pdgm: a deeper dive into the numbers...lupa analysis lds analysis by source and timing pct early...

PDGM: A Deeper Dive into

the Numbers

Panelists

Robert Holly

Moderator

Home Health Care News

Nick Seabrook

Managing Principal

BlackTree Healthcare Consulting

PDGM – A Deeper Dive Into the Numbers

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sponsored by:

www.brightree.com

Brightree is the leading provider of cloud-based software to improve clinical

and business performance of post-acute care companies. Ranked one of the

top 100 healthcare IT companies in the US, Brightree serves more than 2,500

organizations in the HME, home health, hospice, private duty, orthotic and

prosthetic, HME pharmacy, home infusion, and rehabilitation home care

segments.

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Meet Nick Seabrook

▪ Co-Founder & Managing Principal at BlackTree Healthcare Consulting

▪ Father of three: Sadie, Bryce, & Lucy

▪ Die-hard fan of the Philadelphia Eagles and Villanova Wildcats

▪ Favorite quote: “Carpe diem. Seize the day, boys. Make your lives extraordinary!”

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• PDGM Overview Recap

• CMS Charts

• PDGM case mix values

• LDS Files

Overview

PDGM Overview Recap

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Patient-Driven Groupings Model (PDGM)

What is PDGM?

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• Implementation date proposed to be for periods of care beginning on or after January 1, 2020

• Budget neutral – huge win compared to the estimated $950M reduction in payment of HHGM

• Replaces 60-day payment episodes with 30-day periods

• Eliminates the use of the number of therapy visits in payment determination

CY 2019 Final Rule

What is PDGM?

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• Increase total number of case-mix weights from 153 to 432

• Modification to low utilization payment adjustments (LUPAs)

• Model based on claims with through dates in 2017 that were processed by March 2, 2018

– 6,771,059 episodes

– 959,410 (14.2%) excluded due to non-linked OASIS

– 7,458 cost reports

CY 2019 Final Rule cont.

What is PDGM?

PDGM Details

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Base Rate

PDGM Details

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• 30-day periods

• The first 30 day period would be defined as early and all subsequent periods would be classified as late

• A 30-day period could not be considered early unless there was a gap of more than 60 days between the end of one period and the start of another

Timing

PDGM Details

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• Patients discharged from an institutional setting (inpatient hospital, SNF, IRF, LTCH, IPF) in the prior 14 days will be defined as institutional and all others as community

• Second periods with an institutional discharge within 14 days of the SOC would be considered community

Admission Source

PDGM Details

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Source and TimingCase Mix Impact

PDGM Details

Source and Timing Avg Reimb

Community Early $2,164.08

Institutional Early $2,483.18

Community Late $1,455.39

Institutional Late $2,239.14

Source Avg Reimb

Community $1,809.73

Institutional $2,361.16

Difference $551.43

Timing Avg Reimb

Early $2,323.63

Late $1,847.26

Difference $476.37

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• Nineteen percent (19%) of the 30-day periods were considered Questionable Encounters (QE)

• Updated ICD-10 diagnosis tables added ~5,000 diagnosis codes that previously were considered QE that are now not questionable (38,409 to 43,287)

Clinical Grouping

PDGM Details

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• MMTA further classified into 7 subgroups

Clinical Grouping

PDGM Details

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Clinical Grouping Case Mix Impact

PDGM Details

$1,500.00

$1,700.00

$1,900.00

$2,100.00

$2,300.00

$2,500.00

Avg Reimb

Avg Reimb

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Clinical Group/Functional Level Resource Use

PDGM Details

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Functional Level Case Mix Impact

PDGM Details

Functional Level Avg Reimb Difference Percentage

Low $1,835.97

Medium $2,113.72 $277.74 15.1%

High $2,306.65 $192.93 9.1%

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Comorbidity Adjustment

PDGM Details

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Comorbidity Adjustment Case Mix Impact

PDGM Details

Functional Level Avg Reimb Difference Percentage

No $1,942.63

Low $2,047.21 $104.58 5.4%

High $2,266.49 $219.28 10.7%

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• LUPAs have variable thresholds based on HHRG

– Different level for each of the 432 HHRGs

– 10th percentile value of visits for each threshold

LUPAs

PDGM Details

Visit Threshold HHRGs %

2 94 21.8%

3 128 29.6%

4 137 31.7%

5 63 14.6%

6 10 2.3%

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LUPA Thresholds By Clinical Group

PDGM Details

Clinical Group 2 3 4 5 6

Behavioral Health 12 9 15

Complex 16 13 6 1

MMTA - Cardiac 6 9 17 4

MMTA - Endocrine 4 14 13 5

MMTA - GI/GU 9 12 13 2

MMTA - Infectious 10 21 5

MMTA - Other 5 11 10 10

MMTA - Respiratory 9 8 16 3

MMTA - Surgical Aftercare 9 10 12 5

MS Rehab 7 3 8 12 6

Neuro 6 5 9 12 4

Wound 1 13 13 9

Grand Total 94 128 137 63 10

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Estimated Impact

National Impact

Facility Type Pct

Facility Based +3.0%

Freestanding -0.3%

Ownership Pct

For-Profit -0.8%

Gov’t Owned +2.3%

Non-Profit +2.1%

Nursing/Therapy Ratio Pct

1st Quartile (Lowest Nursing) -9.6%

2nd Quartile -1.0%

3rd Quartile +6.2%

4th Quartile (Highest Nursing) +17.3%

Location Pct

Rural +3.8%

Urban -0.6%

LDS Details

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• Available for purchase from CMS for $1,200

• Detailed information of the PDGM Agency Level Impacts spreadsheet

• 2017 claims information

• Data file containing claims and OASIS information, including: episode dates, period dates, wage index, HIPPS code, case mix, actual reimbursement, projected PDGM reimbursement, visits, visit cost, timing, comorbidity, LUPA threshold, diagnosis codes, ADL answers

• Does not include supply costs

LDS File

LDS Analysis

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LDS Summary

LDS Analysis

9,568,951 claims

3,195,274 beneficiaries

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LDS Analysis

Period Number Number Percentage

1 4,113,617 43.0%

2 2,620,833 27.4%

3 872,013 9.1%

4 724,835 7.6%

5 335,965 3.5%

6 299,742 3.1%

7 169,189 1.8%

8 154,358 1.6%

9 90,924 1.0%

10 84,020 0.9%

11 50,768 0.5%

12+ 52,687 0.6%

Total 9,568,951

Period Breakdown

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LDS Analysis

Clinical Grouping % PPS $ PDGM $ $ Change

Behavioral Health 1.6% $ 252,715,846 $ 251,116,899 -0.6%

Complex Nursing 1.2% $ 195,940,440 $ 244,789,162 24.9%

MS Rehab 20.4% $ 3,293,164,269 $ 3,003,388,564 -8.8%

Neuro Rehab 7.6% $ 1,233,273,417 $ 1,169,401,665 -5.2%

Wounds 8.7% $ 1,406,986,666 $ 1,755,269,755 24.8%

MMTA Cardiac 13.7% $ 2,213,667,565 $ 2,374,812,654 7.3%

MMTA Endocrine 3.9% $ 636,316,332 $ 717,737,443 12.8%

MMTA GI/GU 3.6% $ 574,459,642 $ 594,410,897 3.5%

MMTA Infectious 3.3% $ 535,487,510 $ 574,940,363 7.4%

MMTA Other 3.5% $ 559,341,537 $ 575,782,204 2.9%

MMTA Respiratory 6.9% $ 1,110,840,540 $ 1,151,320,780 3.6%

MMTA Surgical Aftercare 3.9% $ 622,351,193 $ 615,775,530 -1.1%

Questionable Encounters 21.8% $ 3,522,645,728 $ 3,299,856,984 -6.3%

Total$ 16,157,190,685 $ 16,328,602,900 1.1%

Reimbursement Change by Clinical Grouping

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LDS Analysis

Clinical Grouping SN PT OT ST MSW HHA Total

Behavioral Health 3.8 2.0 0.8 0.4 0.1 0.7 7.7

Complex Nursing 3.9 1.0 0.3 0.1 0.0 1.2 6.6

MS Rehab 3.2 5.2 1.3 0.1 0.1 0.7 10.5

Neuro Rehab 3.3 4.2 1.8 0.9 0.1 1.0 11.4

Wounds 7.8 1.6 0.6 0.1 0.1 0.8 10.9

MMTA Cardiac 4.9 2.5 0.8 0.1 0.1 0.8 9.2

MMTA Endocrine 7.3 2.2 0.6 0.1 0.1 0.8 11.1

MMTA GI/GU 4.7 2.6 0.8 0.1 0.1 0.8 9.1

MMTA Infectious 5.0 2.1 0.6 0.1 0.1 0.8 8.7

MMTA Other 6.3 2.3 0.7 0.1 0.1 0.8 10.2

MMTA Respiratory 4.5 2.8 0.9 0.2 0.1 0.8 9.3

MMTA Surgical Aftercare 5.5 2.6 0.8 0.1 0.1 0.4 9.6

Questionable Encounters 3.4 4.0 1.1 0.3 0.1 0.8 9.5

Average Visits by Clinical Grouping

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• The below chart illustrates the top 10 primary diagnosis codes that would be considered Questionable Encounters

– Top 10 account for 51% of all episodes with QEs

Questionable Encounters

LDS Analysis

Diagnosis Description Episode Count

M62.81 Muscle Weakness Generalized 179,711

R26.89 Abnormality of gait and mobility 49,095

M54.5 Low back pain 38,716

R26.81 Unsteadiness on feet 30,181

R53.1 Weakness 28,706

R26.9 Unspec abnormalities of gait and mobility 23,742

R29.6 Repeated falls 23,578

R26.2 Difficulty in walking not elsewhere classified 20,297

M19.90 Unspecified osteoarthritis 16,544

Z48.89 Encounter for other specified surgical aftercare 16,281

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LDS Analysis

Overall

$- $500 $1,000 $1,500 $2,000 $2,500

Behavioral Health

Complex Nursing

MS Rehab

Neuro Rehab

Wounds

MMTA Cardiac

MMTA Endocrine

MMTA GI/GU

MMTA Infectious

MMTA Other

MMTA Respiratory

MMTA Surgical Aftercare


Average Reimbursement vs. Average Cost

Avg Cost Avg Reim

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LDS Analysis

1st Period

$0 $500 $1,000 $1,500 $2,000 $2,500

Behavioral Health

Complex Nursing

MS Rehab

Neuro Rehab

Wounds

MMTA Cardiac

MMTA Endocrine

MMTA GI/GU

MMTA Infectious

MMTA Other

MMTA Respiratory




Avg Cost Avg Reim

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LDS Analysis

2nd Period

$0 $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000

Behavioral Health

Complex Nursing

MS Rehab

Neuro Rehab

Wounds

MMTA Cardiac

MMTA Endocrine

MMTA GI/GU

MMTA Infectious

MMTA Other

MMTA Respiratory




Avg Cost Avg Reim

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LDS Analysis

3rd+ Period

$0 $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000

Behavioral Health

Complex Nursing

MS Rehab

Neuro Rehab

Wounds

MMTA Cardiac

MMTA Endocrine

MMTA GI/GU

MMTA Infectious

MMTA Other

MMTA Respiratory




Avg Cost Avg Reim

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LDS Analysis

Reimbursement Analysis

$-

$500

$1,000

$1,500

$2,000

$2,500

Average Reimbursement

Overall 1st 2nd 3rd+

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LDS Analysis

Cost Analysis

$-

$500

$1,000

$1,500

$2,000

$2,500

Average Cost


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LDS Analysis

Margin Analysis• Cost does not include supplies

$- $50

$100 $150 $200 $250 $300 $350 $400 $450 $500

Average Margin


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LDS Analysis

22% 13%

48%34%

23% 26% 20%34% 31% 25% 34%

55%33%

78% 87%

52%66%

77% 74% 80%66% 69% 75% 66%

45%67%

OVERALL EARLY/LATE PERCENTAGES

Early Late

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LDS Analysis

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Average Reimbursement by Clinical Grouping/Timing

Early Late

Overall Early - $2,242.74Overall Late - $1,444.11

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LDS Analysis

7.5% 7.5%

10.1%

5.1%

OVERALL 1ST 2ND 3RD+

LUPA Percentage

Percentage

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LDS Analysis

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


LUPA Percentage by Clinical Grouping/Timing

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LUPA Analysis

LDS Analysis

By Source and Timing Pct

Early – Community 8.1%

Early – Institutional 8.3%

Late – Community 7.1%

Late – Institutional 7.7%

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Functional Analysis

LDS Analysis

1,744

1,748

1,754

1,738 1,740 1,742 1,744 1,746 1,748 1,750 1,752 1,754 1,756

LOW

MEDIUM

HIGH



35%

34%

31%

% Breakdown

Low Medium High

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Comorbidity Analysis

LDS Analysis

1,656

1,731

1,937

1,500 1,600 1,700 1,800 1,900 2,000

NO

LOW

HIGH



56%36%

8%

% Breakdown

No Low High

Questions?

Sponsor: Brightree

www.brightree.com(888) 598-7797

Consulting Outsourcing Education

Presenter: Nick Seabrook

Managing [email protected]

(610) 536-6005 ext. 702

http://www.brightree.com/

Q&A

Robert Holly

Moderator

Home Health Care News

Nick Seabrook

Managing Principal

BlackTree Healthcare Consulting

pdgm: a deeper dive into the numbers...lupa analysis lds analysis by source and timing pct early...

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