8/22/2018. Patient-Driven Groupings Model (PDGM) Leadership Conference. August Overview. What is PDGM? PDGM details.

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1 Patient-Driven Groupings Model (PDGM) 2018 August 5-8, 2018 Overview What is PDGM? PDGM details Concerns 2 1

2 What is PDGM? 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) 4 2

3 What is PDGM? Home Health Groupings Model (HHGM) November 18, 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 5 What is PDGM? Home Health Groupings Model (HHGM) 6 3

4 What is PDGM? Patient-Driven Groupings Model (PDGM) 7 What is PDGM? CY 2019 Proposed 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 4

5 What is PDGM? CY 2019 Proposed Rule cont. 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, ,771,059 episodes 959,410 (14.2%) excluded due to non-linked OASIS 7,458 cost reports 9 What is PDGM? Home Health Groupings Model (HHGM) February 9, Bipartisan Budget Act of 2018 signed into law SEC 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 10 5

6 Rate Setting 12 6

7 Episode Timing 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 13 Reasons for 30-Day Periods Estimated 25% of all episodes are less than 30 days 73% of episodes completed within 60 days 14 7

8 Admission Source 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 15 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 16 8

9 Clinical Grouping Current 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 Clinical Grouping 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 18 9

10 Clinical Grouping Concerns that MMTA was a catch all diagnosis group Proposed rule addressed this and indicated diagnosis subgroups showed fairly equal resource use 19 Functional 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 20 10

11 Functional 21 Clinical Group/Functional Level Resource Use 22 11

12 Comorbidity Adjustment 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: 23 Comorbidity Adjustment 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 24 12

13 Comorbidity Adjustment 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) 25 Comorbidity Adjustment 26 13

14 HIPPS Code Structure 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 27 LUPAs 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: LUPA add-on remains 28 14

15 Miscellaneous Supplies Non Routine Supply (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 29 Miscellaneous 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% 30 15

16 Concerns Disincentives for community referrals Impact on therapy Patients Caregivers Behavioral adjustments Proposed Rate Future Adjustments MMTA Diagnosis Category RAP Billing LUPAs 31 Estimated Impact by State 32 16

17 Estimated Impact by State Rank State 1 VI 2 GU 3 PR 4 MS 5 LA 6 OK 7 NY 8 VT 9 CA 10 OR 11 AK 12 MA 13 TX 14 NJ Rank State 15 AR 16 IL 17 IA 18 NV 19 CT 20 NH 21 DE 22 AL 23 DC 24 NM 25 WI 26 ME 27 PA 28 GA Rank State 29 KY 30 RI 31 SC 32 WV 33 ND 34 NC 35 IN 36 TN 37 OH 38 MO 39 MT 40 WA 41 KS Rank State 42 AZ 43 VA 44 MI 45 MD 46 HI 47 MN 48 WY 49 NE 50 FL 51 UT 52 SD 53 CO 54 ID 33 Questions? Nick Seabrook Managing Principal (610) ext. 702 Consulting Outsourcing Education 17

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