PATIENT-DRIVEN GROUPINGS MODEL (PDGM) · PDGM DETAILS § Comorbidity Adjustment • The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis.

home health

1

PATIENT-DRIVEN GROUPINGS MODEL (PDGM)

2

OVERVIEW

§  What is PDGM?§  PDGM details§  National Impact§  Preparing for PDGM

home health

3

WHAT IS PDGM?

4

WHAT IS PDGM? Timeline§  November 18, 2016

•  Abt Associates published: Overview of the Home Health Grouping Model (HHGM)

§  July 28, 2017•  Home Health Payment Proposed Rule for CY 2018 is published

§  November 7, 2017•  CMS discontinues plans to move forward with HHGM

§  February 1, 2018•  Technical expert panel (TEP) meeting with Abt Associates

§  February 9, 2018•  Bipartisan Budget Act of 2018 signed into law

§  July 12, 2018•  CY 2019 Home Health Proposed Rule introduces Patient-Driven Groupings Model (PDGM)

§  October 31, 2018•  CY 2019 Home Health Final Rule finalized Patient-D

5

WHAT IS PDGM? Home Health Groupings Model (HHGM)§  November 18, 2016 -- CMS contracted with Abt Associates to reassess the current

HHPPS model and develop an alternative payment model that be\er aligns patient needs and payments•  Abt Associates published: Overview of the Home Health Grouping Model (HHGM)•  Setup of HHGM

•  30 day periods•  Timing•  Referral Source•  Clinical Groupings•  Functional and cognitive level•  Comorbidity adjustment

6

WHAT IS PDGM?

Patient-Driven Groupings Model (PDGM)

7

WHAT IS PDGM?

CY 2019 Final Rule§  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

8

WHAT IS PDGM?

CY 2019 Final Rule cont.§  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

home health

9

PDGM DETAILS

10

PDGM DETAILS §  Rate Se\ing

11

PDGM DETAILS

Timing§  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

12

PDGM DETAILS Reasons for 30-Day Periods•  Estimated 25% of all episodes are less than 30 days

•  73% of episodes completed within 60 days

13

PDGM DETAILS Admission Source§  Patients discharged from an institutional se\ing (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

14

PDGM DETAILS

Reasons for Admission Type§  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

15

PDGM DETAILS

§  Source and Timing Case Mix Impact

Source and Timing Avg Reimb

Community Early $2,164.08

Institutional Early $2,483.18

Community Late $1,455.39

Institutional Late $2,239.14

Source Avg Reimb

Community $1,809.73

Institutional $2,361.16

Difference $551.43

Timing Avg Reimb

Early $2,323.63

Late $1,847.26

Difference $476.37

16

PDGM DETAILS

Clinical Grouping§  PPS:

•  Based on clinical severity levels based on 13 OASIS assessment items

§  Proposed PDGM:•  30-day periods are grouped into six clinical groups based on principle diagnosis

17

PDGM DETAILS §  Clinical Grouping

•  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)

17

18

PDGM DETAILS

Clinical Grouping§  Concerns that MMTA was a “catch all” diagnosis group§  Final rule added subgroups within MMTA

19

PDGM DETAILS

§  Clinical Grouping – Final Rule

19

20

PDGM DETAILS

§  Clinical Grouping Case Mix Impact

$1,500.00 $1,700.00 $1,900.00 $2,100.00 $2,300.00 $2,500.00

AvgReimb

AvgReimb

21

PDGM DETAILS Functional§  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

21

22

PDGM DETAILS

§  Functional

PDGM Details

23

PDGM DETAILS

§  Clinical Group/Functional Level Resource Use

24

PDGM DETAILS

§  Functional Level Case Mix Impact

Functional Level Avg Reimb Difference PercentageLow $1,835.97

Medium $2,113.72 $277.74 15.1%High $2,306.65 $192.93 9.1%

25

PDGM DETAILS

§  Comorbidity Adjustment•  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:

25

26

PDGM DETAILS Comorbidity Adjustment§  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 3 times the median value for the individual subgroups

26

27

PDGM DETAILS Comorbidity Adjustment§  Three Levels:

•  No•  Low•  High

§  Low - Secondary Diagnosis within one of the subgroups listed in table 30 §  High - Two or more Secondary Diagnosis within the subgroups listed in table 31§  *Can be only one of the above (can’t be Low AND High)

28

PDGM DETAILS

§  Comorbidity Adjustment

29

PDGM DETAILS

§  Comorbidity Adjustment Case Mix Impact

Functional Level Avg Reimb Difference PercentageNo $1,942.63

Low $2,047.21 $104.58 5.4%High $2,266.49 $219.28 10.7%

30

PDGM DETAILS LUPAs§  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

PDGM Details

Visit Threshold HHRGs %

2 94 21.8%

3 128 29.6%

4 137 31.7%

5 63 14.6%

6 10 2.3%

31

PDGM DETAILS §  LUPA Thresholds By Clinical Group

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

32

PDGM DETAILS Billing§  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 submi\ed 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

33

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

34

PDGM DETAILS

Miscellaneous§  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%

home health

35

NATIONAL IMPACT

36

NATIONAL IMPACT

§  Estimated Impact by State

37

NATIONAL IMPACT

§  Estimate Impact

National Impact

Facility Type PctFacility Based +3.0%Freestanding -0.3%

Ownership PctFor-Profit -0.8%

Gov’t Owned +2.3%Non-Profit +2.1%

Nursing/Therapy Ratio Pct1st Quartile (Lowest Nursing) -9.6%

2nd Quartile -1.0%3rd Quartile +6.2%

4th Quartile (Highest Nursing) +17.3%

Location PctRural +3.8%Urban -0.6%

home health

38

PREPARING FOR PDGM

39

PREPARING FOR PDGM §  What will be impacted at your agency?

•  Intake •  Coding•  Case Management•  Orders Tracking•  Technology•  Billing

§  What can you do now?•  Determine estimated revenue impact•  Evaluate process•  Contact your EMR •  Contact your Senators and Representatives to support the introduction of three bills (S. 3545, S.

3458, H.R. 6932) to eliminate the behavior adjustment

home health

40

QUESTIONS? Erin Masterson

Consulting Manager

[email protected]

(610) 536-6005 ext. 712