Patient-Driven Groupings Model (PDGM) Overview
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Replacing HHGM, the Patient-Driven Groupings Model (PDGM) is sure to be a continued hot topic for home care agencies through the proposed implementation in 2020.
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Patient-Driven Groupings Model (PDGM) Overview
- 1. Patient-Driven Groupings Model (PDGM) 2018 Leadership Conference August 5-8, 2018
- 2. 2 • What is PDGM? • PDGM details • Summary Overview August 2018 Leadership Conference
- 4. 4 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) Timeline What is PDGM? August 2018 Leadership Conference
- 5. 5 November 18, 2016 -- CMS contracted with Abt Associates to reassess the current HHPPS model and develop an alternative payment model that better 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 Home Health Groupings Model (HHGM) What is PDGM? August 2018 Leadership Conference
- 6. 6 Home Health Groupings Model (HHGM) What is PDGM? August 2018 Leadership Conference
- 7. 7 Patient-Driven Groupings Model (PDGM) What is PDGM? August 2018 Leadership Conference
- 8. 8 • 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 CY 2019 Proposed Rule What is PDGM? August 2018 Leadership Conference
- 9. 9 • Increase total number of case-mix weights from 153 to 216 • 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 CY 2019 Proposed Rule cont. What is PDGM? August 2018 Leadership Conference
- 10. 10 • February 9, 2018 - Bipartisan Budget Act of 2018 signed into law • SEC. 51001. Home Health Payment Reform: – Budget neutral HH payment reform by 2020 – Transition to a 30-day Unit of Payment for Home Health Services – Elimination of the use of therapy thresholds in case mix adjustment factors for calculating payments – Annual review to determine the impact of differences between assumed behavior changes and actual behavior changes Home Health Groupings Model (HHGM) What is PDGM? August 2018 Leadership Conference
- 11. PDGM Details
- 12. 12 Rate Setting PDGM Details August 2018 Leadership Conference
- 13. 13 • Proposed PDGM: – 30-day periods – The first 30 day episode would be defined as early and all subsequent episodes 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 Episode Timing PDGM Details August 2018 Leadership Conference
- 14. 14 • Estimated 25% of all episodes are less than 30 days – 73% of episodes completed within 60 days Reasons for 30-Day Periods PDGM Details August 2018 Leadership Conference
- 15. 15 Current PPS: • Episode timing – Early – Late • Therapy thresholds – 0 to 13 – 14 to 19 – 20+ Admission Source PDGM Details August 2018 Proposed HHGM: • Admission timing – Early – Late • Admission source – Community – Institutional Leadership Conference
- 16. 16 • Patients discharged from an institutional setting (inpatient hospital, SNF, IRF, LTCH) 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 Admission Source PDGM Details August 2018 Leadership Conference
- 17. 17 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 Reasons for Admission Type PDGM Details August 2018 Leadership Conference
- 18. 18 Current PPS: • Based on clinical severity levels based on 13 OASIS assessment items Proposed HHGM: • 30-day periods are grouped into six clinical groups based on principle diagnosis Clinical Grouping PDGM Details August 2018 Leadership Conference
- 19. 19 • Nineteen percent (19%) of the 30-day periods were considered Questionable Encounters (QE) • If a 30-day period of care could not be grouped based on the home health reported principal diagnosis, the claim would be returned to the provider for more accurate coding Clinical Grouping PDGM Details August 2018 Leadership Conference
- 20. 20 • Concerns that MMTA was a “catch all” diagnosis group • Proposed rule addressed this and indicated diagnosis subgroups showed fairly equal resource use Clinical Grouping PDGM Details August 2018 Leadership Conference
- 21. 21 Current PPS: • Classified into 1 of 3 functional levels based on six OASIS assessment items • Functional levels based on points: – Low, Medium, High Proposed PDGM: • Classified into 1 of 3 functional levels based on eight OASIS assessment items Functional PDGM Details August 2018 Leadership Conference
- 22. 22 Functional PDGM Details August 2018 Leadership Conference
- 23. 23 Functional PDGM Details August 2018 Leadership Conference
- 24. 24 Clinical Group/Functional Level Resource Use PDGM Details August 2018 Leadership Conference
- 25. 25 Proposed PDGM: • 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, 11 are included in the comorbidity adjustment of the PDGM: Comorbidity Adjustment PDGM Details August 2018 Leadership Conference
- 26. 26 • Further analysis of subgroups was completed to determine which interactions (diagnoses from two subgroups) had a clinically and statistically significant relationship with increased resource utilization • 343 different subgroup interactions – 187 had significant difference in resource use • 27 had value that exceeded $150 – $150 used as approximately 3 times the median value for the individual subgroups Comorbidity Adjustment PDGM Details August 2018 Leadership Conference
- 27. 27 Three Levels Proposed: 1. No 2. Low 3. High • Low - Secondary Diagnosis within one of the subgroups listed in table 44 • High - Two or more Secondary Diagnosis within the 27 subgroups listed in table 45 *Can be only one of the above (can’t be Low AND High) Comorbidity Adjustment PDGM Details August 2018 Leadership Conference
- 28. 28 Comorbidity Adjustment PDGM Details August 2018 Leadership Conference
- 29. 29 Current PPS: • Position 1- Episode timing & therapy threshold • Positions 2 & 3- Clinical & functional scores • Position 4- Therapy utilization • Position 5- Non-routine supply (NRS) score Proposed PDGM: • Position 1- Admission source & timing • Positions 2 & 3- Clinical groups & functional levels • Position 4- Co-morbidity adjustment • Position 5- Unassigned HIPPS Code Structure PDGM Details August 2018 Leadership Conference
- 30. 30 HIPPS Code Structure PDGM Details August 2018 Leadership Conference
- 31. 31 • 216 HHRGs • 30 day payment rate of $1,570.68 Case Mix PDGM Details August 2018 Leadership Conference
- 32. 32 Current PPS: • 60-day episode with four or fewer total visits are paid per visit Proposed PDGM: • LUPAs now have variable thresholds based on HHRG – Different level for each of the 216 HHRGs – 10th percentile value of visits for each threshold – LUPA Thresholds by visits: LUPAs PDGM Details August 2018 – LUPA add-on remains Leadership Conference
- 33. 33 Supplies • NRS Add-on payments eliminated • Estimated 60% of CY2017 episodes did not contain NRS • Additional Clinical Groupings to account for high NRS use – Wound – 9% of estimated periods – Complex Nursing – 4% of estimated periods • 27% of periods with NRS use • 44% of NRS cost Miscellaneous PDGM Details August 2018 Leadership Conference
- 34. 34 • 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 – Potential Notice of Admission to establish the agency as primary if RAPs are eliminated • 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% Miscellaneous PDGM Details August 2018 Leadership Conference
- 35. 35 • Disincentives for community referrals • Impact on therapy – Patients – Caregivers • Behavioral adjustments – Proposed Rate – Future Adjustments Concerns PDGM Details August 2018 • MMTA • RAP billing • LUPAs Leadership Conference
- 36. 36 Estimated Impact by State PDGM Details August 2018 Leadership Conference
- 37. Questions? Nick Seabrook Managing Principal NickSeabrook@BlackTreeHealthcare.com (610) 536-6005 ext. 702 Consulting Outsourcing Education