Patient-Driven Groupings Model (PDGM)
Overview & Format • PDGM details • Preparing for PDGM • Leveraging Technology Brian Harris, Craig Mandeville, Consulting Director CEO at Forcura • Use the Questions section on the GoToWebinar panel to submit questions. • Webinar will be recorded and a link to the recording will be emailed to all registrants.
What is PDGM? • Implementation date proposed to be for periods of care beginning on or after January 1, 2020 • Budget neutral – huge win compared to the estimated $950M reduction in payment of HHGM • Replaces 60-day payment episodes with 30-day periods • Eliminates the use of the number of therapy visits in payment determination
What is PDGM? • Increase total number of case-mix weights from 153 to 432 • Modification to low utilization payment adjustments (LUPAs) • Model based on claims with through dates in 2017 that were processed by March 2, 2018 – 6,771,059 episodes – 959,410 (14.2%) excluded due to non-linked OASIS – 7,458 cost reports
What is PDGM? Patient-Driven Groupings Model
PDGM Details
PDGM Details • PDGM: – 30-day periods – The first 30 day period would be defined as early and all subsequent periods would be classified as late – A 30-day period could not be considered early unless there was a gap of more than 60 days between the end of one period and the start of another
PDGM Details • Patients discharged from an institutional setting (inpatient hospital, SNF, IRF, LTCH, IPF) in the prior 14 days will be defined as institutional and all others as community • Second periods with an institutional discharge within 14 days of the SOC would be considered community
PDGM Details Institutional • 1.4 episodes per patient • Higher initial resource use Community • 2.6 episodes per patient • Lower initial resource use • More likely to have chronic conditions, therefore more likely to require ongoing but less resource-intensive care
PDGM Details Source Avg Reimb Community $1,809.73 Institutional $2,361.16 Difference $551.43 Source and Timing Avg Reimb Community Early $2,164.08 Institutional Early $2,483.18 Community Late $1,455.39 Timing Avg Reimb Institutional Late $2,239.14 Early $2,323.63 Late $1,847.26 Difference $476.37
PDGM Details PPS: • Based on clinical severity levels based on 13 OASIS assessment items PDGM Final Rule: • 30-day periods are grouped into 12 clinical groups based on principle diagnosis Questionable Encounters: • Nineteen percent (19%) of the 30-day periods were considered Questionable Encounters (QE) • Updated ICD-10 diagnosis tables added ~5,000 diagnosis codes that previously were considered QE that are now not questionable (38,409 to 43,287) • Estimated fifteen percent (15%) of periods considered QE after diagnosis update • 11
PDGM Details 12
PDGM Details
PDGM Details PPS: • Classified into 1 of 3 functional levels based on six OASIS assessment items • Functional levels based on points: – Low, Medium, High PDGM: Classified into 1 of 3 functional levels based on eight OASIS • assessment items
PDGM Details
PDGM Details Functional Level Avg Reimb Difference Percentage Low $1,835.97 Medium $2,113.72 $277.74 15.1% High $2,306.65 $192.93 9.1%
PDGM Details • The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis. The home health specific comorbidity list includes 13 broad categories with 116 subcategories. Of those 116 subcategories, 13 are included in the comorbidity adjustment of the PDGM:
PDGM Details • Analysis of subgroups was completed to determine which interactions (diagnoses from two subgroups) had increased resource utilization • 343 different subgroup interactions – 187 had significant difference in resource use • 34 had value that exceeded $150 – $150 used as approximately three times the median value for the individual subgroups
PDGM Details Three Levels: 1. No 2. Low 3. High • Low - Secondary Diagnosis within one of the subgroups listed in table 30 • High - Two or more Secondary Diagnoses within the subgroups listed in table 31 *Can be only one of the above (can’t be Low AND High)
PDGM Details
PDGM Details Functional Level Avg Reimb Difference Percentage No $1,942.63 Low $2,047.21 $104.58 5.4% High $2,266.49 $219.28 10.7%
PDGM Details PPS: • 60-day episode with four or fewer total visits are paid per visit PDGM: • LUPAs now have variable thresholds based on HHRG – Different level for each of the 432 HHRGs – 10th percentile value of visits for each threshold – LUPA Add-on remains Visit Threshold HHRGs % 2 94 21.8% 3 128 29.6% 4 137 31.7% 5 63 14.6% 6 10 2.3%
PDGM Details Clinical Group 2 3 4 5 6 Behavioral Health 12 9 15 Complex 16 13 6 1 MMTA - Cardiac 6 9 17 4 MMTA - Endocrine 4 14 13 5 MMTA - GI/GU 9 12 13 2 MMTA - Infectious 10 21 5 MMTA - Other 5 11 10 10 MMTA - Respiratory 9 8 16 3 MMTA - Surgical Aftercare 9 10 12 5 MS Rehab 7 3 8 12 6 Neuro 6 5 9 12 4 Wound 1 13 13 9 Grand Total 94 128 137 63 10
PDGM Details • For billing purposes, PDGM proposes to keep the RAP/final claim billing methodology – CMS estimates the median time to submit a RAP is 12 days so they are soliciting comments on if this makes sense – 5% of RAPs not submitted until after day 60 • New agencies as of 1/1/2019 would not receive RAP payments under PDGM but required to submit a “no pay” RAP – Potential Notice of Admission in the future • Source of admission indicated by occurrence code on the final claim only (not included on RAPs) – Medicare will automatically adjust claim if community is indicated but an institutional source submits Medicare claim • Clinical Groupings and Comorbidity Adjustment based on diagnoses on the CLAIM, not the OASIS – Up to 25 diagnosis codes can go on claim compared to 6 on OASIS
PDGM Details Supplies • Non Routine Supply (NRS) Add-on payments eliminated • Estimated 71% of CY2017 episodes did not contain NRS • Additional Clinical Groupings to account for high NRS use – Wound – 10% of total estimated periods – Complex Nursing – 4% of total estimated periods • Approximately 30% of periods with NRS use • 47% of NRS charges
PDGM Details • OASIS still completed every 60 days • PEPs (Partial Episode Payments) have same methodology • Outliers have same methodology, although fixed dollar loss would need to change – Based on current rules, 4.77% of estimated total payments would be outlier dollars • CMS requirement that number cannot exceed 2.5%
Preparing for PDGM
Preparing for PDGM • Determine estimated revenue impact – Agency-level detail available on CMS website under “Home Health Agency (HHA) Center” provider section • Evaluate current processes and workflows – Are these sustainable under PDGM? • Evaluate current agency data for key PDGM indicators • Contact your Senators and Representatives to support the introduction of three bills (S. 3545, S. 3458, H.R. 6932) to eliminate the behavior adjustment
National Impact
National Impact Ownership Pct Facility Type Pct For-Profit -0.8% Facility Based +3.0% Gov’t Owned +2.3% Freestanding -0.3% Non-Profit +2.1% Nursing/Therapy Ratio Pct Location Pct 1 st Quartile (Lowest Nursing) -9.6% Rural +3.8% 2 nd Quartile -1.0% Urban -0.6% 3 rd Quartile +6.2% 4 th Quartile (Highest Nursing) +17.3%
Departments Impacted • Education to all staff is essential • Strong interdepartmental communication • Reporting on key indicators driving reimbursement under PDGM • Understand the impact of your primary referral source • Obtain as much diagnosis information as possible at time of referral • Strong communication with Scheduling Department
Departments Impacted • Appropriate visit frequency at start of care • LUPA management under new structure • Timely completion of OASIS/visit documentation • Accurate and complete coding is essential • Will determine Clinical Group and Comorbidity Adjustment • Include all pertinent diagnoses – Up to 25 diagnosis fields available on claim; all of these will be considered when determining comorbidity adjustment • Be cognizant of diagnoses that fall under the Questionable Encounter classification
Departments Impacted • Shorter billing period makes quick turnaround on signed orders even more important • Need to evaluate how quickly agency is currently getting new orders to physicians • Determine if current frequency/method of follow-up with physicians is efficient • Volume of claims requiring billing/collections efforts doubles • For the first 30-day period in an episode, shorter timeframe to resolve all pre-billing issues prior to final claim being available to submit • Monitor claims to ensure no processing errors once new structure is implemented
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