UPDATES

Goodbye RCS1… • SNF PPS Proposed Rule for FY 2019 includes a

payment reform that will replace the current RUGs

Hello PDPM • PDPM – Patient-Driven Payment Model

• PDPM is an enhancement from the original proposed payment reform – RCS 1

• The enhancements/changes are a direct result of stakeholder comments that CMS received after the ANPRM in May of 2017.

• PDPM is proposed to be effective in October 2019.

Goodbye RCS1 …Hello PDPM Timelines

• April 27, 2018 – SNF PPS FY 2019 Proposed Rules were released.

• PDPM was the largest part of that release

• Comment Period is open until June 26, 2018

• Sometime this summer – the SNF PPS FINAL RULE is expected to be released

Why Replace RUGS? • RUGS is an index-maximizing system that has led to 90% of

residents having payments primarily driven by therapy services.

• CMS’ view that Therapy in SNFs is predicated on financial considerations as opposed to resident needs.

• Multiple reports and studies published by the OIG and MedPAC expressing concerns with “thresholding” and Ultra High domination.

• Insufficient Payment for Nursing Services, Extensive and Ancillary Services.

CMS Goals for PDPM • To improve targeting of resources to medically

complex beneficiaries

• To reduce incentives for SNFs to deliver therapy based on financial considerations

• To promote consistency with other Medicare and PAC payment settings by basing resident classification on clinical information and minimizing the role of the ‘volume’ of service provision in determination of payment

RUGS IV

RCS 1

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Implications of PDPM

• A HUGE shift in Concept and Operations for Med A Admissions in the SNF setting

• The magnitude of the change will be felt at all levels – Nursing, Therapy, Ancillary Services, EMR vendors, MACs

• Volume of Therapy may change (?) and Mode of Treatments will change – group and concurrent therapy are allowed/encouraged (up to 25% combined)

• Part A pricing structures will change for Contracted Therapy Providers –Per Diem, Per Minute, % of CMI score

• A more balanced therapy and nursing clinical case-mix will WIN under PDPM !!!

How should SNFs prepare for PDPM? • Evaluate interdisciplinary workflows and systems that impact

length of stay and occupancy in your community.

• Does your Admissions team understand and adhere to the expectations related to LOS ?

• Does your Social Work team understand the expectations related to the LOS and have the tools to support timely discharges to the next level ?

• Does your Nursing team understand the value of providing and optimizing the resident’s highest functional level outside of therapy services ? Do they understand how correct documentation impacts reimbursement?

*Use resources like the CRITICAL PATHWAYS from Gravity

How should SNFs prepare for PDPM? • Evaluate your Upstream and Downstream Relationships

• To keep information exchange consistent and timely

• To keep your occupancy up and to keep the referrals/admissions coming

• To facilitate safe transitions to the next level in a timely manner in order to maintain appropriate LOS and also minimize hospital readmissions

• To have systems in place for appropriate discharge follow up

• To achieve Preferred Provider status

Thank you for participating! Irene Henrich, Director of Quality & Compliance ihenrich@careventures.net

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