The Objective

As nursing facility reimbursement models move away from traditional fee-for-service towards value-based payment, state Medicaid programs need to come up with innovative approaches to meet the new challenges. The New Mexico Nursing Facility Value-basedPayment (VBP) Workgroup was formed to develop an approach that would support nursing facilities’ efforts to achieve high quality outcomes, while increasing access to services for Medicaid members.“Value-based payments are a tremendous opportunity for us to better care for our state’s most vulnerable residents,” said Dr. David Scrase, New Mexico’s Cabinet Secretary for Health and Human Services. “But we needed to get all parties working together using the right incentives and penalties to transform our payments system and create a system that would be both effective and long-lasting.

Competitors to Collaborators

The workgroup is made up of the New Mexico Human ServicesDepartment (HSD), the New Mexico Health Care Association (NMHCA),nursing home provider leadership, and the state’s three Medicaid managed care organizations (MCOs).The three MCOs first came to the NMVBP Workgroup as competitors in the New Mexico Medicaid market. Two established MCOs, Blue Cross and Blue Shield of New Mexico and Presbyterian Health Plan, were joined by a newcomer to the state: Western Sky Community Care. The three MCOs had previously collaborated on other projects with each other, with the HSD, and providers. The Workgroup created a new platform for collaboration and knowledge sharing with the goal of better care through value-based incentives. With this goal in mind, the mission of the Workgroup was to help develop the new NMVBP program incorporating input from all the MCOs.

The Net Health® PointRight
products give us the access
we need to monitor and track
much needed quality information
from the nursing facilities.”

Monica Marthell
Manager, Value Based Payment Initiatives,
Western Sky Community Care

The Challenge

As the payers contracted to administer the Medicaid program, all threeMCOs had to address multiple challenges:

  • An aging population with complex medical and psychosocial needs;
  • Geographically dispersed nursing facilities, many located in rural areas, making access to resources for the facilities to provide services for the MCOs’ members a challenge; and
  • Potential for “measure fatigue” for nursing facilities who need to keep track of and manage myriad quality improvement and value-based programs mandated by the Centers for Medicare and Medicaid Services (CMS).

Key KPIs and Goals

The NMVBP seeks to address these challenges through collaboration between the MCOs and the nursing facilities. The program’s approach is to support quality improvement based on tiered performance in four long-stay quality measures (antipsychotic use, UTI, pressure ulcers, and long-stay hospitalization). The quality measurement method was designed with nursing facilities’ needs in mind:

  • To minimize the data collection burden to the facilities, the measures needed to be Minimum Data Set (MDS)-based, without creating new measures;
  • Measures needed to be evidence-based, current, transparent, and actionable, as well as risk-adjusted to enable comparison between facilities;
  • Data collection needed to fit within the facilities’ MDS workflow, and enable the facilities to identify errors and make corrections easily; and
  • Every facility needed to have the opportunity to “win”, with quarterly payouts to maintain positive momentum.

Advanced Analytic Partnership

To implement the program, the Workgroup needed a third-party advanced analytics partner who could:

  • Collect and aggregate the data by facility, corporation, and MCO;
  • Calculate quarterly payment amounts using facility performance, Medicaid bed days, and add-ons for high acuity cases and telehealth;
  • Provide a portal that would enable the facilities to manage their performance and identify residents at risk through predictive analytics;
  • Allow the MCOs access through a group-level portal to give them visibility into facility performance and facilitate care management; and
  • Provide the performance benchmarking and payment calculations for the NMVBP program.

The Solution

After an extensive due diligence and competitive RFI process, Net Health® PointRight, a Net Health company, was chosen out of five finalists as the NMVBP program’s advanced analytics partner. Net Health PointRight’s Analytics team worked closely with the NMVBP workgroup to develop the performance tier cut points and the final methodology for point distribution to the facilities. Net Health PointRight brings to the program the analytics expertise needed to calculate performance tiers and incentive payments, combined with web-based applications. The design and actionable insights offer benefits to all stakeholders:


  • Dashboards for each MCO provide transparency into facility and group-level performance to identify best practice performers and facilities in need of support;
  • RADAR® predictive analytics filtered by each MCO’s member roster enable care managers to follow their members in nursing facilities and see the same risk management information and the facilities’ care teams.


  • The NMVBP application offers a dashboard view of facility level quality metrics, including the Net Health® PointRight Pro Long StayTM risk-adjusted hospitalization measure. The facility dashboard provides tiered performance level progress tracking payment estimates with drill-down to resident-level details, with performance broken down by MCO;
  • Real-time MDS analysis with targeted feedback ensures the facilities’ assessments are coded accurately and ensure accurate capture of Medicaid bed days; and
  • RADAR® predictive analytics identify residents at risk and facilitate care coordination both within the facility’s care team and with the MCOs.

This transparency into facility performance and clinical data allows collaboration on the members’ care plans even when an on-site facility visit is not possible. In addition, the near real time data enables the MCOs’ Care Coordinators access to information that previously was unavailable to them, such as identifying members who have been admitted or discharged prior to when the MCO is notified by the facility. The benefit of easily accessible data: greater collaboration and more efficient care delivery to the MCOs’ members.

The Results

The NMVBP program went live on January 1, 2020, for an initial two-year period. Net Health® PointRight provided extensive education and training for both the nursing facilities and the MCOs, ensuring that all stakeholders can access and navigate the NMVBP application and assure familiarity with the program measures. Feedback from the users noted that the training was excellent, with ongoing customer support, and the application itself is easy to navigate. Currently all nursing facilities contracted with MCOs across the state are actively using Net Health PointRight to manage care and achieve improved outcomes.

Good Results Despite COVID

The COVID-19 pandemic created an unforeseen challenge to care coordination due to both the devastating impact on the vulnerable nursing home population, and the limitations on in-person visits due to quarantine. The Net Helath PointRight online applications provided visibility into the facilities’ data, enabling the MCOs, Care Coordinators, and facilities to continue collaborating to maintain their members’ clinical outcomes as much as possible. Despite the pandemic, the participating SNFs were not only able to hold their outcomes steady but were able to improve over their 2019 performance in Long-Stay Antipsychotics and Net Health PointRight Pro Long StayTM Hospitalization.

[Net Health] PointRight’s knowledge
of nursing facility data, nursing facility
quality measures, and ability to collect
MDSs has been instrumental to the
success of the project,”

“Their software tools are easy to use
with meaningful data and analytics—
both at aggregate level and down to
the facility and member level.”

Tim Voskuil
Performance and Results Consultant
Network Services
Blue Cross and Blue Shield of New Mexico

Satisfied Customers

The successful rollout of Net Health PointRight’s NMVBP solution has also resulted in satisfied customers both at the MCO and the facility levels.

  • For the MCOs, the timeliness of the MDS data has been invaluable in ensuring that Medicaid bed days are captured accurately without having to do their own internal data extracts and analyses. With Net Health PointRight’s data integrity analysis and program calculations, the NMVBP program is able to disburse accurate payments to the facilities much more timely than other VBP programs.
  • For the facilities, the fact that the NMVBP program itself does not rely on new or “adapted” Quality Measures made it easy to adopt, and the users have found the application to be user friendly. Using Net Health PointRight to make sure their MDS coding is accurate and to track and manage their outcomes down to the resident level has enabled the facilities to achieve and sustain improvement

“The Net Health PointRight products give us the access we need to monitor and track much needed quality information from the nursing facilities,” said Monica Marthell, Manager, Value Based Payment Initiatives, Western Sky Community Care

Quality Improvement

With the support of Net Health® PointRight’s advanced analytic platform and tools, the facilities participating in the NMVBP program have been able to improve their quality through hard work and continuous learning. The framework of the program enabled all stakeholders to:

  • Facilitate care coordination and management for all New Mexico Medicaid members in nursing facilities statewide;
  • Identify residents at risk and/or with special care planning needs for focused intervention;
  • Assess areas of strength and opportunities for improvement facility-wide, using Net Health PointRight’s tools for root cause analysis;
  • Continually assess the facilities’ performance and distribution across the tiers with quarterly performance and payment calculations; and Link nursing facility incentive payments to performance through a program that is actionable, collaborative, and based on performance metrics that are familiar to the facilities.