‘All Systems Are Go’ at CMS for PDPM, But Not All Providers Are Ready

The new Medicare reimbursement model for skilled nursing facilities remains on track for implementation this fall, but not everyone is ready — and operators need to look to the big-picture shifts in value-based care for inspiration as the clock keeps ticking.

That’s according to a recent webinar from the Minneapolis-based consulting firm Health Dimensions Group (HDG), which used the forum to cover policy changes that affect Medicare Part A, a review of the fiscal 2020 SNF PPS proposed rule from the Centers for Medicare & Medicaid Services (CMS), and proposed modifications to the quality review program.

Issued last month, that proposed rule made clear that the Patient-Driven Payment Model will arrive on its projected October 1 implementation date, Brian Ellsworth, vice president of public policy and payment transformation at HDG, said on the webinar.


“The biggest takeaway from the proposed rule is that PDPM is on track to be implemented on October 1, 2019, just four short months from now,” he said. “CMS’s recent statements and this proposed rule clearly indicate that all systems are go. From our point of view, providers are in varying stages of readiness.”

As they continue training for PDPM, operators should look to changes that CMS made to the accountable care organization (ACO) and bundled payment programs. The Pathways to Success model finalized in December removes the no-risk tracks where ACOs could operate without taking on downside exposure, and is aimed at increasing the potential for risk and reward.

While there’s been chatter that ACOs will leave the program altogether if they’re forced to take on downside risk, the ones that remain will be looking for good partners, Ellsworth stressed on the webinar.


“Markets that are moving toward downside risk will have referring patterns and [an] increase in downstream provider expectations,” he explained. “And in some cases, that could occur very rapidly, and without a lot of warning. Post-acute preferred provider networks will continue to proliferate, and some of them may shift to include a risk component with post-acute care in order to further align incentives.”

In the current landscape of value-based care incentives, that hasn’t always been the case. In fact, hospitals having control of bundled payments poses a major threat to post-acute success, Phil Fogg, president and CEO of the Milwaukie, Ore.-based Marquis Companies, argued at a recent conference. And though experts agree on the importance of SNFs having strong relationships with ACOs, the ACOs themselves may not always cooperate.

But as PDPM incentivizes SNFs to take on medically complex patients and offer efficient care, that can move SNFs into more beneficial arrangements with upstream partners, Ellsworth argued.

“That’s one of the things to consider as PDPM’s unfolding and as these markets are shifting to downside risk: How will you be able to forge a win-win relationship there?” he said on the webinar. “And there’s certainly one to be had.”