Webinar: The Proposed Patient-Driven Payment Model (PDPM)—What Does It Mean for Skilled Nursing Facilities?

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Hello, and welcome to MedBridge’s live webinar, the proposed patient driven patient payment model. What does it mean for skilled nursing facilities? You may notice at the outset that the word proposed has been struck through; that is because 48 hours ago, Medicare did finalize the patient driven payment model. So what we are going to be discussing today is an overview of that proposed finalized model to enjoy the full experience of the webinar. Please take a moment to look at the interface below the slide. You’ll find the downloadable course materials, as well as the Q&A and troubleshooting boxes. We invite you to submit questions to the Q&A box. At any time during the presentation, I’m planning to provide written responses to your questions, which will be posted on the MedBridge site at a later date.

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So let’s get started. We have a lot of materials, and I am going to say at the outset that since this is so new, if I happen to say the word proposed, please forgive me because it is finalized a few disclosures financially. I am principal consultant and owner of rehab resources and consulting Inc. Non-Financially. I’m a member of the Alabama board of physical therapy and a delegate for the academy of geriatric physical therapy. On this slide. I have just some common abbreviations that are used throughout the slide deck, and I wanted to provide them here for easy reference. They’re also going to be available in the handout. Now in this first chapter, we’re going to cover the components of the finalized PDPM or patient driven payment model. Here are the references to what we’ll be talking about today. The first bullet was the proposed rule and the second bullet references, the final rule, which was released on Tuesday, July 31st.

So it finalizes PDPM to be effective on October 1st, 2019, as well as finalizing updates to the quality reporting program and the value-based purchasing program today, our time is limited. So I’m only going to be covering the policies related to the PDPM. I want to just briefly review some of the history that went into the development of this model. These clinicians like me that had been working in the skilled nursing facility for the last several years, know that the scrutiny on the utilization of therapy services and the skilled nursing facility has been quite high. In fact, the data shows that as a fiscal year, 2017, greater than 90% of covered SNF PBS days were built using one of the 23 rehab regs. And 60% of those were built in an R U category. So in 2013, Medicare contracted with acumen to conduct a SNF payment method research project in phase one, it focused primarily on therapy.

In other words, how could they replace our minutes that determine the reg level? And they considered a number of alternatives like competitive bidding and a hybrid model. Even a fee schedule that report was put out in may of 2014 in phase two, they used findings from that report as a guide to identify potential models suitable for further analysis, but they also expanded their scope to look at the other aspects of the SNF PBS, and they put together four different technical expert panels to get feedback from stakeholders in phase three, acumen was tasked to assist in developing, supporting language and documentation to support the model, which was ultimately called the resident classification system one or RCS one. You may recall that in April of 2017, Medicare put out the advanced notice of public rulemaking or the advanced notice ANPRM. I’ve never received a lot of comments and then began phase four in October, 2017, they focused on refining the RCS.

One, one model. They conducted additional analysis and the resulting case mix model was named PDPM the patient driven payment model. So this is an illustration of how PDPM will work. Currently. We have four based federal based payment rate components to our case mix suggested two or not PDPM is going to bifurcate the two nursing components into two different rates, a nursing based rate, and a nursing CMI rate. And the therapy case mix is going to be separated into three components, as well as the non therapy case mix being eliminated. And instead it’s going to be distributed amongst these three. So now we are going to have five case mix adjusted components, the finalized PDPM classifies each resident into one of these five and then provides a single payment based on the sum of those, the payment for each component is going to be calculated by multiplying the CMI or case mix index for the residents group by the federal base payment rate.

And then for certain components by a specific day in the variable per diem adjustment schedule, which we’ll discuss later. So we’re going to begin taking a closer look at how each of these residents are going to be classified in each of these groups. The reality is that the system will be more complex than what we’re used to under the reg sports system. So the goals of this project were to compensate SNFs accurately, but instead of reimbursing them or paying them based on the services provided, they want to, they want to pay facilities based on the complexity and the characteristics of the patient. And they also want to address the concerns of over utilization of therapy. The concerns of the office of inspector general, MedPAC the department of justice and other policy watchdogs that the system only rewards therapy delivery and not what the patient actually needs.

And lastly, they wanted to increase simplicity. I think everyone will agree that the reg system has gotten very complex in other words, counting minutes every day and increasing number of OMERS to complete. And so by limiting the number of assessments providers have to provide, I hope that it will simplify the system when the reg for model utilizes service-based metrics to classify the resident such as the type and amount of therapy and or the type or amount of nursing care. The proposed PDPM is going to separately identify and adjust for the needs and characteristics of the resident’s care and combine this information to determine payment. Medicare believes that the PDPM will improve the SNF perspective payment system by basing payments predominantly on clinical characteristics rather than service provision. And again, they also believe that it will help providers and save costs by decreasing the number of assessments.

So the proposed implementation October one 19 is now the finalized implementation beginning October 1st, 2019. These are the data sources that were used to come up with the PDPM beneficiary enrollment demographic information was extracted from CMS enrollment databases. The beneficiaries they study were required to have continuous Medicare part a enrollment during their entire SNF stay. They looked at demographic characteristics like age, and they looked at other enrollment data from other sources. They looked at Medicare parts, a and B claims to conduct claims analysis, both SNF inpatient part, a bills and hospital swing bed bills were used. The part a stays were constructed by linking the claims that were, that were submitted by the SNFs to acute care hospital stays that qualified the beneficiary as well as post discharged types of types of claims that were submitted and service utilization. So they looked at outpatient hospital, physician, home health hospice, and then of course they use the minimum dataset assessments as the primary source of resonant characteristic information used to explain resource use.

So the proposed finalized PDPM is developed to be a payment model that derives almost exclusively from resident characteristics. The case mix system identify certain aspects of the resident’s care, which when present lead to add higher average costs or lower average costs, then the regular patient. For example, if we found that give holding all else constant, the presence of a given condition was correlated with an increase in therapy costs for persons with that condition. Then it could mean that that condition is indicative or predictive of increased costs. So that’s how the case mix is built, taking the average patient and then determining what makes the average patient cost more or cost less. So this slide shows the major differences between reg four and PDPM, and you can see, there are a lot of differences. We have an increase in the number of the rate of components.

We have a shift in the types of ADL’s that are considered. We have the primary clinical reason for this day, that impacts four of the five components. So I want to point out here that this currently says two of the five components, but in the finalized model, that is, is for cognition also plays an important role as does the non therapy ancillary costs. The biggest is probably that the intensity of therapy is not a factor at all in determining the PDPM level, the number of required assessments, definitely increases, but as you can see here, we have a significant number increase in number of types of categories.

So let’s move on and look a little bit more. We have PT and OT that were split out in the finalized version of PDPM. So rather than a combined PT and OT component, we now have two. The comments are stated that combining PT and OT might encourage providers to inappropriately substitute one for the other. And also the technical expert panels stated that PT and OT should be addressed via separate components as clinical practice evolves and has this system is used Medicare does plan to reevaluate those characteristics that are predictive of PT and OT. So right now, while we use functional components and cognitive components, they may change that in the future for the functional component. The RCS model was using section G, but as we’ll see, PD at P M is going to use section GG and Inder PDPM cognition does not play a role in PT and OT case mix.

And we’ll talk more about that in a minute for nursing, the number of nursing categories is decreasing from 43 to 25, and that’s because they are being collapsed. So in chapter two, we’re going to take a closer look at the clinical categories for PT, OT, and SLP. When Medicare began investigating resident characteristics that were predictive of therapy costs, they found that PT and OT costs per day were only weakly correlated with speech costs per day. In other words, what predicted cost for all three was not the same. So the resident characteristics that predicted PT and OT usage was different than those predicting speech. And what’s interesting is the predictors of high PT and OT costs per day were actually predicting lower speech costs and vice versa residents with cognitive cognitive impairments. Historically, according to the claims received less PT and OT, but more speech therapy.

So they found under RCS that, that the most relevant categories that predicted PT and OT cost per day were clinical reasons resident’s functional status and the presence of a cognitive impairment. However, in the finalized PDPM, they received so many comments that the RCS one had way too many group combinations that these tried to reduce the number. And when they analyzed functional status using section GG data, rather than G they found that cognition no longer was predicted. And so under PDPM that has been dropped. So PT and OT are looking at clinical reason for stay and functional status as the predictors of what the case mix is going to be. Now, here are the clinical categories in an earlier slide. I showed you the data sources, Medicare used to do their, their research. And again, this shows the top categories that PT and OT patients have been falling into based on billing for the last five plus years.

They took these categories and then collapsed them down into five in order to reduce the number of categories that, that it creates. Again, they found that the costs associated with these components were essentially the same. So all of these five had similar costs non-surgical and ortho had the same cost, non ortho, and acute had similar costs and major joint replacement or spinal surgery kind of stood out on its own. So what we have now is we have different care. We have different categories, we have major joint replacement, non-orthopedic surgery and acute neuro. We have this category that is, these two are combined into one that says other orthopedic. And then we have these last five that are all combined into one medical management. Now, ortho non ortho surgery and medical the non ortho non-surgical orthopedic, musculoskeletal and ortho surgery are combined into one as well.

So another comment that they received was that that co-morbidities should be included as determinants of payment in PT and OT case mix in response to all of those comments, Medicare did conduct further investigations, and this table shows some of the MDs items that they looked at as well as other ICD 10 codes that they looked at to determine if any of them really affected or predictive of costs. And unfortunately they did not find that these co-morbidities significantly impacted costs and therefore they decided not to include it in the model. Now, if you look at the table that they put in the technical report, you’ll see that only one condition was associated with a statistically significant increase in costs for both PT and OT. And that was J 1700 all within the month prior to admission. However, they determined that that was too small of a cost to include, even though it was actually a $2 and 50 cent difference in PT cost per day and a $2 and 33 difference in OT cost per day, which we all know adds up, but they decided that was not statistically significant enough to include.

So for PT and OT, what’s going to happen is I 8,008, the first line and I in the section I eight that are first line of 8,000 on the MDs is going to be used to capture the primary reason for the skilled nursing facility stay in. The code is going to be mapped to one of the 10 categories. In some cases that ICD 10 code may map to more than one because a resident could be categorized into a surgical clinical category. If they received a surgical procedure during the immediately preceding inpatient stay that related to the primary reason for the parties day and the proposed rule, they had thought talked about using procedural ICD 10 codes to indicate these procedures. In other words, skilled nursing facility providers would have to learn procedural coding and include those codes on the MDs. Thankfully, however, in the final rule, they decided not to do that. Instead, they’re going to add some subcategory questions in J 2000 that will ask you to check a box that indicates the type of surgery a patient had, and that relates to their prior inpatient stay. So therefore you would need to indicate that in order for the patient to be appropriately categorized, another proposal that they had, and this is just a snapshot of [inaudible] that section in the MDs. And so right here, this line is going to be very important for categorizing for the PT and OT case mix index.

So let’s begin to look now at what what characteristics were found to be predictive of speech costs. So in speech, the resident, the characteristics that were found to be predictive were the clinical reason for this day also presents or swallowing of presence of a swallowing disorder or a mechanically altered diet and cognitive status. So a model using predictors of clinical stay for skilled nursing facility or clinical reason for this day, the presence of a swallowing disorder or a modified diet, all of these co accounted for approximately 14.5% of the variation in speech costs per day, they looked at using a much more extensive model and they actually modeled over a thousand different characteristics, but it didn’t really help their predictive their predictive value. So Medicare concluded then that those four predictors alone explained the largest share of variation. And they stuck with those in the final rule.

This slide shows that they looked at the same top 10 clinical categories as they did for PT and OT again, because these were the top 10 clinical categories that explained admissions to a skilled nursing facility. And when they compared these to the actual costs of skilled of speech therapy, only one stood out and that was acute neuro. So therefore the speech next component is going to be determined, basically asking a question, does the patient have an acute neuro diagnosis or not? So they only have two categories for clinical reason to put them into a case mix. The analysis also revealed that costs increase when a patient has either a swallowing disorder as noted in MDs K O 100 Z or a mechanically altered diet as noted in Kao Kao 15, 10, or the presence of both. So when both are present, the SLP costs increased even more. Now, Medicare did say they planned to monitor specifically for any increases in the use of mechanically altered diets among the SNF population, because they want to make sure that these diets are not being prescribed based on a financial consideration rather than for clinical need.

So in chapter three, we’re going to look at the role of function cognition and the nursing categories under the proposed RCS, a resident was going to be categorized basically using only three ADL areas, but due to the urging of providers Medicare investigated using section GG items as well since skilled nursing facilities have been using them now since October of 2016. And they did find that they use of section

GG, better align the payment model with other quality initiatives. And as we would suspect provided a more comprehensive measure of functional abilities they were all very strong predictors of PT and OT costs except for the two wheeling items. So therefore the wheeling items are going to be excluded from the functional measure. Now, this slide shows the relationship of section G two costs of therapy, and this is how they came up with the idea that the more dependent a person is as measured by section GG over here, the lower, the cost of PT and OT, and the more independent someone is, they may receive some therapy, but not as much as those patients who scored right in the middle on section G items.

That’s why PDPM and using section GG did include both the early and the later loss ADL’s. So this chart actually shows how section GG response code in the left side of the column is going to add up two points over here. So for all items except the walking, if your is at oh four in section GG, that’s going to add to three points on the walking items. If a person walks 50 feet, when makes two terms with partial or moderate assistance, that will get you two points. Now, unlike section G section GG measures, functional areas with more than one item. And so this really results in some overlap, for instance, between the two bed mobility items, the three transfer items and the two walking items. So because of this, then a simple, some might inappropriately overweight. So to adjust for it, they are going to be averaging some of these larger mobility tasks they’re going to.

So they’re going to average the scores for the two mobility average, the score for the three transfers and average the score for the two walking items. Those averages then are going to be summed with the scores for eating oral hygiene and toileting hygiene resulting in an equal weighting of the six different activities. So the scoring algorithm produces a function score that ranges from zero to 24, any missing values for section GG, they’re going to receive zero points. Now, again, remember that for quality reporting, you don’t want to have missing items, but in the event, they’re there. It’s going to be a zero. An item scored with a 10, not attempted due to environmental limitations will be assigned also assigned to zero OTs on the call may notice that there are only three of the ADL’s on here, eating toileting and hygiene. And the main reason for that right now is because that is all, all of the self care Gigi items you’ve been collecting up until now.

We know that effective October one of 18 you’ll begin collecting other items, but Medicare doesn’t have any data on that. So they did say that, you know, over the next couple of years, they will re-examine that data and determine if it too should be used to come up with a functional score for the payment model. Now, another thing to keep in mind here is that the proposal talked about using GG oh one 70 H one, does the resident walk, but that item is going to be retired on the MDs effective October one of 18. So instead they are going to use the item walk 10 feet GG, oh 1 71 to determine if the patient has a significant mobility impairment. So if you identify that the patient can’t walk and GG, oh, one 70, then these two items down here will also be scored dependent because it will turn on a skip pattern.

And they’ll just automatically receive a score to zero. So that gives us then is that we have 16 case-mix groups for the PT and OT components. And the reason they dropped the cognition cognition was because they found with the inclusion of section GG that cognition didn’t really play an important role in classification. So they removed it in order to decrease the total number of case-mix indexes. These two slides show the, the the case mix indexes for the various categories, with the section GG or the functional score here, the case mix, as it will appear on the MDs and then the PTC EMI and the OT case mix index. And this, it continues on this slide. Now we’re going to look at the third component of the STK snakes. So, which is cognition. If you recall from the RCS, one proposal cognition was supposed to be considered for PT and OT as well.

But like I just said, they changed their mind. Now currently under skilled nursing facility, PPS cognition is used to classify a small portion of patients that fall into the behavioral symptoms and cognitive performance reg for but in actual it actually in 15% of five day MDs is the bands is not even included. So in these cases, then the assessor is directed to skip the BAMS and use the cognitive performance scale, which is represented by this slide. And on this slide though, the the short-term memory is used for payment, as well as cognitive skills for daily decision-making. Those are the items in the current MDs that are used for payment in 2015, Thomas at all published a study using a new cognitive measure. That was a combination of bins and CPS into one scale. And it’s called the cognitive function score or CFS.

So following suggestions from one of the technical expert panels, Medicare explored and found that there is a relationship between different levels of cognitive scale and resident costs. And they found that this new CFS that uses both bins and C and the cognitive performance scale could be used to put patients into one of four cognitive performance categories. So this shows that that combination of bins and CPS, obviously when a patient is cognitively intact, then then there would not be the necessity to have much resource use that these are the other four, the other three levels. So whether a patient is scored on the beams or through the CA the cognitive function scale, it can be the patient be classified. Similarly, regardless of whether the bins is empty.

So we have these three categories to reduce the number the number of splits they simplified to determine what were you know, the best predictors of cost. And so the research showed that patients who have mild to severe cognitive impairment as defined by this scale was associated with at least a 100% increase in average speech cost per day. The other thing that increased speech costs per day was the presence of a speech related comorbidity. So for each condition or service on this table, that if that was present, then there was at least a 43% increase in average cost of speech per day. So all of these co-morbidities were combined into a single flag. And what that means is that if the patient is coded on the MDs to have one of these comorbidities, then the flag is turned on and the facility where we see an extra that, you know, that’ll be taken into account in considering the CMI it’ll bump it up for the speech component and then to reduce the number of splits, they simplified them to become more consistent with PT and OT.

And the bottom line is there are 12 different payment groups now for speech therapy. This shows the combination of those three categories into a case mix. So you can see it’s a little bit complicated, but essentially if a patient has one clinical condition, for instance neuro and acute neuro condition, and they have a comorbidity or a cognitive impairment along with a a mechanically altered diet and a swallowing disorder, then the case mix is an S well, if they have any one of these, if they have both and mechanically altered diet or swallowing disorder, then their case-mix group is in SF. And their case mix index is a 2.97, but if they have all three and have both an NAD and a swallowing disorder, then it’s a 4.19 case mix index times the federal rate. So, one thing I want to remind everybody is this system does not rely on the provision of therapy.

In other words, providers, if the patient meets all of these characteristics that I just talked about, they’re going to receive money under a speech component. It doesn’t, it’s not, it’s not predicated on the fact that you did, or didn’t obviously things are going to be watched, but that’s why it’s important as we’ll talk to the end about interdisciplinary planning and you know, and, and showing good clinical programs because the facility is going to be getting the provider is going to be getting a payment for all of these groups. And then the facility decides the mix and amount of services to be offered.

So now let’s begin to look at the nursing categories under red for the residents, individual nursing needs were not differentiated very well. For example, a patient that was placed in an RGB had a nursing case mix of a 1.56 at 1.56 basically means that this patient has 56% higher nursing costs than a person with a 1.0, which happens to be CB one. So again, you have to ask yourself, is that always true? And the actual cost data from providers showed that it wasn’t true. So since we discussed earlier, that approximately 60% of all patient days are built using one of the three ultra high rehab regs. Then that means that 60% of all, all, all PPS days are paid at the exact same level of nursing needs. And it implies that that 60% of patients need the exact same amount of nursing resources. Now we know in reality, that’s not true.

So PDPM wants to change that. So the reg for non rehab groups currently classify residents based on their ADL score, the use of extensive services, the presence of specific clinical conditions like depression or pneumonia or septicemia, and the use of restorative nursing services. So those characteristics are associated with nursing utilization based on the strive study under PDPM, Medicare’s going to continue to use that existing reg for methodology, but again, by pulling it out separately, then they are going to be paying specifically based on that mix. They’re also going to reduce the number of nursing regs by decreasing distinctions based on function and the last update for the nursing as the actual case mix indexes. When they went back and looked at the strive study originally, when they came up with nursing case mix indexes, they only considered patients who did not receive who did not receive therapy. Okay. Now, for purposes of this PDPM they put all of that data into the same pot and then came up with the case-mix indexes. So they’re recalculating nursing time using the data from all the patients in the strive study.

Now, the change to using section GG for nursing is a big change. I can’t tell how much I’ve heard from nurses and, and other stakeholders that they’re very concerned about. The switch from G to G G ever since the inception of BMC MDs nursing has been using section G. So there’s going to need to be a lot of training for all staff on the definitions of section GG items and MedBridge is going to be providing. And they were going to have materials and resources for training a section GG for both nurses and therapists specifically PDPM is going to replace the four late loss items from section G to using seven section GG items, eating toileting to bed mobility items of sit to lying and lying to sitting on the side of the bed and three transfer items, sit to stand chair, bed to chair and toilet transfers.

Now, when you think about it, these are still reflective of the tasks included in the four section GI items, but it certainly does present an opportunity for training of nurses and CNAs as well as therapy, because we’re really going to need to understand these definitions and the rating scale. This table shows the actual scoring methodology for the functional items under the nursing category. So you can see that they’re going to use the same the same ADL scoring methodology that we looked at with PT and OT for aiding. The ADL score will be zero to four, zero to four, to self-care average of two mobility, bed mobility items, and average of three transfer items. So the final score will average all of that. And the, the nursing function score will range from zero to 16, with zero being most dependent and 16 being most independent.

I realized that is quite the shift from section GG because it’s opposite the higher the score. And in G the more dependent someone is, but under PDPM the higher, the score is the more independent someone will be. So this the following two slides show the reg four categories with the new PDPM case mix index. Now, one thing I do want to point out here is, as I mentioned, they collapsed some of these codes. So for instance, D and E I’ve been collapsed into one. So H E two and HD two both have the same case mix index that’s because they are now, or they will be under PDPM one category H E one, and HD one will be the same category. Same that same follows all the way through. Now, the only difference here is that when you have an a, they maintained a on its own.

So your PA two and your BA and your CA are going to be maintained on their own because they found that those were associated with much lower nursing utilization, and therefore they didn’t want to put it in with anything else. They also maintained the three extensive services on their own. So those are going to be standalone as well. So on this slide, I want to point out just some changes in the nursing CMI from reg. For the one thing I want to make point of is that there are no losers, but the nursing CMI under PDPM, they all go up, some, some go up more than others, but and, and some individual ones may have decreased a little bit as slightly, but again, because they’re merged now that in totality, they’ve all gone up. All right. So what I pointed out here is that, you know, these highlighted in blue are just the ones that, you know, went up significantly, or what I would call significantly, you know, more than more than a 0.4 0.5 case mix index. So you can see, you know, here’s one that went up 0.3, here’s one that went at 0.3, five here’s one that went up 0.3, nine, so significant increases there. And then on the following slide as well, there are many winners in this. Now, if you go if you go over here, these are the ones that didn’t increase as much. Okay. So certainly don’t consider these losers because they still went up, but they went up by a little less than what we saw on the previous slide.

Okay. The last thing on the nursing is that I wanted to point out the change for HIV and aids patients under reg for providers receive a 128% increase in payment for patients with a diagnosis of HIV aids. The MDs doesn’t allow coding of HIV aids because several states have laws that prevent the reporting of it prevent reporting that information to Medicare. So they have to include it on the claim form when submitting bills and that triggers an add on payment. So under PDPM, however, the rate increase is only going to be at 18% of 1.18, rather than a 1.28. And that’s because they just determined that the costs associated with caring for these patients has decreased since, you know, time and, and care practices have evolved. So now we’re going to shift to the non therapy ancillary case-mix under the current SNF PPS payments for non therapy.

Ancillary costs are included bundled into the nursing component, but this has long been criticized by MedPAC and providers because they didn’t think it accurately targeted provider payments for things like dregs. So when a response to that Medicare conducted research and found there were three categories of cost-related resident characteristics that led to higher NTA costs. And those were co-morbidities the use of extensive services and a residents age. So for resident co-morbidities and extensive services, they used multiple years of data and looked specifically at MDs items and ICD 10 codes age was initially considered, but they determined that the effects were too random and there was very limited predictive value. So they determined that certain conditions were associated with certain, with higher non therapy, ancillary utilization. However, some are left off the list because of clinical concerns about the subjectivity. So for example, esophageal reflux was excluded because it’s a very common condition.

Migraine headache was also excluded because again, coding reliability is not as good for some of those conditions. So how our NTA is accounted for under PDPM, well, each condition or service that’s provided has points associated with it. And it’s very much like the system used in the inpatient rehab facility, it then fits into a total weighted count. So it accounts for the additive effect of having multiple comorbidities or multiple extensive services or dregs while providing still for some granularity. So a patient’s total comorbidity score is going to be the sum of the points associated with all of the residents, comorbidities and services, and then put them into an NTA case-mix group. Now in the handout that is provided to all attendees, we have included the table of all the co-morbidities and services that were finalized. And PDPM two days ago, and this table shows all of the number of points that are associated with each one. It also shows you whether that information is obtained from the ICD 10 code or from an MDs item.

Okay. This also shows the splits between the points assigned and the number of NTA grouping. So you can see that the more points someone obtains then the higher, the case mix index goes for that patient. All right, chapter four, we’re going to talk about the variable rate per diem or VPD a as well as the MDs changes, the social security act requires that skilled nursing facilities must be adjusted for case and based on a resident classification system, it also specifies the payments must be made on a per diem basis or a per day basis. So PDPM could not change that. However, in examining costs over a stay, Medicare found that for certain categories of SNF services costs declined over the course of the stay. This was most, most notable in PT and OT costs that over the course of a 100 day stay, it decreased non therapy.

Ancillary costs, of course also were very concentrated at the beginning of the stay, but then were went lower and speech, and was relatively constant. They couldn’t really look at nursing because nursing doesn’t report costs or minutes or hours on a claim form every month. So they didn’t really have any way to look at nursing. So again, these shows that the there’s, these two slides are from the acumen report and they just show that PT and OT costs remain very high for the first 20 days of his day, and then start declining in the third week. And that MTA is over here really are high. And the first part of this day, and then real, and then decline. So under a P under the PDPM Medicare is going to use a variable per diem adjustment. And that means that they’re going to have one adjustment schedule for both the PT and OT components and another for the for the NTA component. And this table provides the adjustment factors and finalized schedule for the NTA component.

All right, so this shows PT and OT. And again, essentially this schedule shows a point a 0.3% daily rate of decline in PT and OT after day 20. So what that means is the PT and OT case makes, is going to be paid at 100% for the first 20 days. And then every seven days thereafter, they’re going to pay for days 21 through 27, they’re going to pay 98% of that per diem, 28 through 34, 90 6% of that per diem and so on and so forth. So for simplicity, they decided to do it on a weekly basis or every seven days after day 20. Now, practically speaking the the PT and OT component on a given day is equal to the base rate multiplied by the CMI for that resident multiplied by the variable per diem adjustment factor for that particular day.

All right, let’s look at some of the MDs 3.0 changes that were finalized within the SNF PPS. There are two of assessments scheduled and unscheduled and scheduled. You have over here on the left. And again, there are unscheduled assessments such as the started therapy and into therapy cot. We’re all familiar with the OMERS. Now, since the SNF PDPM relies more heavily on resident characteristics that they consider stable over his day, and they want to reduce administrative burden. Medicare made an effort to reduce the number of assessments. So under PDPM the five day SNF PBS scheduled assessment is going to be used to classify the resident under the SNF PDPM for the entirety of their stay effective October 1st, 2019. Now, since Medicare is patients are unique and can experience clinical changes. Then there will also be a new MDs effective October one, 19, that they are calling an interim payment assessment or IPA.

It’s essentially going to be the five day MDs. We’ll talk about more about how to utilize that in, in now the the interim payment assessment is going to be optional. All right, in the proposal, it was required in the finalized rule. It’s optional. And here’s the thing providers determined. What are your criteria for when the IPA completed the ARD, you will choose the ARD that you think reflects that triggering event that caused a significant change in the patient. So payment is going to begin on the same day as the ARD. So again, that you might only do an interim payment assessment. If you feel like the patient’s case next has significantly changed. Now, when an IPA is completed, the variable per diem adjustment will not change it. Doesn’t reset at one, it will stay where it is wherever you are on the patients.

You know, 100 day stay. Medicare said that if it were reset, then providers would be incentivized to do multiple IPA’s during the course of their stay. So if you have not realized it yet, I’m going to say it again right here. The number of therapy minutes that are provided under PDPM does not matter the reg levels of one fifty three, twenty five, five hundred and seven twenty are going away. How many minutes of therapy are provided are going to be up to the clinician and the interdisciplinary team to determine, and it will be driven strictly by what the patient needs. Therefore, there will be no need to report minutes every seven days. However, because of the concern of advocacy groups and a lot of stakeholders that therapy delivery would be significantly cut. Medicare decided to add this section to the discharge PPS assessment, because remember, we’re not doing any other assessments except the five day.

And this one is going to be completed on every patient. That’s discharged from a part a stay. And what this means is that you will have to report the total number of therapy minutes provided during this day. So from day one, what was the total speech individual, the total speech concurrent, the total PT, concurrent, the total OT, concurrent, and so on and so forth, as well as the total number of days of each therapy and CMS intends to use this, to ensure residents are receiving therapy that is reasonable and necessary, and that it’s not being cut significantly.

So this, these, this, these, those two slides show the sections that are going to be added only to the discharge assessment. Now, for those who practice in swing beds, you’re going to have three new items on your MDs effective January one of 19. And that’s because these three items you currently do not collect, but they will be important to determining your PDPM right. So they’ll be added to your swing bed assessment. Let’s look at the change in therapy policies. Now, a PDPM does limit the amount of total group plus concurrent to less than 25%. Now you may be saying, well, LM, you just said that, you know, we’re not going to have to monitor and count minutes. You, you aren’t on a week to week basis, right? You’ll report your minutes on the five day MDs. Like you always have, it won’t have any bearing on what you get paid, but you will need to count your group and concurrent minutes throughout the stay.

But then you’ll only need to report your total at the very end. However, skilled nursing facilities are going to have to report how many concurrent and how many group minutes were provided and that’s going to be tracked. So if you submit your MDs, your DC MDs, and it shows that you provided more than 25% total group and concurrent her discipline, the provider is going to receive a non-fatal warning, edit on the validation report. It’s not a fatal one, but it’s a non-fatal warning, which means that it’s going to be a reminder to the facility that you are out of compliance, still going to go through, but you’re going to be reminded. Medicare wants to monitor that. And if they find any other uses or are, and that, you know, providers are going over a lot, then they will flag it. As you can imagine, they fear that there might be incentive to reduce the amount of an individual therapy provided to SNF residents under PDPM and use concurrent and group differently.

You can see from this table down here at the bottom, that I’ve just provided kind of historically, prior to the allocation of concurrent and group, you can see concurrent was very popular. 5% of the minutes were concurrent, less than 1% were group. Then when they decided to allocate concurrent, it suddenly went from 25 to 8.8% of all minutes, while group bumped up. And then when they decided to allocate group, you can see how we reacted there as well. So since there is no allocation anymore, CMS is concerned that these two numbers are going to significantly jump back up and again, as providers and, and, you know, therapists who own this, we have got to be careful of that. Next is the interrupted stay policy. Other Medicare post-acute care providers have interrupted state policies that provide for when a patient temporarily goes to another setting like an acute care hospital and then returns.

And what this slide shows is that 77% of all SNF stays involved just once day. But in those 23%, that involve more than once day. 70% of them had two stays. Most of these were rehospitalization and readmit to the same facility, but 14% were discharged to community and then readmitted to a SNF without hospitalization. So what they want to do is they want to implement a policy that when a resident is discharged and returned to the same skilled nursing facility by 12:00 AM, at the end of the third day of the interruption window, the stay would be a continuation of the previous day for both the clinical classification and the BPDA when a resident in return is discharged and returned to the same SNF, but the absence exceeds the three-day interruption window. Then it will be considered a new stay. The payment schedule resets and a new MDs would have to be done.

So this is going to become effective October one of 19 in conjunction with the implementation of PDPM. So the resident, if they’re admitted, if they’re gone more than three days, you do a brand new five day MDs. But if they’re re-admitted within three, that three-day window, even if it’s from the community, if it’s from a different SNF, Nope, shouldn’t say that it’s not from a different snip. If they are interrupted from the community or hospital, then you don’t do a new one. It’s only if they are transferred SNF to SNF in less than three days, that you would do a brand new MDs. So they’re not going to require that you pick up where the last skilled nursing facility left off. So here’s some examples. An example, one patient was discharged on day three, sick June, June 30th, readmitted on July 4th, because that’s longer than three days.

You’re going to do a brand new five day MDs and start over on day one for both the MTA and PTO T example to discharged on day seven, June 30th, readmitted seven to you’re not going to do anything new. You’re just going to pick up where you left off and start the BPDA on day eight, because that’s where you left off. Now, the only time that would change is if you felt like there was a need to do one of those new interim payment assessments. So that would be your call. Third example, discharge on day seven, June 30th, readmitted to a different skilled nursing facility on July 2nd. And this example, there would be a new five day MDs and done, and they would start being paid with day one. So again, you always reset the BPDA today. One when they’re remitted to a different SNF, only reset BPDA today.

One when it’s greater than three days and readmitted to the same SNF, always complete a five day when the residents are DC and we admitted to a different SNF and only complete the five day when they’re D seed in greater than three days and readmitted to the same SNF, unless the criteria for the interim payment assessment isn’t met. So remember it is optional. Now, how does PDPM relate to the SNF level of care review? Well, we know that the case mix adjustment aspect of SNF PBS has been based in part on the need for skilled nursing care and therapy. Then during claims review, there is administrative presumption that utilizes the beneficiaries initial classification, and one of the upper 52 regs to assist in making certain SNF level care determinations PDPM does not change Medicare’s basic requirements for SNF coverage. So there’s still going to need a three night hospital stay.

They’re still going to have the need for daily seven day a week nursing and or five to seven days of therapy. There’s, that’s still there, but they must reassign the case mix classifiers for administrative presumption. So this slide just shows that they did finalize do utilize the same nursing categories that they currently use. But remember there’s fewer of them because they collapsed them. And then for the most intensive functional scores, 14 to 18, and that’s what corresponds to these PT and OT and SLP classifiers. These are all affiliated with the high functional scores, as well as anyone who has a 12 plus and the NTA score and Medicare feels like these are going to be those beneficiaries with the greatest likelihood of meeting that level of care criteria. So we’ve covered a lot of information in the last 59 minutes. How do you prepare?

Well, this slide shows Medicare’s analysis of fiscal impact of PDPM. This one shows on residents. In other words, they believe that residents who are less than 65 years old native American ESR D patients length of stay one to 15 days hospital length of stay 31 plus reimbursable therapy minutes at our M R H R V and RL. If you have a typical case load of non rehab at over 50%, if you typically, if a lot of your patients receive no therapy or one to two therapies, and if your typical comorbidity score is greater than six, then what that means what this table means is you will overall likely see an increase in payment under PDPM. If you are a facility with age greater than 90, or your patients are older than 90, if hospital length of stay 31 plus days I’m sorry, not that Los is that your facility length of stay my apologies with a hospital length of stay three days. If you typically bill at an REU, if you typically provide three therapies to comorbidity scores are low. If you see a lot of neuro or non-surgical ortho or an HIV and aids, these are the facilities that will light, or the residents who will likely be paid at a lower amount.

Now silly characteristics. They predict to be winners and losers, government owned providers, small units, hospitals, swing beds. And those those providers who typically bill less than 25% of their days and an our, you are greater than 50% of their days building as a non rehab. These providers will likely see an overall increase in payment providers who will see a decrease our for-profit providers, those with 25 to 100% of their stays and, and long stays and greater than 75% of your days, bill, as in are you, that’s the that’s the raw numbers that CMS predicts will will occur. So once again, this is finalized. Effective date is October one of 19. They believe it allows for one year period of training. They are not going to have a transition period. We are going cold Turkey off of reg four on September 30 and onto PDPM ten one.

They feel like this would mitigate burden associated with trying to carry two systems, trying to manage two systems and be much easier. So now what, well, the first thing is don’t panic. There’s time, we got a lot of time there. People are going to need a lot of training. Coding is going to be extremely important. Understanding functional status is going to be very important. Understanding clinical conditions, partnering with your hospitals to get the appropriate information promoting outcome-based programs is going to be critical understanding what, how much therapy you need and when you need it and for what patients and what Nicks, all of that information is going to be critical under PDPM because no longer does it matter how many minutes you get the, you know, theoretically, if you provide a thousand minutes and you’re getting a low case mix, that’s going to be bad for the facility.

So we as therapists need to begin to understand better what mix of services to provide. And we have to work with our providers to understand that because we are also in a world of quality reporting where outcomes are going to be publicly reported, functional outcomes, falls, dreg regimen, review pressure, ulcers, discharge, to community. All of those are going to be publicly reported and very important to both consumers and payers. People, people need training. People need to be competent in clinical skills. People need to understand the value of effective treatments, not just doing things but effective treatment. So clinical skills, making sure that they’re up on all of their clinical skills and understanding different diagnoses, right? So again, you may have people on your, on your team that aren’t necessarily a practicing at the top of their license between now and October one. It’s going to be critical to bring them up with you or to find team members who are, and we’ll practice at the top of their license.

And lastly is training and documentation. As I mentioned before, section GG is not only going to be important for PDPM, but also for quality outcomes. And so MedBridge is going to be offering beginning, September one, some training programs online for section GG for both nursing and therapy documentation, you know, it’s one thing to code something, but does your documentation back it up and then validating all of these things? Do you have supportive documentation to support what you’ve coded on the MDs? All of those are going to be critical for for succeeding under PDPM. So at this point, I want to switch over and go to some questions. All right. We’ve had some questions sent in and I’m going to try to address how many that, that we can in in the time that we have left. So what are three ways that facilities can prepare for PDPM?

I kind of just addressed that, but I believe that coding, training, understanding the MDs, I believe that understanding clinical protocols clinical management of your patient, not just which disciplines are involved, but managing the patient is going to be critical, understanding the level and intensity of services for certain conditions, you know, that begins with understanding your patient population. Now, do you have data now that you can begin to look at to tell you, which of these categories are my patients going to fall into how would they be classified? And if I were under PDPM today, how would I manage that? The one I have and then, you know, again, making sure that all of your people are on board and understand the need to really be patient focused on that. Another question was, does one count all co-morbidities whether or not it is impactful on the plan of care?

Well, one thing that we that we will have to wait for is the REI guidance. All right. But but we do know that AMI MDs, the only things we’re coding on the MDs are those things that are active or those things that we are having to do. So so again, if it’s, if it’s a comorbidity that’s not active, that you’re not managing under your roof, that doesn’t impact the plan of care, then you would likely not code that. So you know, we’ll know more when the RAs specific manual comes out, which will be next year. We’re still waiting on the REI manual for October one of 18. And just as an FYI, CMS did announce yesterday that they will get it out get it out the first or second week of September. So don’t everybody fall out of your chair.

They actually did say the first or second week of September, which I realize is you know, not, not a whole lot of time per for providers, but that did that is what they said. The another question was, will there be face-to-face trainings, facilities can occur? You know, I hope so. I hope that different state associations will be arranging trainings. I can’t tell you for sure whether Medicare is going to or not. I would I would think maybe, but, you know, I can’t speak for them, but yes, I, I know that different different healthcare cessations. I know that all personally we’ll be out there doing some so there will be face-to-face trainings and I would just encourage you to get in touch with your state associations or your company and find out find out, you know, what’s happening there.

Another question is, will the initial required PDPM have gray stays like we have with the current PPS scheduling. And that answer is yes. You will have the first eight days to complete that five day assessment. So you certainly do have that time. Another question is, does this apply only to Medicare patients and not to managed care Medicaid? I’m going to take that in two parts managed care. It probably does not. I say probably, and this is why some care companies pay facilities based on the regs codes, right? So rather than a, a separate rate, they use a percentage of the part, a fee schedule fee for service fee schedule. So it’s all gonna depend on your contract. Are they going to use PDPM and pay you a percentage of that, or are they going to pay you based on just their own flat rate?

So that would be that the answer to that question, as far as Medicaid goes, that’s a whole big ball of wax. And that’s one reason why CMS has given everybody a year’s notice or a little over a year that we are going to do this okay. Because they realize that state Medicaid programs also use the MDs and the, the states will have to make that decision about whether they are going to stay with their reg system or move to PDPM. So that will be a state by state decision. Another question you mentioned the impact on concurrent and group therapy. Is there any impact on co treatment by PDPM? Nothing specifically was said about co treatment. So just as it is today, you are allowed to do co treatment with patients and, you know, there, you, you reported on the MDs, but there’s no impact on allocation then under PDPM it would be the same thing.

You know, you would not have to you would not have to worry about, you know, how many minutes there’s no penalty or or concern there for how much co treatment is planned. Let’s see, well, facilities decreased the number of MDs coordinators they have on staff. That’s also a question that, you know, I can’t say for sure you would, I would imagine a lot of that would depend on the number of skilled beds or skilled census that they run today. If you’re running a skilled census of you know, 50 patients a day, then, then a lot of that may be determined by how short is your length of stay. Obviously, if you have a very short length of stay and you’re having to do five days and discharge assessments over and over again repeatedly, then, you know, they, they may they may not need to decrease their number of MDs coordinators, but if they typically have longer stays, then there will be a decrease in workload for those MDs coordinators.

I’ll also nothing is happening to the long-term care schedule. So again, if you have a small skilled unit and the majority of your patients are long term, then you’re still having to do all of those MDs. So, you know, that, that also is is, you know, a concern now I noted I had a note that the slide that I mentioned about the MTA characteristics kind of dropped out on you all. I just wanted to point out that the, that the handout that you have available to you has all of the different NTA characteristics that are going to count points. And so what that, what that separate handout shows is that you have some, some conditions that are coded on the MDs that count for points, and you have some services that are also gleaned from the MDs and that will get points.

So on that handout, I have the full list from the finalized rule that shows whether it’s an MDs question or whether it’s an ICD 10 code. And of course, remember that the HIV aids code of B 20 is going to be is going to be taken from the claim. So I believe that that was what I was talking about when, when hopefully the the audio dropped in and that’ll be helpful. So I want to thank everyone for watching this MedBridge live webinar. I want just please listen to the following instructions. As I want everybody to receive CPU’s to obtain your CEU, you must be a MedBridge subscriber at the time of the webinar and have attended the entire duration of this webinar. You must also have signed up for the webinar via demand bridge website to receive CES. You must complete a short quiz and survey, which can be found under the past webinar section on your profile page in MedBridge.

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