Quality Scoring Metrics and Special Population Determination
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Defines quality performance measures, cut points, data sources, and the semi-annual per-diem reimbursement methodology (including a special-population add-on) used by West Virginia Bureau for Medical Services for nursing facilities.
Cut Points were updated for the Quality Measure 'Percentage of long-stay residents who received an antipsychotic medication'.
New quality scoring system and special population determination implemented (system new 10/1/2024).
Reimbursement Criteria and Per-Diem Calculation
Reimbursement criteria and per-diem calculation
Semi-annual scoring and payment allocation criteria for quality measures and special populations.
ALL of the following
ALL of the following
- Each quality measure is valued at twenty-five (25) points of the 100 possible quality performance points.
ALL of the following
- Percentage of long-stay residents with a catheter inserted and left in their bladder.
- Percentage of long-stay residents with a urinary tract infection.
- Percentage of long-stay residents who received an antipsychotic medication.
- Percentage of long-stay residents who have depressive symptoms.
- Measures for informational purposes beginning October 1, 2024 (may be considered for future scoring): Adjusted total Nurse Staffing Hours Per Resident and Percentage of high-risk long-stay residents with pressure ulcers.
ALL of the following
- If there are blanks in data or a provider is not found in Care Compare datasets, the facility will be assigned to Tier 3 for the applicable measure(s).
ALL of the following
ALL of the following
- Resident must have West Virginia Department of Human Services, Bureau for Medical Services as primary payer (Medicaid).
AND coded 1, 2, or 3 on one or more MDS 3.0 indicators
- Behavioral Health (E0200A, E0200B, or E0200C).
- Rejection of Care (E0800).
- Wandering (E0900).
ALL of the following
ALL of the following
- Initial projected annual combined quality pool: $60,000,000 (inflated annually by the SNF without Capital Market Basket Index or comparable index).
- Pool split: 90% allocated to Quality Scoring Metrics and 10% allocated to Special Populations; scores and per-diems updated semi-annually.
ALL of the following
- Compute facility semi-annual quality score (0–100) using the weighted measures and cut scores in the policy document; missing data => Tier 3 for that measure.
- Compute facility quality-adjusted Medicaid days: (facility semi-annual quality score / 100) * Medicaid days.
- Medicaid days source: most recently reviewed cost report or state MMIS data at State discretion; for new providers with no days, set Medicaid days to statewide average occupancy of available bed days for one calendar year.
- Facility share of projected annual quality pool = facility quality-adjusted Medicaid days / total statewide quality-adjusted Medicaid days.
- Facility quality allocation = facility share * projected annual quality measures payment pool.
ALL of the following
- Compute Semi-Annual Special Population adjusted Medicaid days = (Number of qualifying Medicaid assessments / Total statewide number of qualifying Medicaid assessments for the period) * Medicaid days.
- Medicaid days source and new provider rule same as quality calculation.
- Facility share of projected annual special populations pool = facility Semi-Annual Special Population adjusted Medicaid days / Total statewide Semi-Annual Special Population adjusted Medicaid days.
- Facility special-population allocation = facility share * projected annual special populations payment pool.
ALL of the following
- Total semi-annual quality per diem = (facility quality allocation + facility special-population allocation) / total annualized Medicaid days (from most recently reviewed cost report) to set the semi-annual quality per diem.
ALL of the following
- Scores calculated each semi-annual rate period using the most recently available semi-annual MDS assessment data and Care Compare datasets as specified.
- Changes to the 'Quality Scoring Metrics and Special Population Determination' document shall be determined by the State and published to the State website.
Codes, Measures, and Cut Points
| E0200A/E0200B/E0200C | Behavioral Health (E0200A, E0200B, or E0200C) |
| E0800 | Rejection of Care (E0800) |
| E0900 | Wandering (E0900) |
Data Submission, Assignment, and Timing Requirements
Semi‑annual evaluation: Care Compare and MDS data sources and timing
Facilities must be evaluated semi‑annually using CMS Care Compare datasets for quality metrics and the most recent two quarters of MDS data for special‑population determination. For quality metrics, use the most recent Care Compare release at time of calculation (generally the four quarters ending one period in arrears; e.g., July rates use the April Care Compare dataset and January rates use the October dataset). For special populations, use the most recent two quarters of MDS available at calculation (generally the two quarters ending one period in arrears; e.g., July rates use Q4 of the prior year and Q1 of the current year).
- Quality metric source: CMS Care Compare — most recent update at time of rate calculation; typically four quarters ending one period in arrears (July → April dataset; January → October dataset).
- Special population source: most recent two quarters of MDS data at time of rate calculation; typically the two quarters ending one period in arrears (July → prior Q4 and current Q1; January → prior Q2/Q3).
- If CMS changes measurement periods or methodologies, those changes will be addressed in the Technical Users' Guide for Care Compare datasets.
Key Definitions and Outcome Measures
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