Using PDGM Data to Forecast Your Fiscal Impact & Budget for 2020 - PowerPoint PPT Presentation

Using PDGM Data to Forecast Your Fiscal Impact & Budget for 2020 HCA Senior Financial Managers Retreat Presenters: Rob Simione, CPA, Director of Finance

Patient-Driven Groupings Model (PDGM) 2

Overview – Proposed Rule • Who • Effects all Home Health Agencies • What • Change from payment of 60-day episodes to payment of 30-day Periods of Care. • Elimination of Treatment of Therapy Thresholds • Phase out of RAP Payment • Biggest change since 2000 with the implementation of PPS • When • For episodes beginning on or after January 1, 2020 • Why • Better Align Payments with • Patient Needs • Better ensure that clinically complex and ill beneficiaries have adequate access to home health care • Budget Neutral 3

PDGM Architecture * CMS-ABT PDGM Model 2018 4

Proposed Behavioral Adjustment/Rates

New York Comparison • PPS vs. PDGM Summary Comparison Benchmarks PPS Reimburesement PDGM Reimbursement Variance Change New York $ 485,496,174.00 $ 509,963,812.00 $ 24,467,638.00 5.00% National $ 16,259,831,351.00 $ 16,260,262,302.00 $ 430,951.00 0.00% 6

Budgeting Under PDGM Case Study 7

Budgeting Needs Buy In! • Everyone should be involved. • Executive Management • Clinical Directors • Financial Directors • Sales and Marketing • Quality • Need buy in from everyone when it comes to budgeting review. • Goals/expectation have to be realistic and fall in line with Quality Care. • Realistic expectation for growth and staffing. 8 • What can we expect right away and what can we expect to improve as we adjust to the new model! • Where is the opportunity!

PDGM Data Gathering • Total Medicare admissions • Monthly Medicare admissions (seasonality vs. stability) • Sequence of periods by clinical grouping (includes questionable encounters) • Reimbursement by period by sequence by clinical group • Reimbursement per period for 1 st 30-day periods • Reimbursement per period for subsequent 30-day periods • Visits by discipline by period by sequence by clinical group • Utilization by discipline for 1 st 30-day periods • Utilization by discipline for subsequent 30-day periods 9

PDGM Data Gathering • Projected LUPAs • Broken down for 1 st 30 days vs subsequent 30 days. • Top Diagnosis by each Clinical Group • Benchmarks Comparison/Goals from Clinical Operations: • Functional Assessment • Comorbidities • Care Plans/Pathways • Program Development (Joints, Cardiac, Wound, IV Therapy, Telehealth, etc.) • Productivity • Staffing (LPN, COTA, PTA) • Caseloads • Sales & Marketing Goals • Institutional vs Community • Joint and other program development 10

Establish a Baseline for Medicare • CMS is projecting impact analysis based on 2018 claims data, this includes the basis for the behavioral adjustment. • Basis - 2018 Claims Data from Medicare • Medicare discarded roughly 15% of claims because there was no matching OASIS. • Medicare made assumptions on the functional assessment • Medicare assumes that Questionable Encounters with a billable secondary diagnosis will be used to determine reimbursement. • Utilize the 2018 data as the base then use current state Medicare metrics to determine overall impact! 11

Establish a Baseline for Medicare Total Revenue Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM Revenue $ 1,717,339 $ 2,299,525 $ 2,480,486 $ 2,511,951 $ 2,519,811 $ 2,537,786 $ 2,550,913 $ 2,564,937 $ 2,574,486 $ 2,583,864 $ 2,586,489 $ 2,587,772 $ 29,515,359 Behavioral Adjustment $ 137,558.83 $ 184,191.97 $ 198,686.95 $ 201,207.27 $ 201,836.85 $ 203,276.65 $ 204,328.14 $ 205,451.46 $ 206,216.35 $ 206,967.50 $ 207,177.76 $ 207,280.54 $ 2,364,180 PPS Revenue $ 709,900 $ 154,100 $ 864,000 Total Revenue $ 2,289,680 $ 2,269,433 $ 2,281,799 $ 2,310,744 $ 2,317,974 $ 2,334,509 $ 2,346,585 $ 2,359,486 $ 2,368,270 $ 2,376,896 $ 2,379,311 $ 2,380,492 $ 28,015,179 12

Why Sequence Periods by Clinical Group? • Each Clinical Grouping has its own reimbursement rate. • Ability to review detail of each Clinical Group (functional assessment, LUPAs, comorbidities, admission source). • Track visit utilization by each Clinical Group (matching cost with revenue). • What is the financial impact on decisions regarding: • Market Expansion • Specialty Program Development • ACO, Joint and other initiatives • Care Pathway/Plan changes • Case Management • Plan of Care Development 13

Why Sequence Periods by Clinical Group? • Sequencing of episodes demonstrated impact of length of stay and visit utilization: • 30-day vs 60 day • Significant reimbursement difference between 1 st 30 and 2 nd 30 day • Will my agency adjusted it’s visit utilization around: • Therapy Utilization • 2 nd 30-day LUPA Thresholds • Specialty program and initiatives • Remember that a 1 st 30 day early institutional is the first 30-day admission period only! Recert OASIS have a significantly different reimbursement. 14

Why Sequence Periods by Clinical Group? New York National Periods Episodes w/ One Periods Episodes w/ One Clinical Grouping per Admission 30 Day Period per Admission 30 Day Period Behavioral Health Care 1.80 39.90% 1.38 19.10% Complex Nursing Interventions 4.67 15.70% 1.55 13.50% MMTA- Surgical Aftercare 0.75 57.00% 0.54 46.60% MMTA- Cardiac/Circulator 1.56 42.10% 1.30 22.30% MMTA- Endocrine 1.68 39.60% 1.43 16.30% MMTA- GI/GU 1.41 45.60% 1.05 30.90% MMTA- Infectious Disease 1.61 42.80% 0.71 31.00% MMTA- Other 1.44 44.10% 0.80 19.30% MMTA- Respiratory 1.17 48.50% 0.72 28.20% Musculoskeletal Rehabilitation 0.75 60.10% 0.56 42.70% Neuro/Stroke Rehabilitation 1.37 41.50% 0.77 24.90% Wound 2.68 28.80% 0.83 22.80% Questionable Encounters 1.20 49.60% 0.73 29.70% 15

Why Sequence Periods by Clinical Group? New York State Benchmarks Reimbursement per Period Clinical Group 1 2 3 4 2nd 30 Day Variance Recert Variance Behavioral Health Care $2,198 $1,692 $1,716 $1,621 $506 $482 Complex Nursing Interventions $2,059 $1,714 $1,681 $1,625 $345 $378 MMTA- Surgical Aftercare $2,463 $1,793 $2,101 $1,905 $670 $362 MMTA- Cardiac/Circulator $2,455 $1,878 $2,102 $1,964 $577 $353 MMTA- Endocrine $2,465 $1,867 $2,095 $2,040 $598 $370 MMTA- GI/GU $2,414 $1,847 $2,006 $1,916 $567 $408 MMTA- Infectious Disease $2,320 $1,804 $1,894 $1,755 $516 $426 MMTA- Other $2,367 $1,795 $1,977 $1,931 $572 $390 MMTA- Respiratory $2,401 $1,783 $2,056 $1,891 $618 $345 Musculoskeletal Rehabilitation $2,535 $1,842 $2,041 $1,876 $693 $494 Neuro/Stroke Rehabilitation $2,626 $2,014 $2,179 $2,035 $612 $447 Wound $2,638 $2,127 $2,218 $2,142 $511 $420 Questionable Encounters $2,313 $1,739 $1,895 $1,733 $574 $418 16

Sequence of Periods by Clinical Group Periods Clinical Group 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Behavioral Health Care 47 18 8 4 4 2 2 1 Complex Nursing Interventions 124 83 70 66 58 55 49 40 37 31 22 19 2 1 MMTA- Surgical Aftercare 833 270 89 54 21 13 12 10 6 5 5 5 MMTA- Cardiac/Circulator 1,552 881 440 285 158 102 67 52 36 27 19 13 2 MMTA- Endocrine 148 80 36 22 14 6 2 3 3 1 MMTA- GI/GU 244 107 44 22 12 11 5 2 1 1 1 MMTA- Infectious Disease 249 142 77 35 19 11 8 3 4 2 MMTA- Other 195 103 39 18 8 9 5 4 3 2 2 2 MMTA- Respiratory 743 358 149 93 51 28 17 9 7 6 2 Musculoskeletal Rehabilitation 1,593 493 145 84 61 36 20 10 5 3 Neuro/Stroke Rehabilitation 552 271 123 76 47 22 8 6 3 3 5 3 1 1 Wound 344 239 166 135 77 64 48 40 26 23 11 5 2 Questionable Encounters 1,177 479 214 113 84 43 34 22 10 8 7 3 Total 7,801 3,524 1,600 1,007 614 402 277 202 141 112 74 50 7 2 17