It was about an hour after the release of the Center for Medicare & Medicaid Services’ proposed rule for FY19, which contained the big Patient-Driven Payment Model reveal, that a wave of bold and somewhat uninformed statements surfaced.
It was equal only to the saturation of “PDPM experts” who have seized upon this opportunity. The volume of misinformation is notable. Is this our own version of “fake” news?
Here are some of my favorites:
- “The MDS is irrelevant in PDPM.” (Excuse me? I think I count only one non-MDS field.);
- “We have to make way for, and prepare for the ‘new resident’ coming in our buildings.” (… because up until PDPM they have been hiding precisely where?); and
- “I’m going to cut my MDS staff.” (Ouch!)
It’s the last I want to discuss.
Others and I have tackled many of these myths in various McKnight’s blogs, but I’ve yet to see a compelling analysis of the MDS volume issue, other than what was presented on page 387 of CMS’ final rule. That’s where the agency touts a cost savings of $195,925,878, or $12,664 per provider per year. I believe that is what’s behind some operators’ sentiment that it’s appropriate to make cuts to MDS departments.
I’m not sure how $12,664 translates into an MDS full-time equivalent in your building, but before we go there, consider the following:
- Who is taking on the responsibility of ICD-10 coding? It is a significant driver of PDPM reimbursement and MDS coordinators with additional education will be an important asset.
- CMS’s analysis didn’t consider ANY proxies for Interim Payment Assessments (IPA), as they had in prior analyses. No, IPAs are not mandatory at the moment, but, yes, you’ll still need to designate someone to complete them when appropriate.
- CMS’s calculations didn’t anticipate the growing Medicare Advantage population and associated requirements. Many Medicare Advantage plans require that you follow the PPS assessment schedule for its members.
- States often add additional data sets to the MDS to support their own needs. This is fluid, changing from year to year.
- The payment drivers for PDPM require greater clinical assessment skills and likely more time to complete.
We analyzed 4,266,018 MDS assessments received in 2017 to better understand any adjustments to MDS volume under PDPM. Here is what we found:
Isolating PPS 5-day and PPS discharge assessments, there was a 15.77% reduction in total MDS volume. This analysis includes Medicare Advantage PPS assessments. There was no significant difference when we excluded them.
No doubt there will be fewer Medicare PPS assessments under PDPM, but the level of reduction in these assessments is a bit of a moving target. CMS has not provided specific criteria on IPA completion, though it is possible to make some assumptions based on existing MDS requirements such as the significant change in status assessment. We chose not to use this assessment —not even those completed on only Medicare residents — in our analysis, but for a different rationale than what is offered by CMS. We believe counting them would underrepresent the number of IPAs we’ll ultimately see submitted.
One final qualm: PDPM puts emphasis on MDS sections that some may have wrongly categorized as unimportant. Shocking, I know. But there tends to be a more watchful eye on the RUG items than on many other MDS 3.0 items. Monica Walsh, senior vice president of Care Management from Regency Integrated Health Services, had some key insights on this topic of excess time: “PDPM requires a different skill set for the MDS coordinator. While complex scheduling and playing ‘traffic cop’ was needed before, with PDPM, superior skills to assess cognition, depression and function are key.”
To quantify the accuracy of MDS assessments, beyond RUG payment items and including PDPM items, we examined approximately 24,000 MDS assessments from 2018. We identified a 79% issue rate. An issue is defined as a clear logical or clinical disconnect in the MDS which amounts to inaccurate assessment, weak care plans, false quality measures, and survey issues.
Clearly any excess time that MDS coordinators have should be reallocated to honing assessment skills, learning ICD-10 coding, improving clinical documentation, refining MDS coding, and working to determine the requirements of your non-Medicare Part A payers.
“To be successful with PDPM, the role of the MDS coordinator must transition to that of a ‘care management nurse.’ This requires deep clinical assessment from day one and continues throughout the resident’s stay,” says Walsh.
Bottom line: Save your slicing for that hearty piece of autumnal apple pie and preserve your MDS staffing budget.
Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.