Patient-Driven Payment Model

Transcription

1 Patient-Driven Model

2 Why a New System? Top 10 RUGs in 2015 Comprise 90% of SNF Days and 92% of SNF s RUG RUG Description Total Days 2015 Distinct Beneficiaries Per RUG Per Day Per Beneficiary Total Percent Total Days Percent Total RUB Ultra-High Rehab - ADL ,180, ,406 $505 $12,543 $8,672,521, % 31.5% RUC Ultra-High Rehab - ADL ,390, ,902 $493 $13,549 $6,109,148, % 22.2% RUA Ultra-High Rehab - ADL 0-5 8,469, ,600 $402 $7,861 $3,408,497, % 12.4% RVB Very-High Rehab - ADL ,780, ,232 $343 $5,750 $1,985,100, % 7.2% RVC Very-High Rehab - ADL ,489, ,253 $396 $7,539 $2,173,072, % 7.9% RVA Very-High Rehab - ADL 0-5 4,040, ,086 $339 $5,253 $1,371,439, % 5.0% RHC High Rehab - ADL ,995, ,628 $325 $5,077 $647,923, % 2.4% RHB High Rehab - ADL ,638, ,859 $290 $3,929 $474,802, % 1.7% RHA High Rehab - ADL 0-5 1,327, ,126 $248 $3,255 $329,199, % 1.2% RMC Medium Rehab - ADL ,935 68,932 $266 $3,836 $264,416, % 1.0% 57% 81% 86% Source: AHCA Analysis of CMS Skilled Nursing Facility Public Use File

3 CMS Design Criteria CMS Framework Element Basis for System Development Remain within Existing Statutory Authority Use Existing Resources Develop a Readily Implementable System October 1, 2019 Shifts Away from Therapy as Basis for Average Per Diem Cost Report Data Claims, MDS 2006 Nursing Research Remains in Per Diem Builds on Existing Tools MDS, Claims based on Patient Characteristics Minutes only Counted at Discharge

4 RCS-1 Becomes PDPM RCS-1 PDPM

5 PDPM Preliminary Detail

6 Components Snapshot Component PT OT SLP Nursing NTAS Patient Characteristics Primary reason for SNF Care Functional Status Section GG Early and Late Loss Cognitive Status DROPPED Primary reason for SNF Care Functional Status Section GG Early and Late Loss Cognitive Status DROPPED Primary reason for SNF care Cognitive status Presence of swallowing disorder or mechanically altered diet Other SLP- Related comorbidities Clinical information from SNF stay Functional Status Section GG Early and Late Loss Extensive Services Received Presence of depression Restorative nursing services received Comorbiditi es present Extensive Services received Per Diem Structure decreases - after day 20 - decreases - after day 20 - Average Daily No Tapering Average Daily No Tapering decreases - after day 3 - Case Mix Groups

7 PT/OT Case Mix Groups

8 SLP Case Mix Groups

9 Nursing Case Mix Groups Characteristic RUG-IV Nursing RUG Extensive Services Clinical Conditions Depression Description Collapsed RUGs by ADL score bins Tracheostomy & Vent (only two CMGs) Comatose, Septicemia, Respiratory Therapy Radiation Therapy or Dialysis Pneumonia, Surgical Wounds, Burns Behavioral or Cognitive Symptoms Assistance with Daily Living and General Supervision Yes or No # of Restorative Nursing Services 0-1 OR 2 or More GG-Based Functional Score 0-5, 6-14, 11-16, 15-16

10 Nontherapy Ancillary Services Case Mix Group

11 PDPM Per Diems

12 PDPM Mock Up Component Per Diem (U) CMG CMI Total Per Diem Rate by Component Days 1-3 Days 4-20 Days PT* $59.33 TA 1.53 $90.77 $90.77 $79.87 OT* $55.23 TA 1.49 $82.29 $82.29 $72.41 SLP $22.15 SC 2.66 $58.91 $58.91 $58.91 Nursing $ HE2/HD $ $ $ NTAS* $ $ $84.55 $84.55 Non-Case Mix $92.63 NA NA $92.63 $92.63 $92.63 Totals $825.52/Day $ $ *Component payment tapers

13 CMS View is Administrative Simplification Achieved Day 5 MDS Therapy OMRAs Day 30 MDS Day 90 MDS RUGs IV Day 14 MDS Day 60 MDS Discharge MDS PDPM Day 5/ Admission MDS Interim Adjustment Discharge MDS with Therapy Codes

14 Short Stay Policy Discharges of </=3 Days are Considered Same Stay and No New 5-Day Assessment is Required Unless Admitted to Different SNF Transferred SNF to SNF Interim Assessment Needed and Meet Criteria for Assessment Use Discharges of >3 Are Considered a New Stay and Require a New 5-Day Assessment Clinician Assignment to Clinical Options MDS Re-Assessment o Section GG for Functional Score o Cognitive Functional Scale

15 PDPM s Slope and Create Incentives for Shorter LOS as in RCS-1 COSTS Total Per Diem is the Sum of s for Each Component Base s All Component Taper or Decrease Over Stay Except Nursing and SLP Days 1-3 Days 4-20 Day 30 Day 60 Day 100 PT OT SLP Nursing NTAS s Can be Adjusted Using the Interim Assessment But Do Not Re-Set to Day One for Tapering Components