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October 4, 2018


Medicaid New SMMC Five-Year Contract Begins January 1, 2019

Please join us for the training webinar October 4 at 2:00pm free to FAHA H&S members. This webinar will explain the new credentialing and recredentialing requirements for nursing homes contracted with the health plans for the Medicaid LTC population.

FAHA H&S Medical Directors Dr. Ken Brummel-Smith and Dr. Paul Katz will present extensive detailed information on how to best implement and/or improve your current antipsychotic reduction program.

As of today, 35% of the LeadingAge Florida members do not meet the requirement of being at or exceeding the state average of 14.7%. Thus, these members are at risk to have their contracts terminated by the health plans. There have been improvements since the previous reporting period where 43% of the membership were above the then state average of 15%.


In anticipation of tomorrow’s webinar, below are follow-up articles specific to the antipsychotic percentage requirements and reduction programs.


It is apparent that the added requirements placed in the contract to the health plans are there to enact the goals of the Agency. These requirements and goals are real, measurable and will affect providers.

Two of the Agency goals are reducing antipsychotics and implementing value-based contracting. These goals are clearly written into the new contract and were part of the rebidding process requiring the health plans to implement. These requirements include possible fines if not implemented and monitored.

Why this is potentially problematic to the nursing facility is how this requirement is implemented. For example, a new requirement of re-credentialing will include reviewing the nursing facility providers quality star ratings and antipsychotic percentage. The below is directly from the new contract between the Agency and the health plans:

Within the new contract, there is an eighteen-page section explaining the sanctions/liquidated damages and fines that will be applied if the requirements of the contract are not met. There are 100 specific items to be sanctioned or fined by the Agency ranging from $500 per day to $25,000 per occurrence based on the severity of the offense. These damages will not be passed through to the provider but, the health plans will be diligent in their requirements to ensure they are not fined. Below is a fine for not meeting credentialing requirements:

Value based purchasing is another goal of the Agency to implement through the SMMC contract. Value based purchasing was a repeated theme throughout the rebidding process and is linked to various goals of the Agency. The Agency is requiring the health plans to implement value-based purchasing contracts within their provider network. There are specific contract volume requirements for each year of the five (5) year contract. Most of these will be physician-based contracts but, there are specific measures such as, potentially preventable admissions(PPA) and readmission(PPR) and potentially preventable emergency department visits (PPV) that will affect nursing facility providers.

If you have questions, please contact Dana McHugh via email or by calling her at (850) 339-2909. 



Reducing the Use of Antipsychotics in Nursing Homes

Paul Katz, MD
FAHA H&S Medical Director
Professor and Chair, Department of Geriatrics, College of Medicine, Florida State University

The past several years has witnessed a dramatic reduction in the inappropriate use of antipsychotics in nursing home residents. The prevalence of antipsychotic use in the fourth quarter of 2017 was just under 15% compared to a prevalence in 2011 of 24%!1 This decline has been fueled by several factors, most importantly a concerted effort by CMS to disseminate best practice guidelines while at the same time incorporating the use of antipsychotics into the quality measurement system.

A systematic review of interventions to reduce inappropriate prescribing of antipsychotic medication identified a few potentially effective approaches (see table below).2 The impact of a given intervention was dependent on several factors, most importantly staff engagement, staff availability and integration of the family into the care plan.

Table 1: Interventions to Decrease the Use of Antipsychotics in Nursing Homes2
• Distribution of educational materials
• Educational meetings
• Audit and feedback
• Local opinion leaders
• Reassignment/redefining of staff roles
• Change in physical structure, facilities and equipment
• Presence and organization of quality monitoring mechanisms

A recent report of antipsychotic use in Australia offers additional insights. This initiative, referred to as the HALT study, sought to reduce the use of antipsychotic medication in the nursing home through two key interventions3:

1) Education/training of health care staff and 2) creation of a de-prescribing protocol. In this study the education intervention involved a 3-day workshop where “nurse champions” reviewed concepts around dementia, behavioral and psychological symptoms of dementia (BPSD) and person centered non-pharmacologic treatments. Upon return to their respective facilities, the nurse champions trained additional staff in the concepts and techniques recently acquired.

Deprescribing was facilitated by the creation of an “individualized” deprescribing protocol by a pharmacist which stipulated dose reductions of specific medications over a two (2) week period. Physicians could restart antipsychotic medication if deemed appropriate as well as prescribe the use of short acting benzodiazepine as needed. At twelve (12) month follow-up, antipsychotic use declined by 81.7% without a concomitant change in BPSD or other adverse outcomes such as falls or hospitalizations.

While the type of intervention employed to reduce the use of antipsychotics is clearly important, it is often not sufficient to guarantee success. Priorities must be aligned between those delivering care at the bedside with those individuals making decisions at the administrative level. Reducing antipsychotics requires a concerted team effort. The focus must not merely be that of regulatory adherence but rather on enhancing the safety and quality of life for each affected resident.

1. https://www.nhqualitycampaign.org/files/AP_package_20180416.pdf Accessed August 3, 2018.
2. Coon JT, Abbott R, Rogers M et.al. Interventions to reduce inappropriate prescribing of antipsychotic medication in people with dementia resident in care home: A systematic review. J Am Med Dir Assoc 2014;15: 706-708.
3. Brodaty H, Aerts L, Harrison F et al. Antipsychotic deprescription for older adults in long term care: The HALT study. J Am Med Dir Assoc. 2018;19: 592-600.


ACO Announcements Add to Existing Skilled Nursing Pressures Value-based arrangements generate much of their savings by shifting spending away from the post-acute setting, according to recent government announcements. That ups the already-high pressure on skilled nursing facilities to lower patient length of stay while maintaining quality of care. Read more...

Health plan updates

Important: Medicare Compliance FDR Attestation. All contracted providers for Medicare (Parts C and/or D) or Medicaid must complete an annual Medicare Compliance Attestation by December 31st of each year.

To help improve the accuracy of our claims’ payments, we recently enhanced our system edits to identify claims submitted that are missing laterality specification modifiers. To prevent inappropriate billing claim denials, all providers should ensure they are accurately coding and billing the applicable laterality modifier in accordance with CPT and CMS billing guidelines when submitting claims for payment.

Copyright 2018 — Publication of FAHA H&S
Chair: Brian Robare
President/CEO: Steve Bahmer
Principal/Editor: Dana McHugh

Copyright Information: Copies of the articles and other information in this publication may be non-commercially reproduced for the purpose of educational or scientific advancement. Otherwise, no part of this publication may be reproduced or utilized in any form, or by any means, mechanical or electronic, including photocopying, microfilm and recording, or by any information storage and retrieval system, without the written permission of the managing editor. For permission to reproduce, contact the principal/editor via email or phone at (850) 999-6034. 

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