The Patient-Driven Groupings Model (PDGM) will significantly change reimbursements for home health organizations, and as our industry learns more about how it will impact day-to-day operations, questions continue to surface. Axxess has created a resource page with quick reference guides and videos to help explain these changes. One of the most common questions asked is, “What are the chances that PDGM will be delayed?” Given the amount of resources it will take to prepare for this major change, and CMS’ track record with rolling out new regulations and initiatives, it is a fair question.
The Origin of PDGM
The Medicare Payment Advisory Commission (MedPAC) has been long advocating for changes to the home health payment system, especially with the therapy threshold’s impact on payment. The Centers for Medicare and Medicaid Services (CMS) has also conducted numerous studies and data analyses on the Home Health Prospective Payment System (HHPPS), which has led to several case-mix adjustments. Ultimately, this review led to the development of the Home Health Groupings Model (HHGM) which evolved into PDGM. While our industry seeks clarification on unknown aspects of PDGM, there currently are no efforts to prevent or delay the January 1, 2020, start date. Advocacy groups are working to modify the proposed behavioral adjustments ( S. 3458, H.R.6932) but neither of these proposals includes a delay. The remaining questions about PDGM will be answered in the coming months and the mandated rollout will occur in 2020.
The president signed the Bipartisan Budget Act of 2018 (BBA) into law on February 9, 2018. It requires that specific home health payment overhauls must occur beginning in 2020. The BBA amended the Social Security Act by establishing 30-day units of service for home health payments, eliminating therapy thresholds in case-mix adjustment factors, and mandating budget neutrality. The specific language states the Secretary of Health and Human Services (HHS) “shall calculate a standard prospective payment amount (or amounts) for 30-day units of service” in a budget-neutral manner beginning January 1, 2020.
PDGM Behavioral Adjustment
The BBA gives the HHS secretary the authority to make assumptions about behavior changes by our industry that could occur because of the implementation of PDGM. This has led to the 6.425 percent behavioral adjustment that decreases payments. While this change is difficult to swallow, our industry must admit that there are operators in our space who have contributed to this negative assessment. For example, as the therapy thresholds changed over the years, behaviors related to therapy delivery changed as well. Therapy delivery was not always based on a patient’s specific needs derived from an individualized assessment and treatment plan. Another example is the disproportionate use of certain diagnoses in the top six slots when they increased case-mix points that are no longer used since no case-mix points are awarded (e.g. GERD and Low Vision). The law requires that the HHS secretary annually demonstrate data showing the differences between assumed behavior and actual behavioral changes between 2020 and 2026.
Approaching PDGM Deadlines
The BBA ordered a technical expert panel to identify and prioritize recommendations for PDGM. This technical panel met in 2018 and included home health providers, patient representatives, and other relevant stakeholders. They were tasked with identifying and prioritizing changes to the payment system for home health under the Social Security Act. The HHS secretary must submit a report of the findings of this technical panel and recommendations to the House Committee on Energy and Commerce and the Senate Committee of Finance no later than April 1. This report will give our industry additional insight about the implementation of PDGM. The proposed rule for home health payment will come out by mid-year and will show the final proposals that will evolve into the final rule in the late fall.
PDGM Delay Unlikely
For all these reasons, it appears that PDGM will proceed as planned on January 1, 2020. Barring any unforeseen technicalities, there does not appear to be any likelihood PDGM will be delayed. Any delay would require another law passed by Congress and approved by the president. Our industry would be well-served to proceed with the assumption that PDGM will go into effect as planned. If a law changes the implementation date, we will have additional time to prepare for this major disruption.
Axxess is a partner you can trust on the journey to PDGM success. Our PDGM resource page features answers to other frequently asked questions, quick reference guides, and videos to help providers prepare for, navigate, and thrive in this changing environment.