James M. Berklan

I don’t know about you, but with all the hype during the run-up to PDPM implementation on Oct. 1 — TWENTY-ONE DAYS (21!!!) AND COUNTING! — it’s beginning to feel a little like the morning of the third-grade Halloween party.

The hour is almost at hand and, well, who can concentrate? It’s almost as if all the Halloween candy has already been eaten and the sugar rush is in full gear.

While there’s good reason for the excitement, however, we should remember that this huge transformation is simply paving the way for more change. If all goes according to plan, another, possibly more impactful, change will be coming in about two more years.

I know, with Washington doing the planning, you don’t have reason to put your hat and coat on yet. But do keep ulterior motives in mind. Their impact would be unprecedented on providers.

More than three years ago, MedPAC first recommended a unified post-acute payment system. It was taken half-seriously by many stakeholders. Who could earnestly think that skilled nursing facilities, home health agencies, inpatient rehab facilities and long-term care hospitals could exist under a single payment and incentive system? It would, in part, mean aligning quality measures, regulations and risk management efforts.

Yet work on these fronts has ensued.

Part of the progress toward the 4-in-1 payment model has included the creation of the alluded to Patient-Driven Payment Model. Coupled with the start of PDGM in January for home health agencies, the movement’s direction is clear. Payment is going to hinge on residents’ clinical characteristics, and how well they’re attended to.

MedPAC’s recommendation was to refocus distribution of payments in 2019 and 2020 before making the leap to a fully unified system the next year.

Last week, the Congressional advisory panel met to discuss some of its hopes and concerns. Implications of the potential unified system seeped into the dialog. There were worries about perverse incentives possibly leading to under delivery of care, and how rising acuity would be handled by each sector.

MedPAC’s proposed program would function on a small number of risk-adjusted measures based on claims. Expect to see a spotlight flashing hotter on hospitalization rates, Medicare per-beneficiary spending, successful discharge-to-the-community rates and other focused measures.

Another major focal point will be what the withhold from providers could be. Currently, 5% is being proposed to fund incentives, but that could change. Smaller providers’ limited access to financing is a concern, according to a report from Modern Healthcare.

The report also noted that Commissioner David Grabowski suggested that a lower initial withhold might be more prudent. The level could rise as the program matures and providers become more comfortable with it, he offered.

If the anxiety-filled past weeks and months are any indication, “getting comfortable with it” could become a very familiar, repeated condition for long-term care and other post-acute providers in the months and years ahead.

Follow Executive Editor James M. Berklan @JimBerklan.