{"id":875,"date":"2019-02-20T18:45:25","date_gmt":"2019-02-20T18:45:25","guid":{"rendered":"http:\/\/stonegateblog.wpengine.com\/?p=875"},"modified":"2020-11-06T22:09:58","modified_gmt":"2020-11-06T22:09:58","slug":"pdpm-enhancing-senior-care-with-a-new-payment-model","status":"publish","type":"post","link":"https:\/\/srsnf.com\/pdpm-enhancing-senior-care-with-a-new-payment-model\/","title":{"rendered":"PDPM: Enhancing Senior Care With a New Payment Model"},"content":{"rendered":"\n

Despite high spending in the Medicare program \u2013 $702 billion<\/a> in 2017 \u2013 ensuring consistent, high-quality senior care is often an elusive goal. To tackle the challenge, the Centers for Medicare & Medicaid Service (CMS) continues to evolve its Medicare payment structure. The newest system is the Patient-Driven Payment Model (PDPM)<\/a>, a Medicare reimbursement plan for patient stays of 100 days or less in a skilled nursing facility (SNF)<\/a>. The new model, which will launch October 1, 2019, is designed to trim costs, enhance senior care, and simplify a complex payment system.<\/p>\n\n\n\n

Pulling out the RUG<\/strong><\/p>\n\n\n\n

PDPM represents a monumental shift in how CMS pays nursing homes for Medicare patients. It replaces the current SNF case-mix methodology \u2013 Resource Utilization Groups Version Four (RUG-IV) \u2013 with an entirely new way of calculating reimbursement.<\/p>\n\n\n\n

\u201cIn the RUG system, Medicare rates are tied to the volume of therapy minutes a patient receives,\u201d says Eddie Parades, senior vice president of government affairs at StoneGate Senior Living, a leading provider of senior living services in Texas, Oklahoma, and Colorado. \u201cThe current RUG model is based on utilization of services, and that translates into a built-in incentive to potentially drive up cost of care.\u201d<\/p>\n\n\n\n

With the new PDPM, therapy minutes are no longer the basis for payment. The system hinges on how patients are classified and the resources they will need in their stay. PDPM assigns every patient a case-mix classification that determines the daily reimbursement rate for their care. \u201cThe payment rate is patient specific and established by patient need, not services delivered, Parades says. \u201cThe patient classification is primarily driven by the ICD-10 diagnosis code, and that is then influenced by case-mix multipliers associated with individual patient co-morbidities and care needs captured by clinical assessments.\u201d<\/p>\n\n\n\n

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Putting patients first<\/strong><\/p>\n\n\n\n

\u201cI believe PDPM will be an improved payment model and will be the most accurate payment-driven system in two decades,\u201d Parades predicts. \u201cHistorically, our SNF payment system has been based on the volume of services the patient receives. PDPM flips the equation and bases payment on the patient\u2019s condition and needs. This patient- centered care model will recognize higher medication costs and allow providers to accept more medically complex patients<\/a>.  Basically, the sicker and more complex a patient is, the more payment recognition you will receive.<\/p>\n\n\n\n

\u201cThis will also provide for new care metric data gathering, which should provide patients with more insight in making informed decisions about which SNF offers services best tailored to their condition and preferences.\u201d<\/p>\n\n\n\n

Preparing for change<\/strong><\/p>\n\n\n\n

\u201cPDPM requires careful preparation, and StoneGate Senior Living is investing considerable thought, time, and education to ensure we are well prepared before the transition,\u201d Parades says. Key readiness steps include:<\/p>\n\n\n\n