Skip to Main Content

insightsarticles

Medicare Proposed Rule for CY 2023 Medicare Physician Fee Schedule

07.27.22

Release Date: July 07, 2022
Federal Register Publication Date: Scheduled for July 29, 2022
Effective Date: January 1, 2023
End of Comment Period: September 6, 2022

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment rates under the Physician Fee Schedule (PFS) for the calendar year 2023, as well as other Part B provisions. Following is a summary of the major provisions of this proposed rule.

PFS Proposed Changes to Conversion Factor:

  • PFS conversion factor reflects the statutory update of 0%, expiration of the 3% increase in PFS payments for CY2022 provided by the Consolidated Appropriations Act of 2021 (CCA), 1.55% reduction necessary for changes in relative value units for budget neutrality, and anesthesia-specific practice expense and malpractice adjustments of 0.53%.

Major Provisions Proposed:

  • Future rebasing and revision of the Medicare Economic Index (MEI) cost share weights that would use publicly available data from the US Census Bureau NAICS 6211 Offices of Physicians to set PFS payments rates. Using new MEI cost weights for PFS rate setting would not change overall spending on PFS services but would likely result in significant changes to payments among the various PFS services. Therefore, CMS is not proposing the use of the newly proposed method for CY2023 rate setting and is seeking comment on the proposed updated MEI cost share weights to calibrate payment rates and update the geographic practice cost indices (GPCI) under the PFS in the future.
  • Changes in coding and documentation for Other Visits (hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) intended to reduce administrative burden using a similar approach to changes finalized in the CY2021 PFS final rule for office/outpatient Evaluation and Management (E/M) visit coding and documentation. Also propose to maintain the current billing policies that apply to E/M visits while potential revisions are considered for future rulemaking. 
  • Delay the Split (or Shared) E/M visits policy finalized in CY 2022 related to the definition of substantive portion as more than half the total time. Until CY 2024, clinicians will continue to have a choice of meeting the definition of substantive portion based on history, physical exam, medical decision making, or more than half of the total practitioner time spent.
  • Proposing to cover several services that were temporarily available as telehealth services during the PHE through CY 2023 on a Category III basis and extending the time these services are temporarily included on the telehealth services list for a period of 151 days following the end the PHE. 
  • Telehealth claims would require the appropriate place of service (POS) indicator to be included on the claim instead of modifier “95” after the period of 151 days following the end of the PHE. For Medicare telehealth services furnished via audio-only technology modifier “93” would be available, where appropriate. 
  • Establish a new General Behavioral Health Integration (BHI) service for monthly care integration where mental health services performed by Clinical Psychologists (CP) or Clinical Social Workers (CSWs) is the focal point of care integration. This new General BHI service would also allow a psychiatric diagnostic evaluation to serve as the initiating visit. 
  • Make an exception to the direct supervision requirement under “incident to” regulations to allow behavioral health services provided by auxiliary personnel (such as licensed professional counselors and licensed marriage and family therapists) incident to the services of a physician or non-physician practitioner (NPP) to be allowed under general supervision of a physician or NPP, rather than under direct supervision.
  • Proposing new HCPCS codes and valuation for Chronic Pain Management and treatment services (CPM) that would include a bundle of services furnished during a month. 
  • Opioid Treatment Program (OTP) would revise the pricing methodology for the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. CMS also proposes to allow the OTP intake to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with buprenorphine, when authorized by the Drug Enforcement Administration (DEA) and Substance Abuse and mental Health Services Administration (SAMHSA). Audio-only communication technology to initiate treatment with buprenorphine would also be permitted where audit-video technology is not available. 
  • Create a new G-code for audiologists to bill for services without a physician referral for non-acute hearing or balance assessments unrelated to disequilibrium, hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. Billing the new G-code would be limited to once every 12 months.
  • Expand coverage for certain colorectal cancer screening tests by reducing the minimum age to 45 years and considering a follow-up screening colonoscopy after a Medicare covered at-home test to be a preventative service.
  • Preventive vaccine administration would receive annually updated payment amount based on the increase in the MEI and adjustment for geographic locality. Also, CMS proposes to continue the additional payment for at-home COVID-19 vaccinations and clarifies that policies regarding the administration of COVID-19 vaccines and monoclonal antibody products will continue until the Emergency Use Authorization (EUA) declaration for drugs and biological products is terminated.
  • CMS proposes a variety of changes for the Quality payment Program and Medicare Shared Savings Program.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs):

  • Add the new chronic pain management and behavioral health integration services to the RHC/FQHC-specific general care management HCPCS code, G0511.
  • Policies to extend telehealth flexibilities for 151 days after the PHE would be applicable to RHCs and FQHCs as well. 
  • Provider-based RHC’s payment limit per visit would be established by using a 12-consecutive month cost report. 

Sources: 
CMS-1770-P Medicare and Medicaid Programs; CY 2023 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicare and Medicaid Provider Enrollment Policies, Including for Skilled Nursing Facilities; Conditions of Payment for Suppliers of Durable Medicaid Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and Implementing Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts

Related Industries

Related Services

Consulting

Business Advisory

Related Professionals

Principals

BerryDunn experts and consultants

Release Date: July 27, 2022 
Federal Register Publication Date: August 1, 2022 
Effective Date: October 1, 2022  

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that would update Medicare payment rates and policies for Inpatient Rehabilitation (IRF) Prospective Payment System (PPS) and IRF Quality Reporting Program (QRP) for the fiscal year 2023, as well as other provisions. Following is a summary of the major provisions of this final rule. 

IRF PPS Final Changes to Payment Rates: 

CMS finalized a 3.9% net increase in FY 2023 Medicare IRF PPS rates and a 0.6% decrease in outlier payments to maintain outlier payments at 3% of total payments. Net overall IRF payments will increase by 3.2%, or an estimated $275 million (note: the net overall increase is 3.2% due to rounding). Components of the increase are broken down as follows: Table of IRF PPS Final changes to Payment Rates

Major Final Provisions: 

  • Apply a 5% cap on any decrease in IPF’s wage index to mitigate negative effects of year-to-year variation in wage index 
  • IRF teaching payment adjustment to reflect higher costs similar to the IPPS indirect medical education (IME) adjustment.  
  • IRF QRP expands quality data reporting requirements to include all IRF patients, regardless of payor, beginning on October 1, 2024 
  • Outlier threshold amount increased from $9,491 to $12,526 for FY2023.  
  • Labor-Related Share remains the same as FY2022 at 72.9%. 
  • Standard Payment Conversion factor is $17,878 for FY2023 
  • Update to IRF Cost-to-Charge Ratio (CCR) ceiling and urban/rural averages for FY2023.  
    • Estimated national average CCR of 0.466 for rural IRFs. 
    • Estimate national average CCR of 0.392 for urban IRFs. 
    • National Ceiling of 1.41 for FY2023 

Sources:  

CMS-1767-F Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2023 and Updates to the IRF Quality Reporting Program. 

Article
Medicare Final Rule for FY 2023 Inpatient Rehabilitation Facility Prospective Payment System

Release Date: July 27, 2022
Federal Register Publication Date: July 29, 2022
Effective Date: October 1, 2022

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that would update Medicare payment rates and policies for Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) for the fiscal year 2023, as well as other provisions. Following is a summary of the major provisions of this final rule.

IPF PPS Final Changes to Payment Rates:

CMS finalized a 3.8% net increase in FY 2023 Medicare IPF PPS rate and a 1.2% decrease to the outlier payments to maintain outlier payments at 2% of total payments. Net overall IPF payments will increase by 2.5%, or an estimated $90 million increase (note: the net overall increase is 2.5% due to rounding). Components of the increase are broken down as follows:

Table of IPF PPS Final Changes to Payment Rates

*Market based update for FY23 would be the highest implemented due to recent high inflationary trends impacting the outlook for price growth over the next several quarters.

Major Final Provisions:

  • Apply a 5% cap on any decrease in IPF’s wage index to mitigate negative effects of year-to-year variation in wage index
  • IPF Federal per diem base rate from $832.94 to $865.63
  • IPF Labor-Related Share from 77.2 percent to 77.4 percent.
  • Update to IPF Cost-to-Charge Ratio (CCR) ceiling and urban/rural averages for FY2023.
    • National Median CCR of .05720 for rural IPFs.
    • National Median CCR of .4200 for urban IPFs.
    • Rural ceiling of 2.0412
    • Urban ceiling of 1.7437

Sources:

CMS-1769-F Medicare Program; FY 2023 Inpatient Psychiatric Facilities Prospective Payment System-Rate Update and Quality Reporting-Request for Information.

Article
Medicare Final Rule for FY 2023 Inpatient Psychiatric Facility Prospective Payment System

Read this if you are a Skilled Nursing Facility (SNF) providing services to Medicare beneficiaries.

There are a few Skilled Nursing Facilities (SNF) reimbursement opportunities on the Medicare cost report. Two of them could reimburse providers for sizable expenses that the majority of SNFs experience every year: the Utilization Review (UR) and Medicare bad debts. 

Utilization Review: Medicare cost report opportunities

UR meetings historically focused on managing lengths of patient stay and reducing costs. The implementation of the SNF value-based purchasing program and the related incentive payment adjustment, which resulted in a reimbursement rate increase or reduction by up to 2%, led some facilities to increased physician or medical director involvement in the UR management in order to improve clinical outcomes. 

With the increase in physicians’ UR time, there frequently is a cost increase for SNFs. CMS Provider Reimbursement Manual – Part 1, Chapter 21, Section 2126.2, outlines the requirements for 100% reasonable Medicare program UR cost reimbursement.  The only mechanism for SNFs to get reimbursement for these costs is through the Medicare cost report. 

Why is this important? BerryDunn maintains a database of SNF Medicare cost report filings and analyzes the data annually, looking for trends and opportunities to help providers optimize available reimbursement. The cost report data shows that from 2016 to 2019 only 1.95% of rural SNFs and 2.82% of urban facilities claimed reimbursable Medicare UR costs. Of the facilities claiming UR costs, the median requested reimbursement was $9,000 or $2.07 per Medicare patient day. 


Figure 1 Source: HCRIS as filed full utilization SNF cost reports, 2017 - 2019

Optimize your reimbursement: Utilization Review checklist available

To support SNFs with reimbursement for these costs, BerryDunn’s healthcare consulting team has developed a checklist that provides insight on the Medicare cost report opportunities. Download the Utilization Review checklist.

Article
Leaving money on the table? Reimbursement opportunities for Skilled Nursing Facilities

Read this if you work for a healthcare organization that serves uninsured or self-pay patients.

The No Surprises Act was passed in 2020 as part of a COVID relief package, with the goal of reducing surprise bills for patients who received medical or surgical services. One part of the act requires healthcare facilities and providers to give Good Faith Estimates (GFEs) to uninsured and self-pay patients starting on January 1, 2022. Read on for frequently asked questions about this topic, an update for 2023, and resources where you can find more information.

Frequently asked questions about good faith estimates for healthcare

What is a good faith estimate?

A Good Faith Estimate (GFE) is a document provided to a patient that details the expected charges for healthcare services provided. It is not a bill.

Who needs to provide GFEs, and to whom?

At this time, GFEs need to be provided to uninsured and self-pay patients. 

The following healthcare facilities must comply:

  • Federally Qualified Health Centers (FQHCs)
  • FQHC Look-Alikes
  • Tribal/Urban Indian Health Centers
  • Rural Health Clinics (RHCs)
  • Hospitals
  • Hospital outpatient departments
  • Critical access hospitals
  • Title X Family Planning Clinics
  • Health care providers who serve uninsured and self-pay patients

How should information about the GFE process be communicated to uninsured and self-pay individuals?

Information about the availability of GFEs for uninsured or self-pay individuals must be:

  • Written in a clear and understandable manner and prominently displayed:
  • On the facility’s website and easily searchable from a public search engine
  • In the office (such as in the patient waiting room), and
  • Onsite where scheduling or questions about the cost of items or services occur, such as at the registration or check-out areas
  • Explained verbally when scheduling an item or service or when questions about the cost of items or services occur
  • Made available in accessible formats, and in the languages spoken by individuals considering or scheduling items or services

How does the US Department of Health and Human Services (HHS) define uninsured and self-pay individuals?

HHS has a two-fold definition:

  • Individuals who have no health insurance coverage
  • Individuals who do have health insurance coverage, but do not want to have a claim submitted to their insurer

Both of these groups of individuals must receive a GFE.

What content is required in a GFE?

A GFE must include the following:

Patient information

  • The patient’s name and date of birth

Services estimated

  • A description of the primary item or service in clear and understandable language and, if applicable, the date the primary item or service is scheduled
  • A list of items or services reasonably expected to be furnished for the primary item or service

Information about services, providers, and estimated charges

  • Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service
  • The name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the GFE, and the State and office of the facility’s location where the items are services are expected to be provided
  • Lists of items or services that the provider or facility anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service. (A disclaimer should state that separate GFEs will be issued upon scheduling or upon request of the listed items or services.)

Disclaimers

  • A disclaimer that there may be additional items or services that the provider or facility recommends as part of the course of care that must be scheduled or requested separately and are not included in the GFE
  • A disclaimer that the information provided in the GFE is only an estimate and that actual items, services, or charges may differ from the GFE
  • A disclaimer that the individual has a right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the GFE.
  • “Substantially in excess” is defined as at least $400 more than the total amount of expected charges.
  • This disclaimer must include instructions about where an uninsured or self-pay individual can find information about how to initiate the patient-provider dispute resolution process and state that the initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services that are furnished.
  • HHS strongly encourages providers and facilities to include an email address and telephone number for someone within the provider’s or facility’s office that has the authority to represent the provider or facility in a billing dispute.
  • A disclaimer that a GFE is not a contract and does not require the uninsured or self-pay individual to obtain the items or services identified in the GFE.

HHS encourages sliding fee discount providers and facilities to include information about the provider’s or facility’s sliding fee schedule and any other financial protections that it offers. Sliding fee discount providers and facilities have flexibility to determine how best to demonstrate the expected charges associated with each listed item or service, and to determine what additional information to include, if any.

What are the required methods for providing a GFE?

A GFE must be provided in written form either on paper or electronically, based on the individual’s requested method of delivery and within the required time frames. GFEs that are provided electronically must be provided in a manner that the individual can both save and print. A GFE must be written using clear and understandable language that can be understood by the average uninsured or self-pay individual.

If the individual requests a GFE in a method other than on paper or electronically (such as by telephone or verbally in person), the provider or facility may verbally inform the individual of the information contained in the GFE. However, the provider or facility must also issue the GFE in written form.

What is the timeline for providing a GFE?

When providing a GFE to an uninsured or self-pay patient, the following time frames must be followed.

When the service is scheduled: When the GFE must be provided:
If scheduled at least 3 business days prior to the date that the item or service will be furnished Not later than 1 business day after the date of scheduling
If scheduled at least 10 business days prior to the date that the item or service will be furnished Not later than 3 business days after the date of scheduling

Please note, when a GFE is requested by an uninsured or self-pay patient, a GFE must be provided not later than 3 business days after the date of the request.

How long should a provider or facility retain a copy of GFEs?

A GFE is considered part of the patient’s medical record and must be maintained in the same manner. At the request of an uninsured or self-pay individual, the provider or facility must provide a copy of any previously issued GFE within the last six years.

Update for 2023

  • As of the start of 2023, all of the preceding requirements remain in place.
  • As of January 1, 2023, HHS has paused enforcement on the next phase of GFE implementation

The next phase of GFE implementation, which began on January 1, 2023, requires that GFEs for uninsured and self-pay patients include expected charges from co-providers or co-facilities that are part of an episode of care for a patient coordinated by a provider or facility. However, on December 2, 2022, HHS paused its enforcement of this requirement based on comments it received during the rulemaking process indicating that compliance with this provision was likely not possible by January 1, 2023.

HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay individuals do not include expected charges from co-providers or co-facilities. We will provide an update when HHS issues any communication about changes to GFE-related enforcement.

Helpful resources for FQHC, RHCs, and other healthcare facilities

If you have questions about the information provided in this article or are interested in an external review of your healthcare facility’s compliance with current GFE requirements, please contact Robyn Hoffmann or Mary Dowes.

Article
Healthcare Good Faith Estimates (GFEs): Updates for 2023

Read this if your organization receives charitable donations.

As the holiday season has passed and tax season is now upon us, we have our own list of considerations that we would like to share—so that you don’t end up on the IRS’ naughty list!

Donor acknowledgment letters

It is important for organizations receiving gifts to consider the following guidelines, as doing some work now may save you time (and maybe a fine or two) later.

Charitable (i.e., 501(c)(3)) organizations are required to provide a contemporaneous (i.e., timely) donor acknowledgment letter to all donors who contribute $250 or more to the organization, whether it be cash or non-cash items (e.g., publicly traded securities, real estate, artwork, vehicles, etc.) received. The letter should include the following:

  • Name of the organization
  • Amount of cash contribution
  • Description of non-cash items (but not the value)
  • Statement that no goods and services were provided (assuming this is the case)
  • Description and good faith estimate of the value of goods and services provided by the organization in return for the contribution

Additionally, when a donor makes a payment greater than $75 to a charitable organization partly as a contribution and partly as a payment for goods and services, a disclosure statement is required to notify the donor of the value of the goods and services received in order for the donor to determine the charitable contribution component of their payment.

If a charitable organization receives noncash donations, it may be asked to sign Form 8283. This form is required to be filed by the donor and included with their personal income tax return. If a donor contributes noncash property (excluding publicly traded securities) valued at over $5,000, the organization will need to sign Form 8283, Section B, Part IV acknowledging receipt of the noncash item(s) received.

For noncash items such as cars, boats, and even airplanes that are donated there is a separate Form 1098-C, Contributions of Motor Vehicles, Boats, and Airplanes, which the donee organization must file. A copy of the Form 1098-C is provided to the donor and acts as acknowledgment of the gift. For more information, you can read our article on donor acknowledgments.

Gifts to employees

At the same time, many employers find themselves in a giving spirit, wishing to reward the employees for another year of hard work. While this generosity is well-intended, gifts to employees can be fraught with potential tax consequences organizations should be aware of. Here’s what you need to know about the rules on employee gifts.

First and foremost, the IRS is very clear that cash and cash equivalents (specifically gift cards) are always included as taxable income when provided by the employer, regardless of amount, with no exceptions. This means that if you plan to give your employees cash or a gift card this year, the value must be included in the employees’ wages and is subject to all payroll taxes.

There are, however, a few ways to make nontaxable gifts to employees. IRS Publication 15 offers a variety of examples of de minimis (minimal) benefits, defined as any property or service you provide to an employee that has a minimal value, making the accounting for it unreasonable and administratively impracticable. Examples include holiday or birthday gifts, like flowers, or a fruit basket, or occasional tickets for theater or sporting events.

Additionally, holiday gifts can also be nontaxable if they are in the form of a gift coupon and if given for a specific item (with no redeemable cash value). A common example would be issuing a coupon to your employee for a free ham or turkey redeemable at the local grocery store. For more information, please see our article on employee gifts.

Other year-end filing requirements

As the end of the calendar year approaches, it is also important to start thinking about Form 1099 filing requirements. There are various 1099 forms; 1099-INT to report interest income, 1099-DIV to report dividend income, 1099-NEC to report nonemployee compensation, and 1099-MISC to report other miscellaneous income, to name a few.

Form 1099-NEC reports non-employment income which is not included on a W-2. Organizations must issue 1099-NECs to payees (there are some exclusions) who receive at least $600 in non-employment income during the calendar year. A non-employee may be an independent contractor, or a person hired on a contract basis to complete work, such as a graphic designer. Payments to attorneys or CPAs for services rendered that exceed $600 for the tax year must be reported on a Form 1099-NEC. However, a 1099-MISC would be sent to an Attorney for payments of settlements. For additional questions on which 1099 form to use please contact your tax advisor.

While federal income tax is not always required to be withheld, there are some instances when it is. If a payee does not furnish their Tax Identification Number (TIN) to the organization, then the organization is required to withhold taxes on payments reported in box 1 of Form 1099-NEC. There are other instances, and the rates can differ so if you have questions, please reach out to your tax advisor. 1099 forms are due to the recipient and the IRS by January 31st.

Whether organizations are receiving gifts, giving employee gifts, or thinking about acknowledgments and other reporting we hope that by making our list and checking it twice we can save you some time to spend with your loved ones this holiday season. We wish you all a very happy and healthy holiday season!

Article
Making a year-end list and checking it twice

Read this if you are in the senior living industry.

Happy New Year! While it may be a new calendar year, the uncertainties facing senior living facilities are still the same, and the question remains: When will the Public Health Emergency end, and how will it impact operations? Federal and state relief programs ended in 2022, and facilities are trying to find ways to fund operations as they face low occupancy levels. Inflation was at 7.1% in November and staffing remains a significant challenge. So, what can the industry expect for 2023?

Occupancy

Through the pandemic, occupancy losses were greater in nursing facilities than in assisted living (AL) and independent living (IL) facilities. This trend of care shifting away from nursing facilities had started before the onset of the pandemic. From 2018-2020, nursing facility volume decreased by over 5% while AL facilities occupancy increased by 1.1%.

Nursing facility occupancy nationwide was 80.2% in January of 2020 and declined to as low as 67.5% in January 2021. In 2022, nursing facility occupancy began to recover. As of December 18, 2022, nationwide occupancy had rebounded to 75.8%.

The assisted living and independent living markets were certainly impacted by the pandemic but not to the extent of the nursing facilities. AL and IL occupancy was reported at 80.9% in March 2021, a record low occupancy for the industry. Through the third quarter of 2022, NIC reported IL occupancy at 84.7%, which was up from 83.8% in the second quarter of 2022. AL occupancy was at 79.7%. in the third quarter of 2022. 

Providers are starting to see some positive signs with occupancy, but are reporting the recovery has been slowed by staffing shortages.

Cost of capital

The lending market is tightening for senior living providers and occupancy issues are negatively impacting facilities bottom lines. In addition, there has been significant consolidation in the banking industry. As a result, interest and related financing costs have risen. For those facilities that aren’t able to sustain their bottom lines and are failing financial covenants, lenders are being less lenient on waivers and in some cases, lenders are imposing default lending rates. 

Ziegler reports in their Winter 2022 report the lending market for senior housing is beginning to pick up. The majority of the lenders surveyed were regional banks, and reported they are offering both fixed and floating rate loans. Lenders are also reporting an increased scrutiny on labor costs coupled with looking at a facility’s ability to increase occupancy. 

Despite these challenges, analysts are still optimistic for 2023 as inflation seems to be tapering, which will hopefully lead to a stabilization of interest rates.

Staffing

Changes to five-star rating
In July 2022, the Centers for Medicare and Medicaid Services (CMS) modified the five-star rating to include Registered Nurse (RN) and administrator turnover. The new staffing rating adds new measures, including total nurse staffing hours per resident day on the weekends, the percentage of turnover for total nursing staff and RNs, and the number of administrators who have left the nursing home over a 12-month period.

Short-term this could have a negative impact on facilities ratings as they are still struggling to recruit and retain nursing staff. The American Healthcare Association has performed an analysis, and on a nationwide basis these changes resulted in the number of one-star staffed facilities rising from 17.71% to 30.89%, and the percentage of one-star overall facilities increasing from 17.70% to 22.08%.

Staffing shortages 
Much like the occupancy trend, nursing facilities faced staffing issues even before the pandemic. From 2018 to 2020, the average number of full-time employees dropped at a higher rate, 37.1%, than admissions, 15.7%. Data from the Bureau of Labor and Statistics and CMS Payroll Based Journal reporting shows nursing facilities lost 14.5% of their employees from 2019-2021 and assisted living facilities lost 7.7% over the same time period. This unprecedented loss of employment across the industry is leading to burnout and will contribute to future turnover.

This loss of full-time employees has created a ripple effect across the healthcare sector. Nursing facilities are unable to fully staff beds and have had to decline new admissions. This is causing strain on hospital systems as they are unable to place patients in post-acute facilities, creating a back log in hospitals and driving up the cost of care.

While the industry continues to experience challenges recruiting and retaining employees, the labor market is starting to swing in the favor of providers. Some healthcare sectors have recovered to pre-pandemic staffing levels. Providers are also starting to report lower utilization of contract labor.

While the industry continues to experience challenges recruiting and retaining employees, the labor market is starting to swing in the favor of providers. 

Minimum staffing requirement
CMS is expected to propose a new minimum staffing rule by early spring 2023. Federal law currently requires Medicare and Medicaid certified nursing homes provide 24-hour licensed nursing services, which are “sufficient to meet nursing needs of their residents”. CMS issued a request for information (RFI) as part of the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule. CMS received over 3,000 comments with differing points of view but prevailing themes from patient advocacy groups regarded care of residents, factors impacting facilities' ability to recruit and retain staff, differing Medicaid reimbursement models, and the cost of implementing a minimum staffing requirement. In addition to the RFI, CMS launched a study that includes analysis of historical data and site visits to 75 nursing homes. 

In a study conducted by the American Healthcare Association, it is estimated an additional 58,000 to 191,000 FTEs will be needed (at a cost of approximately $11.3 billion) to meet the previously recommended 4.1 hours per patient day minimum staffing requirements.

One potential consequence of the minimum staffing requirement is higher utilization of agency staffing. Nursing facilities saw a 14.5% decrease in staffing through the pandemic and are still struggling to recruit and retain full-time staff. To meet the minimum staffing requirements, providers may need to fill open positions with temporary staffing. 

Provider Relief Funds (PRF) 

Don’t forget if you received PRF funds in excess of $10,000 between July 1 and December 31, 2021, Phase 4 reporting period opened January 1, 2023, and will close March 31, 2023.
Many of the changes to the industry brought on by the pandemic are likely to remain. Facilities who are putting a focus on their staff and working to create a positive work environment are likely to keep employees for longer.

While there are many challenges in the current environment, they were made to be met, and we are here to help. If you have any questions or would like to talk about your specific needs, please contact our senior living team. Wishing you a successful 2023.
 

Article
Status of the senior living industry: The good, the bad, and the uncertain

Read this if you are a primary care provider, leader, or administrator in a primary care practice or hospital ownership setting.  

Valuing primary care providers

One doesn’t have to venture far into healthcare headlines over the past two decades to find robust discussions about healthcare worker shortages, and more recently, provider well-being. In this sad new world of low satisfaction and increasing burnout, leaders and administrators across the healthcare delivery spectrum are struggling to find ways to make provider happiness a priority. Nowhere is this felt more acutely than in primary care. So, it begs the question, how are we—as healthcare administrators and strategic leaders—valuing our primary care providers?

The idea that volume or incentive-based compensation models will solve all motivation and productivity concerns is neither realistic nor sustainable. Typical models champion wRVUs and maybe some patient/procedure per hour/day metrics, but are these compelling for primary care providers? We need to remember that many of these practitioners made the conscious decision to practice in primary care, which was not likely driven by a desire for high income. In fact, making the motivation all about financial incentives can often backfire. While it may potentially or temporarily increase or “improve” results, it is often at the cost of patient care and can ignite further burnout.

Conversations with primary care providers

Actively listen to the physicians and associate providers in your organization and you will quickly hear how important it is to recognize the complexity of their patient population. But being heard is just the starting point. Conversations with providers need to lead to an organizational investment in metrics that show that you value and care about what your primary care providers value and care about. This cannot be overstated or underestimated.

Empanelment (or “panelization”) is a fundamental metric for any organization with a primary care presence of any significance, and this metric should be shared with those primary care providers. Transparent reporting in this metric alone would be a sea change for many in our current environment.

Measurement for measurement's sake is not enough

But measurement for measurement’s sake is not enough, because if we are measuring something, we need a goal we are seeking to achieve. Knowing (or thinking we know) the right size panel for our providers is not a simple answer. Every community is different, and as any provider will tell you, they each have different mixes of complexity. They may see a drastically different patient population than even the provider with whom they share an office, so measuring all patients equally is not a valid approach.

Empanelment is as complex as each patient when we consider socio-economic factors, chronic conditions, and other determinants of health. Each patient is unique and has a unique level of complexity related to their care, so treating each patient like a ‘1’ simply doesn’t work. Complexity demands differentiation of some sort to better communicate and manage the workload involved. This is why weighted empanelment—assigning a comparative value per patient in order to reflect appropriate complexity—is so helpful. Many organizations have developed their own weighted models for years, often with mixed results. Because as soon as we believe we have solved a problem, a new one is created. Now we have to decide what criteria determines complexity, and how that will actually be calculated. Once that is done, we realize that the output has to be validated, repeatable, and most importantly, it needs to be comparable. 

Historically, most chosen criteria are either incredibly hard to track, impossible to validate, or a painful mixture of both! Over the last twenty years or so, weighted empanelment models and methods have been built, scrapped, used on a limited basis or for limited purpose, and are often very burdensome to manage or duplicate.

Research-verified weighted panel calculations

BerryDunn has helped healthcare delivery organizations operationalize research-verified weighted panel calculations: one building block toward a better model that fits the value-based future, brings insight to both providers and administrators, and creates value in the communities they serve.  

Our model is easy to implement and understand, providing organizations with an important tool and metric that can be used to effect needed change to drive and enable an improved administration-provider relationship.

If you have any questions regarding the information in this article or would like to have a conversation about primary care provider empanelment or provider compensation and productivity, please contact Markes Wilson.

Article
Why should we consider weighted panels for primary care providers?