Friday, October 19 | Legislative/Policy, Post-Acute Care
The Patient Driven Groupings Model (PDGM) recently released by CMS is a good news/bad news scenario for home health organizations. We’ve examined the proposal closely and submitted comments to the Centers for Medicare & Medicaid Services on behalf of our home health and hospice clients.
The good news is that the proposal is budget-neutral. Under the previous Home Health Groupings Model (HHGM), which was withdrawn last year following the public comment period, organizations faced an estimated 15 percent cut in reimbursement. Also, the proposed start date of PDGM is January 1, 2020, so agencies will have time to prepare, regardless of the outcome of the new proposal.
However, PDGM keeps the unit of payment 30-day period, rather than the current 60-day episodes. According to CMS, PDGM “relies more heavily on clinical characteristics and other patient information (e.g., principal diagnosis, functional level, comorbid conditions, referral source, and timing) to place patients into more meaningful payment categories.”
Significant change in comorbidity adjustment methodology
The proposed rule outlines the changes to the comorbidity methodology that could increase the episodic payment. Patient diagnoses will determine if the patient qualifies for a comorbidity adjustment of none, low or high. PDGM analysis from Home Health Care News shows that nearly two-thirds of episodes would not trigger a comorbidity adjustment. A little more than 30 percent would trigger a low adjustment, with an additional payment of about $35. Fewer than 6 percent of cases would qualify for a high adjustment and a $350 estimated supplement. Under HHGM, a $150 increase was triggered with any comorbidity adjustment due to the simple no/yes algorithm.
Upon referral, a patient will be grouped into one of six categories:
The patient’s functional level (low, medium, high) will be determined from the Outcome and Assessment Information Set (OASIS), then a comorbidity adjustment (none, low, high) will be calculated based on the secondary diagnoses on the claim. Potential comorbidity adjustments can be made based on individual subgroups and 27 comorbidity subgroup interactions.
National Association for Home Care & Hospice (NAHC) President William Dombi described the Patient Driven Groupings Model as “a modestly adjusted and ‘warmed over’ version of the highly criticized [HHGM] re-labeled as [PDGM]. Many of the same weaknesses present in HHGM exist in this new version.”
During our recent webinar on PDGM, NAHC outlined several potential concerns, including a potential loss of volume by home health organizations because incentives are focused on impatient discharges. Changes in costing methodology could reduce payments, as could a change in the Low Utilization Payment Adjustment (LUPA). The behavioral adjustment is seen as a wild card, and the clinical groupings are heavy on MMTA.
PDGM has the potential to substantially impact your home health business and should be watched closely. Learn more from our PDGM focused free webinar, click here.
Call to Action: Proposed Cuts Could Deprive Home Health of Necessary Funds
Wednesday, September 20 | Post-Acute Care,Value-based Care
Millions of older Americans could be greatly impacted if the Centers for Medicare & Medicaid Services goes through with its proposed rate cut to the Home Health Prospective Payment system for Calendar Year 2024. One of the most concerning aspects of the proposed rule revolves around its potential impact on home health reimbursement.
MoreMonday, September 18 | Thought Leadership,Human Services,Care Coordination,Cause Connected,Legislative/Policy,Value-based Care
The opioid crisis is one of the most serious healthcare issues in our nation today. But there is hope. We believe there are three strategies your organization can leverage to combat opioid addiction and overdose: integrated care, policy and technology. This blog outlines some examples of all three and lists helpful resources your organization can use.
MoreNavigating Managed Care
A Look at the Future of Value-Based Contracting
Tuesday, June 27 | Care Coordination,EHR Solutions and Operations,Interoperability,Post-Acute Care,Value-based Care
In today's rapidly evolving healthcare landscape, managing the cost of care and improving patient outcomes are crucial priorities. To address these challenges, value-based reimbursement has emerged as a widely embraced approach. This system focuses on optimizing healthcare services while managing expenses. At the core of this strategy lies value-based contracting, a payment model that aims to align provider reimbursement with the outcomes achieved by patients. By incentivizing quality care and efficient resource utilization, value-based contracting promotes a more coordinated and effective healthcare system.
More