How Payers Overcome Nursing Shortages to Improve Patient Experience

While Medicare continues to ramp up efforts to reward quality over quantity of services, payers find themselves strapped for personnel to ensure the collection and reporting of care quality data. More and more, health plans working with Medicare beneficiaries in their homes are looking for strategic partners to manage nursing shortages and ensure proper care management and information gathering.

The challenge facing payers is most salient in the Medicare Advantage market, where the average Medicare beneficiary can choose from nearly 40 options, more than ever before in history. Medicare Part C has proven highly lucrative for payers, with more than 26 million Medicare beneficiaries (42 percent of the total Medicare population) and $343 billion in federal government spending. But things are about to change.

Beginning in 2022, Medicare Advantage plans must hone in on patient experience after the Centers for Medicare & Medicare Services (CMS) announced that this measure would quadruple in value and determine a third of a plan’s scores, better known as Star Ratings.

The change comes at a hard time for payers as demand for a limited pool of nurses — the clinicians chiefly responsible for delivering and documenting care to this patient population — outpaces supply. According to the US Bureau of Labor Statistics, more than 275,000 additional nurses are needed over the next decade to keep pace with requests for care services. If MA plans fail to reach adequate staffing levels, they will put a significant portion of their revenue at risk. In addition, with a growing population of seniors wishing to age at home, payers must work creatively to meet the healthcare needs of their members and satisfy changing expectations.

Ed Motherway, President of CareScout, agrees. “The increasing senior population, coupled with age-related disorders and the rise of chronic illnesses, sets the stage for a significant shift to home healthcare. Consumers are still coming around to the idea that home-delivered services are frequently more convenient, less expensive, and just as effective as hospital-based or skilled nursing facilities. That means the quality of these home health experiences delivered by nurses will be critical.”

Assessments and revenue for home health

CMS has clarified the agency’s intention to tie payment to value over the years. Medicare leaders view this quality strategy as essential to improving both the cost and quality of care. What this means for health plans serving Medicare beneficiaries is an increasing responsibility to capture and report quality data, namely Outcome and Assessment Information Set (OASIS) data collection requirements under Medicare Fee for Service (FFS), Medicare Advantage, and Medicaid.

Data requirements have become a vital feature of the federal agency’s quality efforts around home health. Following the enactment of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, post-acute care providers —long-term care hospitals (LTCHs), skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs) — are required to submit standardized data to CMS. What’s more, HHAs also must satisfy a Medicare condition of participation (CoP) to update and revise the comprehensive assessments during set times as a patient transitions to the home as part of the Home Health Quality Reporting Program.

Participants — including MA plans — must track data points in three areas: outcomes, process, and patient-reported outcomes for this and similar post-acute Medicare programs. Doing so begins as soon as a physician orders home health services under Medicare Part A, and nurses are instrumental in the data collection process.

“Clinical assessments cover a broad spectrum that includes LTCI, Medicare and nursing homes,” Motherway states. “Not only are the assessments key to determining eligibility for a growing number of medical programs, but the quality of each assessment experience is becoming more important for the success of providers.”

A strategy for clinical assessments

Due to nursing shortages and competition, payers need a strategy for ensuring that objective, accurate, and timely clinical assessments are administered effectively. Additionally, for health plans to satisfy requirements and deliver a superior patient experience, they need to look outside their organizations.

“While the ability to complete assessments on a timely and quality basis is a key function, the requirement often competes for a limited supply of skilled nursing staff,” Motherway explains. “Against the growing nurse shortage, it makes sense to develop network relationships where you can outsource assessment requirements, especially those where the assessment engagement will exceed quality experience expectations.”

And as the demand for post-acute care and home health increase with Baby Boomers joining the Medicare population, a sense of urgency should be compelling payers to move quickly and think about their ability to scale their offerings without sacrificing quality.

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About CareScout

A trusted leader with more than 20 years of experience, CareScout performs objective, accurate, and timely clinical assessments to help payers make informed decisions. CareScout’s nationwide network of 35,000+ registered nurses and licensed social workers can easily and seamlessly supplement your existing clinical assessment services.

Learn more about CareScout here.