Nursing homes across the country are rethinking their operational strategy as they prepare for a drastically new payment model that goes into effect in less than five months.
The Patient Driven Payment Model, or PDPM, which takes effect Oct. 1, significantly changes how skilled-nursing facilities have traditionally been paid under Medicare by moving away from a system that determines reimbursement based primarily on the volume of therapy services a patient receives to one that takes into account a patient’s unique health characteristics.
The new model is an attempt by the CMS to transition the long-term care sector to value-based payment, and it’s forcing nursing homes to reevaluate how they assess patients.
For some nursing homes, the model is a welcome change, but for others it may be a tough transition. It all depends on how much the facility has relied on the volume of therapy services for its operational strategy, stakeholders say.
“I wouldn’t say that a building that offers ultra-high therapy services is going to fail, but (they) are going to have some work to do to adopt a whole-person assessment process and service delivery arrangement,” said Mike Cheek, senior vice president of reimbursement policy at the American Health Care Association, which represents post-acute providers.
The new model was finalized by the CMS last July to replace the long-standing Resource Utilization Group payment system, known as RUG, with general support from the post-acute care industry. As nursing facilities care for sicker patients, many claim the RUG system doesn’t adequately reimburse them for their services because it looks at therapy minutes as a primary basis for payment. More skilled-nursing patients are too frail or won’t benefit from large amounts of therapy and the RUG system doesn’t support the other aspects of care provided like dementia management or speech therapy. As a result, patients were either given unnecessary amounts of therapy or nursing homes received lower payments for those patients because less therapy was provided.