I am an amateur thespian and have been involved as such at our local community theater. Last Christmas, I was cast as George Bailey in a live radio production of “It’s a Wonderful Life.” To be as authentic as possible, we even dressed in 1940’s attire for the live audience.
My getup consisted of a 40’s style suit accented with a hand-tied bow tie and a fedora.
During the show, I honestly enjoyed wearing bow ties so much that after the run, I continued to wear them frequently, many times with my fedora.
Take a look sometime at the way men dressed in the 1940’s. Routinely, they wore suits, ties and hats, distinctively, across the social strata. There’s something about that style that’s missing in 2024.
Today, when some of those distinctions are revived, it gets noticed. I have experienced this often when complete strangers unexpectedly compliment my hat and bow tie.
Distinctively noticeable
You may be aware that in July, the Centers for Medicare & Medicaid Services updated the Five-Star rating system, in part, with newly adjusted staffing data. Both the adjusted staffing data and the staff turnover data were revised according to new specifications. These changes were enumerated in CMS memo QSO-24-14-NH, and the updated revised July 2024 5-star user’s guide.
Specifically, until this revision, the total nurse and RN staffing data was adjusted for acuity based on the old STRIVE study and RUG IV data, and the turnover time period was 60 days.
Starting with the July update, these staffing figures are now adjusted for acuity based on the case-mix index derived from the PDPM Nursing category HIPPS code, and turnover is now based on a 90-day absence. These are a big change.
In the CMS memo note above, the agency indicated that with these changes, they would “…maintain the same overall distribution of points for staffing measures [but] it is still possible for a facility’s staffing star rating to change. Changes to facility staffing ratings after July 31, 2024, may be due to a few reasons, including:
- The updated staffing level case-mix adjustment methodology
- Changes in the number of staffing hours reported by facilities from one quarter to the next; and/or
- Updates to the staffing turnover methodology”
You may have noticed a distinct change to your staffing star rating in July. Here are some interesting national statistics: 2,419 facilities lost at least one staffing star, and among those, six facilities lost four staffing stars, 41 lost three staffing stars, 253 lost two staffing stars, and 2,119 lost one staffing star. These changes had the potential to affect the overall star rating as well.
More attention-getting detail
In addition to the ongoing effect on the Five-Star ratings, these changes to the staffing star calculations have future implications for the Skilled Nursing Facility Value Based Purchasing Program, or SNF VBP.
Through FY 2025, The SNF VBP will have been based solely on a rehospitalization measure, the SNFRM.
Starting with FY 2026, more measures will be in play that will affect your ability to retain some or all of the 2% VBP withhold. The following table, from FY 2025 rulemaking, is the list of measures and timeline for implementation.
You may have noticed that starting next year, your VBP incentive multiplier will be based on performance in four measures, two of which are the staffing measures that have been revised, as noted previously.
Too much can be overwhelming
Have you seen the yellow tux that the owner of the Savanna Bananas wears? It’s outrageous, but fun. I, however, endeavor to keep my bow tie and fedora combo a bit more subdued.
Time and space limit the detail necessary to explain the minutiae of the SNF VBP. However, two concepts are important to keep in mind.
The first is performance standards. CMS calculates and routinely updates the performance standards for the quality measure(s) that govern scoring that will determine your VBP incentive multiplier, or how much of the 2% a facility will be able to get back.
The second concept is baseline and performance years. For FY 2026 SNF VBP, the baseline year was FY 2022, and the performance year is FY 2024.
Facility performance on each quality measure in the performance year is compared against the performance standards calculated in the baseline year to determine the all-important score(s) and incentive multiplier.
This may be overwhelming, but stick with me.
Pulling it all together, or keeping it simple?
Too much can be too much. Remember Porter Wagner’s get-up? Enough said.
The FY 2025 rule-making cycle added one more wrinkle to our SNF VBP conversation. Remember the pesky changes to the staffing calculations we talked about?
Well, those changes also affect the performance standards for the staffing measures that will impact the SNF VBP in FY 2026.
Beginning with FY 2025, CMS has adopted a policy that would allow updates to previously finalized SNF VBP measure specifications. That means updates to the numerical values for the performance standards for a measure for a program can change if a measure’s specifications were technically updated between the time that CMS published the performance standards for a measure and the time that they calculated SNF performance on that measure at the conclusion of the applicable performance period.
In other words, since the FY 2024 performance year staffing data is based on updated measure specifications, the performance standards established in the FY 2022 have been updated so there can be an apples-to-apples comparison.
Complicated, you bet. Here’s the low down for the total nurse staffing measure.
These performance standard changes may not seem significant, but they will affect FY 2024 performance comparisons. Your FY 2026 SNF VBP incentive multiplier will feel this effect.
One more thing
When I am deciding which bow tie I will wear, I often ask my wife. She has an eye for coordination that is impeccable.
In the same way, you should be asking yourself: What will this look like when it all comes together?
CMS has posted SNF VBP Early Look Performance Score Reports for FY 2026 in IQIES. While these reports do not contain data from the actual baseline and performance periods that will affect FY 2026 payment, they do offer a glimpse into what the expanded scoring methodology will look like and will prepare you for understanding your confidential feedback report next year.
Quality noticeability
I’m a bit bashful when it comes to compliments. Red-faced, I often offer a quick “thank you” and move on to some other topic of conversation. I have, however, noticed that the attention my bow tie and fedora combo have gotten can be valuable.
The conversations they engender cross-generational, political, religious, etc., lines. I have gotten to know people I would never have encountered otherwise, and I’m thankful for that.
In the same way, as you start to pull these concepts together and dress your facility for Five-Star and SNF VBP success, the point will be to get noticed.
Five-star ratings are obvious and have significant positive and negative residuals
A bit more subtle in its application, the SNF VBP incentive can have a substantial financial impact.
Both are worthy of frequent attention.
I am keenly aware that my bow tie requires repeated adjustments throughout the day, and my fedora needs to sit at just the right angle.
Likewise, your facility’s quality reflection needs your attention to maintain its noticeability. Put on your five-star bow tie and SNF VBP fedora and enjoy as valuable connections spot you.
Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation. For further inquiries, he may be contacted here.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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