The Centers for Medicare and Medicaid Services (CMS) has made headway separating metrics changes in the past year-and-a-half, tying some to the pandemic and others to implementation of the Patient-Driven Payment Model (PDPM).
John Kane, technical advisor and SNF payment team lead for CMS, helped the skilled nursing industry better understand the impacts of PDPM during a presentation at the SimpleLTC 2021 Virtual Symposium Wednesday.
Therapy minutes, depression coding, stays with infection isolation and long-term care nursing home stays were the four major metrics Kane discussed during the presentation, attributing the first two to PDPM implementation and the last two to the pandemic.
A swap in the number of dual-eligible residents, those covered by both Medicare and Medicaid, and non-duals, was another metric clocked by the CMS representative — Kane said this was the first time CMS recorded duals outnumbering non-duals, 60% to 40%.
Those statistics are usually reversed, Kane noted. He attributes the shift to more Medicaid patients being transitioned from Medicaid stays to Medicare Part A stays once COVID-19 hit.
“We look not just to see that it changed, it’s important to recognize when it changed,” Kane said. “CMS has been conducting a significant amount of data monitoring and analysis to try to understand what some of these trends have been, that have occurred since the implementation of PDPM, as well as what has been impacted and what changes have occurred due to the COVID-19 [public health emergency, PHE].”
PDPM was implemented in October 2019, shifting how facilities were reimbursed to serve the patients and his or her diagnoses, rather than being tied to services rendered at a SNF. CMS sought feedback on potential parity adjustments to the new model, which increased payments to nursing homes by 5% in 2020, a total gain of $1.7 billion.
Metrics changes tied to PDPM
Kane said that “very few metrics” had no real change between 2019 and 2020.
SNF stays with depression, based on CMS data findings, is linked to PDPM, Kane said. The percentage of stays doubled in October 2019 when PDPM took effect, eventually tripling to 13% from its starting point of 4%.
PDPM affected the number of therapy minutes per day too, Kane said, a significant decrease of 33%. CMS, along with others in the industry, was expecting a drop in therapy minutes since the previous payment model, RUG-IV, heavily relied on therapy minutes (services rendered) to determine reimbursement.
“Under RUG-IV, there were really only two qualities that I needed to know about a person’s stay in order to know what we were paying for that person, in over 90% of the cases. That was what their general functional status was, and the number of therapy minutes that they’ve received, and that was that,” explained Kane. “That was one of the main things that we were trying to do with PDPM, was to broaden the types of things that were relevant in assigning a payment classification.”
Therapy minutes specific to concurrent, or ongoing therapy and group therapy, on the other hand, increased with PDPM only to drop in 2020 with an overall reduction in the amount of therapy provided due to isolation efforts.
Concurrent and group therapy increased about 23% and 20% respectively between August and October 2019, and decreased 22% and 21% between February and April 2020.
CMS is still assessing the impact on beneficiaries, Kane added, related to changes in therapy minutes.
Metrics changes tied to the pandemic
Perhaps unsurprisingly, the percentage of stays with infection isolation and percentage of long-term care nursing home stays jumped in April of last year, from 1% to 15% and 20.8% to 49.5%, respectively.
Resident eligibility shifts were more of a rogue trend, Kane said, with the number of dual-eligible residents outnumbering non-duals due to patients transitioning from long-term care, Medicaid stays to Medicare Part A stays.
“For as long as we have data, looking back years and years, that percentage has always been… about 60/40,” said Kane, referring to 60% non-dual eligible patients and 40% eligible for both Medicare and Medicaid coverage. “We all of a sudden saw a higher percentage of dual stays than we saw non-duals.”
Kane pointed to the three-day stay waiver, as a driver behind the push to Medicare Part A.
The waiver was made by the CMS at the beginning of the pandemic in order to allow hospitals to reserve beds for severely ill patients, discharging those who could recover at a SNF.
Prior to the pandemic, a patient needed to have a three-day inpatient hospital stay before Medicare would cover the SNF stay that followed.
