The news surrounding the launch of PDGM has been primarily focused on the impact on Home Health Care (HHC) providers, and rightly so. Nonetheless, there are other groups directly impacted by the proposed changes, and doctors in particular, have likely not received much information on the how PDGM will impact them.
PDGMs Impact on doctors: Community based vs. Institutional based settings
Right or wrong, The Centers for Medicare and Medicaid Services (CMS) is changing case mix calculations and is giving focus to the referral source. This is due in part to CMS collected data and the agency’s belief that patients coming from institutional settings are typically sicker and, thus, need more care and resources. While critics are quick to point out challenges to that line of reasoning, it currently appears that the case mix calculations will be set so that a case mix weight for a community episode will be 0.8782 and an institutional referral will be 1.1855. This means that some doctors will find that the HHCs they have worked with in the past will need to shift their referral mix way from the community-based settings to more institutional based settings.
Big changes with LUPAs
Low Utilization Payment Adjustments (LUPAs) are where most doctors will see changes and will likely have the most questions. The first immediate change is the 60 day episodes will be a thing of the past. CMS is moving to a 30 day episode with the belief that this time change will give patients a higher standard of care. Within the 30 day episodes, LUPAs are being redefined so that instead of the standard 4 or fewer visits, the new rules will break down LUPAs in 216 scenarios, each with a new LUPA standard that could range from 2-6 visits. What that means is agencies used to a four-visit threshold over 60 days may have to start thinking about a 6-visit threshold over 30 days, which will essentially feel like the therapy work has more than doubled. Doctors will want to know about these changes and begin adjusting their expectations as well as that of their patients.
The good news for doctors
Ultimately, the impact of PDGM will be to increase the amount of in home therapy patients receive in a shorter period of time. That should lead to better outcomes, including, but not limited to, fewer expensive readmissions. Thus, while there may be some early challenges in 2020 with this new regulation is rolled out, I believe all parties can see that this ultimately delivers better care to the patients.
Sheri Yarbray is a CEO, the founder of Your Therapy Source LLC a home healthcare company, a STEM entrepreneur, and proud mom. Sheri is passionate about delivering high quality home healthcare to patients, inspiring young women to move into STEM careers, and sharing ideas about managing a balance between a work and a home life. You can follow Sheri on LinkedIn @Sheri Yarbray
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