PDPM Data Trends Part III: PDPM Isolation Policy Hurt Providers that Followed Public Health Guidance <p><em>​This is the third of a series of articles related to the implementation of the Patient-Driven Payment Model (PDPM) supported by examples of data trends reported by the Centers for Medicare &amp; Medicaid Services (CMS), academic researchers, as well as analyses conducted by AHCA/NCAL. The series will delve into questions related to patient care delivery, outcomes, and payment model implications informed by observed PDPM data trends. </em></p><p>In the Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System (SNF PPS) proposed rule<sup>1</sup>, CMS issued a Request for Information (RFI) on whether PDPM adequately accounts for patient care needs associated with an active infectious disease requiring quarantine. Here AHCA/NCAL presents evidence suggesting that CMS should modify their isolation policy to mitigate for significant PDPM rate disparities when following CMS and Centers for Disease Control (CDC) public health guidance to cohort such patients during public health emergencies (PHE). <br></p><p>Historically, SNF patients that require isolation and treatment for “highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission” have been classified into one of the highest intensity Nursing component extensive services case-mix groups based on time study analyses. The SNF Minimum Data Set Resident Assessment Instrument (MDS-RAI) directs that SNFs may only code MDS item O0100M2 – Isolation or Quarantine for Active Infectious Disease if a resident requires transmission-based precautions, is placed in single room isolation, and remains in the room<sup>2</sup>. Under PDPM, Medicare patients with the MDS isolation or quarantine item reported are classified into the ES1 Nursing component case-mix group (CMG). This isolation item is also assigned one non therapy ancillary (NTA) component point, which could elevate patients into the next higher NTA CMG. <br></p><p>During the COVID-19 PHE, with massive numbers of quickly spreading cases overwhelming hospitals and SNFs, CMS recognized there was an insufficient capacity of single-occupancy isolation rooms and issued blanket waivers effective March 1, 2020, permitting “grouping or cohorting residents with respiratory illness symptoms and/or residents with a confirmed diagnosis of COVID-19, and separating them from residents who are asymptomatic or tested negative for COVID-19<sup>3</sup>.” The waiver further specified that cohorting residents “aligns with CDC guidance to preferably place residents in locations designed to care for COVID-19 residents, to prevent the transmission of COVID-19 to other residents.”<br></p><p>From January 2020 through September 2021 there were 521,570 SNF PPS MDS assessments containing a diagnosis code of an active COVID-19 infection, with 80.9 percent of patients located in urban counties. During this time span, only 44.9 <span>percent</span> of patients with an active COVID-19 infection were able to be isolated into a single-occupancy room. The remaining 287,379 beneficiaries were in cohorted quarantine following CMS guidelines and therefore were ineligible for the Nursing component ES1 classification or the additional NTA point. Both components defaulted to lower valued CMGs as if the patient’s active COVID-19 condition requiring significant care needs did not exist. <br></p><p style="text-align&#58;left;">The devastating impact of this policy shortfall is reflected in Figure 1 that depicts the monthly average Nursing component CMIs for SNF Medicare patients in urban locations with an active COVID-19 diagnosis. The blue line shows that patients in single room isolation had nursing component CMIs nearly double those of patients in cohorted room isolation (red line). </p><p style="text-align&#58;center;"><span><img src="/Monthly-Issue/2022/JuneJuly/PublishingImages/PDPM-Figure1.jpg" class="ms-rteImage-2 ms-rtePosition-4" alt="" style="margin&#58;5px;" /></span>&#160;</p><p>In a similar but less dramatic manner, Figure 2 depicts the monthly average NTA component CMIs for SNF Medicare patients in urban locations with an active COVID-19 diagnosis. Here, the blue line shows that patients in single room isolation had NTA component CMIs which were about 15 <span>percent</span> higher than those of patients in cohorted room isolation (red line). <br></p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/JuneJuly/PublishingImages/PDPM-Figure2.jpg" class="ms-rteImage-2 ms-rtePosition-4" alt="" style="margin&#58;5px;" />&#160;</p><p>The impacts on total PDPM per-diem rates were substantial. Table 1 includes the average CMI and federal per-diem rate impacts for each PDPM component observed for all patients with an active COVID-19 diagnosis, comparing patients in single room versus cohorted room isolation during both FY 2020 and FY 2021. It is striking that while there were nominal differences in CMIs and payments for the PT, OT, and SLP components for COVID patients across all variables, there were substantial differences in the Nursing and NTA components. As depicted by the cells with bold text, the net daily reimbursement difference for cohorted COVID-19 patients was nearly $150 per day in urban and rural locations across both years, driven by significant CMI inequities in the Nursing and NTA components for active COVID patients that were placed in cohorted quarantine. <br></p><p style="text-align&#58;center;"><span><img src="/Monthly-Issue/2022/JuneJuly/PublishingImages/PDPM-Table1.jpg" class="ms-rteImage-2 ms-rtePosition-4" alt="" style="margin&#58;5px;width&#58;596px;height&#58;422px;" /></span>&#160;</p><p style="text-align&#58;left;">AHCA/NCAL believes that there are no differences in the care needs of Medicare beneficiaries with an active COVID-19 or similar highly transmissible infection that justify maintaining an arbitrary and inflexible isolation coding policy that penalizes providers for following public health guidance. AHCA/NCAL is submitting comments to CMS requesting the Agency revise the definition of MDS Item O0100M2 to create a pathway for coding cohorted isolation when the provider is following government infection control guidance, and that the PDPM payment model is revised to remove the unfair payment discrepancies described here. <br></p><p style="text-align&#58;left;">Readers may submit comments to CMS about the FY 2023 SNF PPS proposed rule through AHCA/NCALs Voter Voice at&#58; <a href="https&#58;//www.votervoice.net/AHCA/Campaigns/93978/Respond" target="_blank">https&#58;//www.votervoice.net/AHCA/Campaigns/93978/Respond</a>. Comments must be submitted by June 10, 2022. <br></p><p><span><em>Daniel Ciolek is associate vice president, Therapy Advocacy, for the American Health Care Association.</em></span></p><p><br></p><p><span class="ms-rteStyle-References"><span class="ms-rteFontSize-1"><sup>1</sup> &#7;87 FR 22720. April 15, 2022. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; Request for Information on Revising the Requirements for Long-Term Care Facilities To Establish Mandatory Minimum Staffing Levels. CMS-1765-P<br>² CMS MDS RAI Manual, Version 1.17.1., October 2019<br>³ &#7;COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers</span></span></p>2022-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2022/JuneJuly/PublishingImages/060722_PDPM.jpg" style="BORDER&#58;0px solid;" />Policy;COVID-19Daniel CiolekThe series will delve into questions related to patient care delivery, outcomes, and payment model implications informed by observed PDPM data trends.
Five Stars is No Longer the Bar<p><strong class="ms-rteForeColor-2">​ADVERTORIAL</strong></p><p></p><p>As competition for funding, staffing and resources grows at a breakneck pace, providers find it difficult to prioritize their efforts in a manner that effectively impacts their care and efficiently uses the minimal resources they have. </p><p>While accreditation may be the last thing providers want to consider, it may be one of the most strategic and valuable endeavors providers can achieve to effectively improve their outcomes and enhance their financial outlook. <br></p><h3>The Spotlight is Bigger, The Demand is Greater</h3><p></p><p>Since the pandemic, aging care providers have seen a progressive shift in the focus and demand for customized care. Not only are people living longer but these and other circumstances have presented new challenges, including&#58;<br></p><ul><li>ability to serve individuals with higher acuity needs,</li><li>variations in state regulations and oversight,</li><li>increased competition within the industry, and</li><li>greater scrutiny by residents, caregivers, regulators, payers, and healthcare partners.</li></ul><p></p><h3>Providers Need Guidance to Match Today’s Complex Care Needs</h3><p></p><p>This shift has highlighted the need for assessing and standardizing practices around all levels of care for patients and residents living in nursing homes and assisted living settings.</p><p>Joint Commission accreditation addresses the functions and processes necessary to deliver high-quality care, such as&#58; <br></p><ul><li>infection prevention, </li><li>patient and resident rights, </li><li>medication errors, </li><li>hand-off communications, and </li><li>health care acquired infections. </li></ul><p>And unlike punitive CMS certification inspections, the Joint Commission provides guidance through collaboration, feedback, and coaching to drive ongoing improvement over time and across all sites and services.</p><h3>The Joint Commission Difference</h3><p>Among CMS certified organizations, those that were also Joint Commission accredited excel. A JAMDA study<sup>1 </sup>revealed Joint Commission-accredited organizations outperformed their non-accredited counterparts on all five short-stay measures, key long-stay measures, and the four areas tied to the star rating&#58; health inspections, quality measures, staffing, and RN staffing. <br></p><p>Beyond CMS certification, a 2021 study<sup>2</sup> found, when compared to Joint Commission accredited organizations, non-accredited nursing homes had significantly more variability in COVID-19 case rates and a larger proportion of non-accredited nursing homes had higher than expected COVID-19 case rates. <br></p><h3>It’s About Your Residents&#58; Give Them What They Want</h3><p>When it comes to choosing an extended care facility, accreditation can play an important role in the decision-making process. Research<sup>3</sup> indicates that potential assisted living community residents and their caregivers are more likely to visit and tour a facility that is Joint Commission accredited. </p><h3>Inspire Your Staff </h3><p>Today’s employees are mission driven. While salary is important, quality residential care is a top priority and staff are dedicated to organizations that advance the care of their residents. Having the Joint Commission’s Gold Seal of Approval<sup>®</sup> demonstrates your commitment to providing optimal client care. Our program also gives you the framework to establish and verify staff qualifications, provide training, and evaluate staff competency. Finally, job satisfaction is critical to staff retention. The Joint Commission helps organizations develop strong business policies and processes to provide safe, collaborative care whether across shifts, departments, or settings. </p><h3>Finding New Revenue Streams </h3><p>Accreditation can facilitate partnerships with organizations that share your commitment to high-quality through referrals, contractual relationships, and more. Also, new value-based incentive programs continue to emerge that reward quality efforts, including accreditation. Used as an indicator of quality by states and third-party payors, Joint Commission accreditation can lead to greater reimbursement, ability to participate in networks, bonus points on value “scorecards,” and more. </p><div class="ms-rteElement-BlockQuoteRight">“It has improved our regulatory survey preparedness. Compared to other surveys, the Joint Commission is far more collaborative. You understand why you’re putting processes in place rather than merely meeting a standard.”<br>Lori Pearson<br>Vice President of Clinical Excellence<br>Consulate Management Company</div><h3>Profitability in Cost Savings</h3><p>The accreditation framework helps organizations overcome operational inefficiencies. Joint Commission accreditation can be used in lieu of state licensure surveys to reduce the burden of additional inspections. It can also prevent inadvertent harmful events before they become costly problems. Research1 has shown that Joint Commission accredited nursing homes saved an average of $5,480 in CMS certification fines compared to their non-accredited counterparts. </p><h3>Rise Above with Distinction in Quality</h3><p>Accreditation can enhance your credibility and set you apart from your competitors. To enhance your marketing, the Joint Commission offers free publicity assistance including suggestions for celebrating your accreditation, sample news releases, and downloadable The Gold Seal of Approval<sup>®</sup> artwork. </p><h3>Showcase Care Specialties with Post-Acute and Memory Care Certifications</h3><p>To help you promote unique programs that meet the distinct needs of your community, the Joint Commission offers Post-Acute Care Certification and Memory Care Certification. To address the growing need for dementia care, the Joint Commission is collaborating with the Alzheimer’s Association to enhance its Memory Care Certification requirements as well as to provide future education programs and presentations. The initial program re-launch will take place July 2022.</p><h3>Accreditation on Your Terms</h3><p>Joint Commission offers you flexibility and a process that’s built to fit your needs. Access to the application is available 24/7 with the option to designate blackout dates. And the requirements, while comprehensive, are not prescriptive so you can meet the intent of the standard based on your goals, resources, and capabilities. The Joint Commission also offers tailored survey options to streamline the application and survey process. Whether offering specialized services within your nursing home (memory care, post-acute care) or delivering multiple disciplines across a larger network (assisted living, home care, behavioral care, etc.), we offer efficient survey options that cater to your unique needs and services. </p><p>You will have access to a range of professionals to help with the day-to-day accreditation activities, and we also offer a robust array of programs and resources vetted by industry experts to help you prepare and stay ready for accreditation.</p><p>To discover how Joint Commission accreditation and certification can elevate your organization’s performance, please contact us at 630-792-5020 or email <a href="mailto&#58;ncc@jointcommission.org" target="_blank">ncc@jointcommission.org</a>. You can also visit <a href="https&#58;//www.jointcommission.org/ncc" target="_blank">www.jointcommission.org/ncc</a><br><br><em>Gina Zimmermann is the executive director for business development for Nursing Care Center and Assisted Living Community Services at the Joint Commission. In this role, she oversees the strategic direction and performance of the Nursing Care Center Accreditation Program and Assisted Living Community Accreditation Program.</em><br></p><p><span class="ms-rteFontSize-1">Reference</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">1 </sup><span class="ms-rteFontSize-1">“Comparing Public Quality Ratings for Accredited and Non-accredited Nursing Homes”, </span><em class="ms-rteFontSize-1">JAMDA</em><span class="ms-rteFontSize-1"> 18 (2017) 24e29 D </span><a href="https&#58;//www.jointcommission.org/-/media/tjc/documents/accred-and-cert/ncc/jamda-pdf.pdf" target="_blank"><span class="ms-rteFontSize-1">https&#58;//www.jointcommission.org/-/media/tjc/documents/accred-and-cert/ncc/jamda-pdf.pdf%20</span></a><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">2 </sup><span class="ms-rteFontSize-1">“A Multistate Comparison Study of COVID-19 Cases Among Accredited and Nonaccredited Nursing Homes“, Policy, Politics, &amp; Nursing Practice (2021) 1-6</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">3</sup><span class="ms-rteFontSize-1"> Research commissioned by The Joint Commission and conducted by Directions Research, Inc., 2018</span><br></p>2022-05-02T04:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2022/GinaZimmerman.jpg" style="BORDER&#58;0px solid;" />Policy;CMSGina ZimmermannWhile accreditation may be the last thing providers want to consider, it may be one of the most strategic and valuable endeavors providers can achieve to effectively improve their outcomes and enhance their financial outlook.
PDPM Data Trends Part II<p><em>​​​​This is the second of a series of articles related to the implementation of PDPM supported by examples of data trends reported by CMS, academic researchers, as well as analyses conducted by AHCA. In this series we will contemplate questions related to patient care delivery, outcomes, and payment model implications informed by observed PDPM data trends. </em><a href="/Monthly-Issue/2022/AprilMay/Pages/PDPM-Data-Trends-Part-I.aspx" target="_blank"><strong>Read Part I.</strong></a><br></p><p>On October 1, 2019, the Medicare Part A skilled nursing facility (SNF) prospective payment system (PPS) transitioned to the Patient Driven Payment Model (PDPM). In the fiscal year 2022 SNF PPS proposed rule<sup>1</sup> and final rule<sup>2</sup>, CMS proposed but did not implement an approach to apply a parity adjustment intended to assure that total PDPM payments would not be higher than they would have been under RUG-IV. &#160;</p><p>To rule out impacts of the COVID-19 pandemic, CMS removed SNF claims with a COVID diagnosis and claims related to COVID waivers from their analysis and estimated that PDPM overpaid SNFs in 2020 by 5.0 percent for patients as compared to 2019. </p><p>The CMS approach assumes two things. First, the patient acuity composition of the non-COVID/non-waiver patients in 2020 was the same as 2019. Second, that there were no COVID spillover factors that skewed the average PDPM physical therapy (PT), occupational therapy (OT), speech language-pathology (SLP), nursing, and non-therapy ancillary (NTA) component average case-mix index (CMI) rates in 2020. In AHCA comments<sup>3</sup>,&#160;the association supported the general CMS approach. However, AHCA voiced concerns about COVID “spillover” effects and a patient acuity shift in this population that needed mitigation. </p><p>This article highlights an AHCA analysis of two PDPM data trends from claims data suggesting that the PDPM data CMS proposed using for its parity adjustment approach in the FY 2022 payment rule is not like the 2019 comparison population, and that COVID “spillover” effects also upwardly skewed PDPM CMIs into 2021. <br></p><p>The red line in the figure provides data trends for SNF Part A admissions between November 2019 and June 2021 after a 3-day qualifying hospital stay that did not have a COVID-19 diagnosis. The blue line shows the shifting PDPM nursing component average CMIs for urban providers during this same period. <br></p><p><strong class="ms-rteFontSize-1">Figure&#58;&#160; SNF Admission and Nursing Component CMI Trends (Non-COVID/Non-Waiver Claims)</strong></p><p style="text-align&#58;center;"><img src="/Topics/Special-Features/PublishingImages/2022/Figure1.jpg" alt="" style="margin&#58;5px;width&#58;681px;height&#58;524px;" />&#160;</p><p style="text-align&#58;left;"><br></p><p style="text-align&#58;left;">As depicted by the red line, SNF non-COVID admissions from a 3-day inpatient stay dropped over 50% between January and May 2020, with only a partial recovery through June 2021. This corresponds to a suspension of elective surgeries, and a shift to home care for low acuity patients reluctant to enter a SNF, bottoming out as expected during the two COVID surges during this period. It is unclear whether this shift in admission volume and patient acuity mix patterns is temporary, or if it represents a permanent “new normal<sup>4,5</sup>.&quot;&#160;Throughout the pandemic, hospitals have been discharging fewer and sicker patients to SNFs than in 2019. </p><p style="text-align&#58;left;">Additionally, the blue line in the chart shows ongoing COVID “spillover” effects elevating CMIs beyond pre-pandemic levels. As depicted by the green box, Nursing CMIs shifted upwards even before the PHE onset. During this period MDS assessments were showing a spike in reported pulmonary conditions, the first COVID cases and deaths in SNFs occurred, and quarantines started. The blue box indicates another upward CMI shift in April when the full force of the pandemic hit. By July 2020, when most patients were vaccinated and COVID cases were lower, the CMIs of non-COVID patients also trended towards pre-pandemic levels but had not stabilized at a “new normal.” <br></p><p style="text-align&#58;left;">“Spillover” occurs in non-COVID patient CMIs when MDS assessment item patterns change from what would have occurred if not for the pandemic. For example, the pandemic environment of mandatory isolation and visit restrictions resulted in more mood and mental disorders and lower functional mobility reported. These factors significantly impact nursing component CMIs. Notable is that the Nursing component CMIs show an inverse relationship to admission trend, suggesting that during COVID surges hospitals were more reluctant to discharge lower acuity patients to SNFs, increasing the proportion of higher acuity patients. These numbers could approach pre-pandemic levels during an endemic phase of COVID where there is less anxiety and fewer restrictions impacting visitations and mobility. It’s less certain if hospital discharges return to pre-pandemic patterns.</p><p style="text-align&#58;left;">These and similar patterns are important considerations as CMS revisits the necessity of a parity adjustment, and if so, what the adjustment would be. Recently, CMS issued the fiscal year 2023 SNF PPS proposed rule<sup>6</sup> attempting to mitigate AHCA’s concerns, primarily by only analyzing months with low COVID prevalence. This revised approach reduced the proposed PDPM parity adjustment from 5.0 to 4.6 percent. While this is a move in the right direction, AHCA will analyze and comment on whether there are remaining unresolved COVID-era “spillover” effects and patient acuity shifts that CMS must account for to avoid a parity adjustment overcorrection that could impact access to care.</p><p style="text-align&#58;left;"><em>Daniel E. Ciolek is the Associate Vice President, Therapy Advocacy at the American Health Care Association. </em></p><p style="text-align&#58;left;"><em><br></em></p><p style="text-align&#58;left;"><em>​<br></em></p><p style="text-align&#58;left;"><strong class="ms-rteFontSize-1">References</strong><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">1</sup><span class="ms-rteFontSize-1">&#160;86 FR19954, Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year, 2022, </span><a href="https&#58;//www.govinfo.gov/content/pkg/FR-2021-04-15/pdf/2021-07556.pdf" target="_blank"><span class="ms-rteFontSize-1">Proposed Rule</span></a><span class="ms-rteFontSize-1">, April 15, 2021</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">2</sup><span class="ms-rteFontSize-1"> 86 FR42424, Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022; and Technical Correction to Long-Term Care Facilities Physical Environment Requirements, </span><a href="https&#58;//www.govinfo.gov/content/pkg/FR-2021-08-04/pdf/2021-16309.pdf" target="_blank"><span class="ms-rteFontSize-1">Final Rule</span></a><span class="ms-rteFontSize-1">, August 4, 2021</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">3</sup><span class="ms-rteFontSize-1"> </span><a href="https&#58;//www.regulations.gov/comment/CMS-2021-0062-0247" target="_blank"><span class="ms-rteFontSize-1">AHCA Formal Comment Letter</span></a><span class="ms-rteFontSize-1"> Regarding FY 2022 SNF PPS Proposed Rule – CMS-1746-P, Submitted June 4, 2021</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">4</sup><span class="ms-rteFontSize-1"> Medicare Payment Advisory Commission (MedPAC) Report to Congress, </span><a href="https&#58;//www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch7_SEC.pdf" target="_blank"><span class="ms-rteFontSize-1">Chapter 7</span></a><span class="ms-rteFontSize-1">, Skilled nursing facility services, March 2022.</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">5</sup><span class="ms-rteFontSize-1"> Brown, D. 2021. </span><a href="https&#58;//www.mcknights.com/news/a-new-normal-experts-dont-see-discharges-to-snfs-returning-to-former-levels/" target="_blank"><span class="ms-rteFontSize-1">A new normal&#58; Experts don't see discharges to SNFs returning to former levels</span></a><span class="ms-rteFontSize-1">. McKnight's Long Term Care News, April 15.&#160;</span><br class="ms-rteFontSize-1"><sup class="ms-rteFontSize-1">6</sup><span class="ms-rteFontSize-1"> 87 FR22720 Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; Request for Information on Revising the Requirements for Long-Term Care Facilities to Establish Mandatory&#160;</span><span class="ms-rteFontSize-1">Minimum Staffing Levels, </span><a href="https&#58;//www.federalregister.gov/documents/2022/04/15/2022-07906/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities" target="_blank"><span class="ms-rteFontSize-1">Proposed ​Rule</span></a><span class="ms-rteFontSize-1">, April 15, 2022.</span>​<br></p><p style="text-align&#58;left;"><br></p>2022-04-27T04:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2022/Figure1.jpg" style="BORDER&#58;0px solid;" />PolicyDaniel Ciolek​​​​This is the second of a series of articles related to the implementation of PDPM supported by examples of data trends reported by CMS, academic researchers, as well as analyses conducted by AHCA.
PDPM Data Trends Part I<p>​On October 1, 2019, the Medicare Part A skilled nursing facility (SNF) prospective payment system (PPS) transitioned to the Patient Driven Payment Model (PDPM).&#160;PDPM is a case-mix model that relies on the accurate assessment and coding of over 150 items on the SNF minimum data set (MDS) patient assessment instrument.&#160;Additionally, many of the patient characteristics and care needs identified by these data elements are used for care planning, various quality measures, and are being considered for incorporation into the SNF value-based payment program.<br></p><p>The Centers for Medicare and Medicaid Services (CMS) has described PDPM as a marked improvement over the prior Resource Utilization Groups, Version 4 (RUG-IV) payment model for the following reasons<sup>1</sup>&#58;<br></p><ul><li>Improved payment accuracy and appropriateness by focusing on the patient, rather than the volume of services provided, particularly the rehabilitation therapies.</li><li>Significantly reduced administrative burden on providers by reducing the volume of assessments.</li><li>Re-allocated SNF payments to underserved beneficiaries without increasing total Medicare payments.<br></li></ul><p>In this article we discuss three questions related to the responsiveness of PDPM to adjust payments related to care needs, whether PDPM was calibrated appropriately, and whether provider adjustments in therapy services have impacted outcomes.<br></p><h3 class="ms-rteElement-H3B">Is PDPM responsive to different patient care needs?</h3><p>It appears so. From day one of PDPM implementation providers were more attentive to the comprehensive assessment and coding of those clinical characteristics and care needs that impact the cost of care. By separately determining payments for each of five case-mix-adjusted components (physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillary (NTA) services), the model adjusts payment rates to differences in care needs. Although the PDPM payment model was designed before the COVID-19 pandemic, and any additional costs necessary to provide the more intensive care needed for COVID-19 patients were not contemplated, PDPM generally performed as intended and was able to differentiate many of the cost of care differences between COVID and non-COVID patients. <br></p><p>An AHCA analysis of SNF PPS 5-day assessments depicted in Fig. 1 highlights significant differences in PDPM Nursing component case-mix index (CMI) rate multipliers for urban provider patients with a primary reason for SNF stay diagnosis of COVID-19 versus all other admission diagnoses between April 2000 and July 2021. Generally, COVID-19 patient CMIs were 0.3 to 0.5 points higher than non-COVID patients. With an unadjusted urban federal rate of $108.16 in fiscal year (FY) 2021, this translated to about an additional $32.44 to $54.08 per day per COVID patient within just the Nursing component. <br></p><p><strong>Fig. 1. PDPM Nursing Component CMI Trends – Urban Providers - COVID vs. Non-COVID Primary Diagnosis</strong><sup><strong>2</strong></sup> <br></p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/AprilMay/PublishingImages/Figure1%20PDPM.png" class="ms-rteImage-1" alt="" style="margin&#58;5px;width&#58;562px;height&#58;359px;" />&#160;</p><p>Similar patterns were observed for the SLP and NTA components while the opposite pattern occurred with the PT and OT components. This makes sense because the Nursing, SLP, and NTA component CMIs are influenced primarily by more complex medical conditions and specialized service needs while the PT and OT component CMIs are weighted more towards post-surgical conditions and function level. With COVID-19 being mapped to a lower level PDPM Medical Management condition group, and infection control measures including isolation restricting a patient’s ability to move about, it is not surprising that the PT and OT component CMIs for COVID-19 patients trended lower during COVID-19 surges. <br></p><p>Overall, the shifting of month-to-month average CMIs for all components consistent with COVID-19 surges indicates that PDPM is responsive to patient care needs. However, further analysis is needed to determine whether PDPM adequately captures all care costs associated with a COVID-19 diagnosis. <br></p><h3 class="ms-rteElement-H3B">Was PDPM accurately calibrated in a budget-neutral manner?</h3><p>Perhaps not. While more responsive to adjusting payments to reflect different care needs than the prior RUG-IV payment model, CMS did not factor in possible changes in MDS coding patterns once additional MDS items impacting case-mix rates were added to the PDPM rate calculation approach. For example, as depicted in Fig. 2, CMS notes that prior to the PDPM implementation, only about four percent of Medicare patients were coded with having depression on admission, while this number rose to double digits beginning October 2019 and remained stable even as the COVID-19 pandemic hit. The MDS items D0300 and D0600 reflecting the presence of depression can by themselves impact the PDPM Nursing component unadjusted federal rate from $16.43 to $44.90 per day.<br></p><p>Whether such coding changes reflect more accurate coding will ultimately be determined through Medicare audits. However, given that recent CMS Chronic Conditions Warehouse SNF provider public use files for 2019 indicates that 54 percent of SNF Medicare admissions have a history of depression<sup>3</sup>, the increased reporting of depression may reflect improvements in assessment that can translate to improved care planning related to the mood disorder. <br></p><p><strong>Fig. 2. Percentage of SNF Stays Coded with Depression</strong><sup><strong>1</strong></sup><br></p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/AprilMay/PublishingImages/Fig2.jpg" alt="" style="margin&#58;5px;width&#58;635px;height&#58;166px;" />&#160;</p><p>In contrast, other items MDS items impacting payments only showed a change with the onset of the COVID-19 pandemic consistent with a highly infectious disease. Beginning April 2020, the reporting of MDS item O0100M2 reflecting isolation or quarantine for active infectious disease skyrocketed from less than two percent to over 15 percent and remained in double-digits (Fig. 3). In other cases, the coding for some MDS items changed upon PDPM implementation and then changed again with the onset of COVID-19. <br></p><p><strong>Fig. 3. Percentage of SNF Stays Coded with Isolation</strong><sup><strong>1</strong></sup></p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/AprilMay/PublishingImages/Fig3.jpg" alt="" style="margin&#58;5px;width&#58;635px;height&#58;100px;" /><br></p><p><br>Since the patient population did not change with PDPM, only the payment model, CMS is considering adjusting the payment model to account for the observed coding patterns that differ from what was anticipated so that total Medicare payments under PDPM are equivalent to what would have been paid under RUG-IV. However, teasing out the impact of unanticipated COVID-19 factors from PDPM-specific factors during a still-ongoing pandemic is challenging, and any recalibration overcorrection could be problematic. <br></p><p>In the FY 2022 SNF PPS proposed rule<sup>4</sup> and final rule<sup>5</sup> CMS suggested a conceptual approach to account for the impact of the COVID-19 by analyzing SNF Part A stays without a COVID-19 diagnosis or use of the 3-day qualifying hospital stay (QHS) or benefit period waivers as indicated by a DR condition code on the SNF claim. As depicted in the Expected CMI column in Table 1, CMS estimated what the average component CMI would be under PDPM if no coding pattern changes occurred upon implementation. </p><p>However, the Actual FY 2020 average CMI for the SLP, Nursing, and NTA components for patients without COVID and that did not access SNF care via the COVID-19 waivers were higher than expected, which resulted CMS estimating that payments were 5 percent more than expected. </p><p><br></p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/AprilMay/PublishingImages/Table%201%20PDPM.png" alt="" style="margin&#58;5px;width&#58;635px;height&#58;205px;" /><br></p><p>CMS proposed a “parity adjustment” to the component base rates to recalibrate payments to be budget neutral. In response to public comments related to using skewed COVID-era data to estimate a parity adjustment, in the final rule CMS deferred any decisions in order “…to refine the data we have collected in developing a proposed methodology that will be included in the FY 2023 SNF PPS Proposed Rule.” More current MDS data suggests that this was the right decision. As demonstrated in the last column of Table 1, AHCA analysis of the Urban and Rural average PDPM SLP, Nursing and NTA component CMIs of non-COVID patients during July 2021 were lower than the FY 2000 average CMIs. This is significant as July 2021 was a period before the onset of the Delta and Omicron COVID-19 variants when most SNF residents were vaccinated and the infection rates in SNFs were at their lowest levels since the pandemic started. This indicates that there does appear to be some “spillover” impact of the COVID-19 pandemic on non-covid patient CMIs’ that is exacerbated during surges that needs further evaluation prior to finalizing any proposed parity adjustment. <br></p><h3 class="ms-rteElement-H3B">Did providers “right size” therapy service delivery as intended by CMS?</h3><p>Early indicators suggest yes. While providers changed therapy service delivery patterns upon implementation of PDPM there were no noticeable differences in patient outcomes related to therapy service delivery. As stated above, one of the motivators and goals of CMS for PDPM was to shift the incentives of the payment model from the volume of therapy services provided to providing the amount of therapy based on patient need. CMS anticipated reductions in therapy minutes as providers would no longer be incentivized to furnish just enough therapy to achieve the various RUG-IV case mix payment thresholds, particularly the 720-minute Ultra-High and 500-minute Very-High rehab groups. <br></p><p>In the FY 2022 SNF PPS final rule5 CMS indicated that the amount of therapy minutes during the 5-day assessment decreased from 91 minutes to 62 minutes per day. Additionally, patients receiving any concurrent or group therapy during part of a stay increased from one to about 30 percent in the months leading up to the pandemic, while nearly all patients returned to individualized therapies for infection control purposes upon the first wave of the COVID-19 pandemic. A recent qualitative survey suggests that therapy services also shifted significantly to bedside care6.Overall, most therapy continues to be delivered one-on-one. AHCA noted this in submitted comments to CMS describing quarterly trends, “…the SLP peak average percentage of the use of concurrent and or group therapy minutes per stay in FY 2020 was 2.35 percent, for PT it was 5.62 percent, and for OT it was 5.59 percent.”<sup>7</sup><br></p><p>With regards to the payment thresholds, a CMS official reported that, as was intended, therapy service delivery reflects a normal distribution in reported therapy minutes rather than the previously observed spikes at 500 and 720 minutes1. As depicted in Fig. 4., researchers analyzing SNF data for patients with a hip fracture diagnosis prior to and for the first six months of PDPM observed a similar normalization of therapy minutes reported on the 5-day assessment away from spikes at the previous RUG-IV thresholds. <br></p><p><strong>Fig. 4. Distribution of Therapy Minutes Provided as Reported in 5-Day Scheduled Assessment for Patients With Hip Fracture Diagnosis Before and After the Patient Driven Payment Model (PDPM)</strong><sup><strong>8</strong></sup><br>&#160;</p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/AprilMay/PublishingImages/Figure%204%20PDPM.png" alt="" style="margin&#58;5px;width&#58;630px;height&#58;302px;" />&#160;</p><p><br></p><p>Regarding patient outcomes, CMS has indicated they are closely monitoring whether any changes in therapy service delivery are having detrimental impacts on patient outcomes. In the FY 2022 SNF PPS final rule, CMS stated “…we observed no significant changes in the percentage of stays with falls with major injury, the percentage of stays ending with Stage 2–4 or unstageable pressure ulcers or deep tissue injury, the percentage of stays readmitted to an inpatient hospital setting within 30 days of SNF discharge, or other similar metrics.”<sup>5</sup> <br></p><p>As depicted in Table 2<sup>8</sup>, researchers analyzing SNF data for patients with a hip fracture diagnosis prior to and for the first six months of PDPM reported similar findings that changes in therapy service delivery patterns under PDPM (minutes and individual vs nonindividual) did not impact outcomes related to hospital readmissions, length of stay, and functional score at discharge parameters investigated. </p><p><br></p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2022/AprilMay/PublishingImages/Table%202%20PDPM.png" alt="" style="margin&#58;5px;" />&#160;</p><p>Additional outcomes analyses may be necessary to identify best practices for “right sizing” therapy service delivery, however, these preliminary findings suggest that the CMS intent for the payment model to incentivize person-centered care and to provide services based on the “clinical judgment” of the therapy clinician appears to be occurring. &#160;<br><br><a href="/Monthly-Issue/2022/AprilMay/Pages/PDPM-Data-Trends-Part-2.aspx" target="_blank">&#160;Part II</a> is now available.<br><br><span class="ms-rteFontSize-1"><sup>1</sup> Kane, John, Patient Driven Payment Model&#58; Understanding the Impacts. 72nd AHCA/NCAL Convention &amp; Expo. October 11, 2021.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>2</sup> AHCA Analysis of CMS SNF PPS 5-Day Assessments.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>3</sup> Skilled Nursing Facility by Provider and Service Table 2019. <a href="https&#58;//data.cms.gov/provider-summary-by-type-of-service/medicare-post-acute-care-hospice/medicare-post-acute-care-hospice-by-provider-and-service" target="_blank">Data.CMS.Gov</a>.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>4</sup> 86 FR19954, April 15, 2021. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022. Proposed Rule.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>5</sup> 86 FR42424, August 4, 2021. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022; and Technical Correction to Long-Term Care Facilities Physical Environment Requirements. Final Rule.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>6</sup> Reddy, A, et al. Rapid changes in the provision of rehabilitation care in post-acute and long-term care settings during the COVID-19 pandemic. <a href="https&#58;//www.ncbi.nlm.nih.gov/pmc/articles/PMC8390362/" target="_blank">JAMDA. 2021, Nov;22(11)&#58;2240-2244</a>.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>7</sup> AHCA <a href="https&#58;//downloads.regulations.gov/CMS-2021-0062-0247/attachment_1.pdf" target="_blank">submitted comments</a> re. FY 2022 SNF PPS Proposed Rule. CMS–1746–P.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1"><sup>8</sup> Rahman, M, et al. Association between the patient driven payment model and therapy utilization and patient outcomes in US skilled nursing facilities. <a href="https&#58;//jamanetwork.com/journals/jama-health-forum/fullarticle/2787896" target="_blank">JAMA Health Forum. 2022.3(1).e214366</a>.</span><br></p>2022-04-01T04:00:00Z<img alt="" height="894" src="/PublishingImages/Headshots/DanCiolek.jpg" width="740" style="BORDER&#58;0px solid;" />PolicyDaniel CiolekThis is the first of a series of articles related to the implementation of PDPM supported by examples of data trends reported by CMS, academic researchers, as well as analyses conducted by AHCA.