looking in the rearview mirror, it tells you what has happened. MDS data provides you with a descriptive and prospective view – much like looking through your windshield, it tells you where you are going.
By understanding these data sets and their capabilities in greater depth, you can improve your patient and caregiver experience, while containing costs. Contact PointRight to learn more about how to leverage PAC data to maximize your organization’s transition to value-based care.