What Every Administrator Needs to Know About the PROPOSED Patient Driven Payment Model (PDPM)

Transcription

1 What Every Administrator Needs to Know About the PROPOSED Patient Driven Payment Model (PDPM) Presented by: Robin L. Hillier, CPA, STNA, LNHA, RAC-MT (330) PDPM Overview Introduced in the FY 2019 Proposed SNF PPS Update Rule Proposed to be effective 10/1/ day comment period ended June 26 Final Rule expected in August, refinements could continue until effective date Builds on RCS-1 proposed last year in Advanced Notice of Proposed Rulemaking, significant improvements have been made 1

2 PDPM Overview Moves away from RUGS Utilizes diagnosis and condition codes Rate is the total of six components Five case mix components each use a different grouper methodology One flat-rate non-case-mix component Utilizes tapering over the course of a stay Reduced assessment burden Budget neutral (?) winners/losers PDPM Components PT* OT* ST Nursing Non-therapy Ancillary (NTA) Non-case-mix component 2

3 PT and OT Components 1 st Tier: Diagnosis that represents the primary reason for the SNF stay Major Joint Replacement or Spinal Surgery Other Orthopedic Non-surgical orthopedic/musculoskeletal Ortho surgery except major joint or spinal surgery Medical Management Medical Management Acute infection Cancer Pulmonary Cardiovascular and coagulations Non-Orthopedic Surgery and Acute Neurologic Non-orthopedic surgery Acute Neurologic PT and OT Components 2 nd Tier: Functional score based on certain GG items Eating Oral hygiene Toileting hygiene Sit to lying Lying to sitting on side of bed Sit to stand Chair/bed-to-chair transfer Toilet transfer Walk 50 feet w/2 turns Walk 150 feet 3

4 PT and OT Components GG scoring rules Set up assistance or independent 4 Supervision or touching assistance 3 Partial/moderate assistance 2 Substantial/maximal assistance 1 Dependent, refused, not attempted 0 (Note: LOWER SCORES RECEIVE HIGHER REIMBURSEMENT!) SLP Component 1 st Tier: Presence of neurologic condition, SLP-related comorbidity or cognitive impairment: None Any one Any two All three SLP-related comorbidity: CVA, TIA or stroke: Hemiplegia or hemiparesis; TBI; Trach; Vent; Laryngeal cancer; Apraxia, dysphagia, ALS, oral cancers, speech and language deficits Cognitive impairment: based on BIMS or CPS 4

5 SLP Component 2 nd Tier: Presence of swallowing disorder or mechanically altered diet Neither Either Both Nursing Component 1 st Tier: Extensive services Special care high Special care low Clinically complex Behavior symptoms/cognition Reduced physical function 5

6 Nursing Component 2 nd Tier: GG based function score Eating Toileting Hygiene Average of: Sit to lying Lying to sitting on side of the bed Average of: Sit to stand Chair/bed-to-chair transfer Toilet transfer Same scoring methodology as used for the therapy components Non-therapy Ancillary (NTA) Component 50 conditions and services qualify for point values of 1, 2, 3, 4, 5, 7 or 8 points (most are 1 point) 12 or higher

7 Non-therapy Ancillary Component High point items: HIV/AIDS 8 Parenteral/IV High 7 IV Meds 5 Vent/respirator 4 Parenteral/IV Low 3 Lung transplant 3 2 point items: transfusion, organ transplant, MS, opportunistic infections, Asthma COPD - lung disease, necrosis, chronic myeloid leukemia, wound infection, diabetes mellitus Non-case-mix Component 7

8 Variable Per Diem Adjustment PT and OT Days 1-20 are paid at 100% Every seven days thereafter, the rate would decrease by 2% Days 21-27: 98% Days 28-34: 96% Days 35-41: 94% Days 84-90: 80% Days 91-97: 78% Days : 76% NTA Days 1-3: 300% Days 4-100: 100% Proposed Assessment Schedule 5-day assessment Interim payment assessment Only required when there is a change in a 1 st Tier payment indicatore Tapering doesn t reset with day one End of the stay assessment Would require reporting of therapy days, minutes 8

9 Interrupted Stay Policy If the resident discharges back to the hospital and returns to the SNF within 3 days, they remain in the same payment categories (or an IPA could be conducted) and they variable rate adjustment does not reset If the resident returns to the SNF after midnight of the third day, it would be treated like a new stay, with a new 5-day assessment for grouping and resetting the variable rate schedule to day 1 Fiscal Implications Theoretically budget neutral Revenue goes down for high therapy cases, goes up for clinically complex cases AIDS cases NTA add-on, 18% increase to the nursing component 9

10 Concerns ICD-10 coding Program integrity Changes in incentives relative to therapy What happens to states who use RUGs? What Should You be Doing Now? Understanding the diagnosis responsible for the SNF stay Upgrading ICD-10 coding capabilities Improving MDS accuracy Section GG Speech comorbidity items BIMS Nursing tier items Reimagine the role of the assessment coordinator Explore new care delivery models emphasizing nursing care Develop strategies for determining therapy/restorative needs 10