Me Medi dicare care Par art t A SN SNF Paym yment ent Syst ystem em Refo eform: m: Intr In troductio oduction n to to Resi esident dent Cl Clas assifica sification tion Syst ystem em - I Z IMMET H EALTHCARE 2018
Intr In troduction oduction to to th the e Resi esident dent Cl Classification assification Syste ystem m - I Concepts Structure Implications Z IMMET H EALTHCARE 2018
RCS S is is NOT OT th the e Unif ifie ied d Post st-Acute Acute Payment yment System stem • IMPACT Act mandated MedPAC to outline a unified payment system that would replace the four current post-acute care Medicare payment systems (SNF, HHA, IRF, LTCH) • Objective is to base payment on patient characteristics rather than setting or amount of therapy furnished (significant redistribution of PAC dollars) • IMPACT Timeline: Propose system by 2023, then implement • MedPAC demonstrated that the system is highly feasible & accurate; recommends implementation in 2021 with 3-year optional phase-in • See June 2017 MedPAC Report to Congress, chapter 1 for details Z IMMET H EALTHCARE 2018
Abo bout t RCS CS-I • Advanced Notice of Proposed Rulemaking (5/4/17; CMS-1686) • Public comment period extended from 6/26 to 8/25/17 and left open ended • Based on extensive research and TEPs (possible refinements) • Target date is October 1, 2018 • Likelihood of implementation? • Budget Neutrality assumed (Parity adjustments) • No mention of “phase -in / blend- in” but possibility • Improvement over RUGs? • Shift from Volume to Patient Characteristics as $ driver Z IMMET H EALTHCARE 2018
Abo bout t RCS CS-I • N O CHANGE IN M EDICARE “ CLINICAL ” / “ TECHNICAL ” ELIGIBILITY REQUIREMENTS • “Focus on reducing administrative burden for providers” • MDS remains basis for rate setting, but 5-day sets the “ Composite score ” for the entire benefit period (assuming no discharges or sig. changes) • Remaining PPS MDS schedule is eliminated, including COTOs • Sets up benchmarking mechanism from admission – discharge • Recognizes disproportionate costs during first days of stay • Frequency / Amount of therapy does not impact reimbursement • Therapy is “just another component of the care plan” – Nursing acuities, Diagnosis coding & certain Ancillaries drive revenue Z IMMET H EALTHCARE 2018
RCS CS Str tructur cture T N • RUG-IV contains 3 rate components: O • Therapy, Nursing (including NTAs) and Overhead • Blended into one of 66 distinct per diem rates Per Diem RUG • RCS includes 5 distinct, (4 variable) rate components: • PT/OT (30 categories) 1 of 30 • SLP (18 categories) 1 1 of 18 • Nursing (43 RUGs) Composite • Non-Therapy Ancillaries (6 levels) • Overhead / Non-Case Mix Adjusted (1 rate) 1 of 43 1 of 6 How many possible combinations??? Z IMMET H EALTHCARE 2018
Pos ossi sible ble RCS CS Ra Rate te Co Comb mbin inations ations PT/OT: 30 • While there are technically SLP: 18 139,320 possible composite Nursing: 43 combinations, many are NTA: 6 “ mutually exclusive ” Overhead: 1 139,320 Z IMMET H EALTHCARE 2018
PT/OT • 30 categories RCS: : Wher here e Do W o We e Sta tart? t? • 18 categories SLP One step at a time… Nrsng • 43 RUGs • 6 groups Each h co compo mponent nent ha has s its ts own wn NTA grouping ping process cess usi sing ng different fferent • 1 CBSA variables iables and nd sc scor oring ing OH meth me thodol odologies ogies RCS Composite Z IMMET H EALTHCARE 2018
Why y is is th the P e Pat atient ient He Here re? • 10 “Clinical Categories” capture the “range of general resident types” found in SNFs • MDS Section I: ICD-10 code • “Primary reason for SNF stay” • DRG “Mapping” Non- Orthopedic Major Joint Non-Surgical Acute Orthopedic Rep. or Spinal Surgery (Except Orthopedic/ Neurologic Surgery Major Joint) Surgery Musculoskeletal Acute Medical Cardiovascular Cancer Pulmonary Infections Management & Coagulations Z IMMET H EALTHCARE 2018
The 10 categories are collapsed into 5 for PT/OT Major Joint Non- Other Medical Acute Rep. or Spinal Orthopedic Orthopedic Management Neurologic Surgery Surgery Non- Major Joint Non-Surgical Acute Cancer Rep. or Spinal Orthopedic Orthopedic/ Neurologic Surgery Surgery Musculoskeletal Orthopedic Acute Surgery (Except Infections Major Joint) Acute Pulmonary Neurologic 2 for SLP Non- Medical Cardiovascular & Coagulations Neurologic Management Z IMMET H EALTHCARE 2018
Physical ysical / Oc Occupa cupational tional Compo mponent nent Calcu culation lation Cognitive Clinical Functional Impairment (2) Category (5) Score (3) Major Joint Rep. MDS Section or Spinal Surgery Clinical: I8000 / I0020 Other 14 – 18 Primary reason for SNF stay (ICD-10) Orthopedic Intact or Mildly Functional: G Impaired Non-Orthopedic Trans, Eating, Toileting: Self Perf only 8 – 13 Surgery Moderately or Cognitive: C Severely Cognitive Function Scale Impaired Acute 0 – 7 Neurologic All patients score in one PT/OT group no Medical matter if they receive therapy (or how much) Management Z IMMET H EALTHCARE 2018
PT PT/OT /OT Fu Func nction tional al Sco core re • RCS PT/OT scoring differs from RUG-IV ADL system • Transfers, Eating and Toileting Self-Performance scores only • Each ADL scored on a 0 – 6 scale; (v. 4 in RUG-IV) • 0 – 18 point range • Unlike RUGs, higher point totals represent lower dependence; • Fully functional residents are reimbursed at the highest rates • Greater need reduces PT/OT rate but increases RCS Nursing RUG • The difference in net impact varies for each component score • Nursing increase may or may not exceed PT/OT increase • Any inflexible capture strategy may be counter-productive Z IMMET H EALTHCARE 2018
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RCS: S: P PT/OT OT Fu Functional ctional Score ore v. RUG-IV IV: : Self lf-Per erfor formance mance Scale cale RCS-I I Scoring oring Z IMMET H EALTHCARE 2018
PT PT/OT /OT Ca Case se-Mi Mix x Cl Clas assif sification ication Gr Grou oups ps See handout for complete listing of case-mix groups Z IMMET H EALTHCARE 2018
Speec eech h Languag guage e Patholog thology y Component mponent Calculation lculation Swallowing SLP Related Clinical Disorder or Comorbidity or Category (2) Mechanically- Mod. to Severe Altered Diet (3) Cog Imp (3) MDS Section Both Both Acute Clinical: I8000 Neurologic Sw Dis: K0100Z Either Either MA Diet: K0510C2 Non- Comorb: Misc. Neurologic Neither Neither Cognitive: C (CFS) All patients score in one SLP group no matter if they receive therapy (or how much) Z IMMET H EALTHCARE 2018
SLP LP Rel elated ated Co Como morb rbidit idities ies Z IMMET H EALTHCARE 2018
SLP LP Ca Case se-Mix Mix Cl Clas assifi sification cation Gr Grou oups ps See handout for complete listing of case-mix groups Z IMMET H EALTHCARE 2018
PT PT/OT /OT & SLP: LP: Co Cogni gniti tive e Fu Func nction tion • New cognitive measure: Cognitive Function Scale (CFS) • Combines Brief Interview for Mental Status (BIMS) and Cognitive Performance Score (CPS) into one scale Note: Impairment reduces PT/OT but increases SLP component. PT/OT rate reduction exceeds SLP enhancement (almost always). Z IMMET H EALTHCARE 2018
Nu Nurs rsin ing g Ca Case se-Mix ix Cl Clas assif sificatio ication • 43 “nursing RUGs” • RUG-IV Reimbursement drivers, ADL scoring & splits and hierarchy remain intact • Minus Rehab RUGs • Reweighted indices • 19% HIV/AIDS rate enhancement only applies to this component • Triggered by ICD-10 code B20 on the UB-04 See handout for complete listing of case-mix groups and comparison of RUG-IV to RCS CMI weights Z IMMET H EALTHCARE 2018
NTA Gr NT Grou oup p Cl Clas assif sification ication • Non-Therapy Ancillaries • Based on the number of services and conditions • Hospital look-back as allowed in RUG-IV • Greatest rate impact for days 1 - 3 See handout for complete listing of NTA service / condition drivers and related Points Z IMMET H EALTHCARE 2018
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RCS CS Ra Rate te Co Comp mpos osite ite Ca Calc lcul ulation ation • 5-day MDS (ARD 1 – 8) establishes Composite for the entire benefit period with limited exceptions • Significant Change / Readmissions • Each component has a “Base Rate” adjusted by CBSA • Multiply each Base Rate by respective CMI weight • “Variable Per Diem Adjustment Factors” • PT/OT and NTA components decrease as the benefit period progresses (see handout for detail on Base Rates & VPDA) Z IMMET H EALTHCARE 2018
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