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Publish Date February 28, 2020
The elephant in the room: PDPM clinical success metrics
Steven Littlehale
I've finally identified the cause of that lingering ache in my stomach. It's been steadily making itself known since April 2018. Sometimes the intensity has spiked into more of a jabbing punch, but most of the time it's just been background noise … until now.
No, it's not too much coffee. It's PDPM.
Are we prepared to defend the increase in Patient Driven Payment Model revenue with superior clinical outcomes?
The lay and professional media have been saturated with innuendos or direct accusations around how our industry has "slashed therapy minutes" to make the most out of our reimbursement no longer being tied to therapy minute provision. In addition, there has been an acknowledgement that PDPM is not going to be budget neutral as the Centers for Medicare & Medicaid Services intends. Between these two, the stage has been set for some tough love.
Still, I'm not buying it. I've yet to see data to support the cannibalization of therapy, even though both skilled nursing providers and therapy companies anecdotally describe a clear change in therapy delivery systems. Budget neutrality is another story entirely — and here I have seen the data!
An analysis done by CORE Analytics demonstrated that CMS' projected PDPM analysis was off. A much larger than anticipated proportion of skilled nursing facilities have seen an upside under PDPM. This is consistent with the earnings calls by the publicly traded companies. Many of these facilities were the ones anticipated to "take a hit" under PDPM, thus balancing out those that were projected to see an upside. Back to my belly ache.
On my initial readings of PDPM, I was excited — and I still am — but I got something wrong. I assumed that PDPM was value-based care. Ultimately, I had to admit that it was a step toward value-based care, but PDPM in and of itself wasn't. Facilities are financially rewarded for capturing patients' characteristics (and, by proxy, patients' needs), but it's less clear how care outcomes are measured and, ultimately, how the success of PDPM is judged from a care perspective
When I think about how we might measure PDPM's impact on the clinical outcomes for the patient, the usual suspects come to mind: hospital utilization metrics, successful discharges to community, ER use,, etc. But are they sensitive enough and timely enough to track the subtle nuances of PDPM? Moreover, these are all claims-based measures; they are not actionable and offer almost no assistance to providers' QAPI efforts. Might the current and proposed MDS 3.0 updates slated for FY 2021 help?
The possibilities are there! Both versions of MDS have a broad and diverse array of meaningful indicators of quality. A sharp clinical eye sees that measuring our effectiveness in managing pain, nutrition, depression, social isolation along with functional abilities is within our grasp.
It's up to us and our professional associations, not CMS, to identify these measures, rally around them and advocate for consistent adoption throughout our profession. Let's demonstrate, with superior outcomes, that we've delivered value to the patient and the healthcare system as a whole.
Hats off to Genesis Healthcare, by the way, who reported at the eCap summit that it has taken on this challenge. CEO George Hager indicated that they were using the modified Barthel ADL index to measure how patients have improved under their care.
This, in my opinion, is the best way to ultimately defend any PDPM financial uplift.
Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.
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