There’s a great deal of conversation about the Patient Driven Payment Model and the role it plays in reimbursement and care delivery. But, while everyone is focused on conjecture and what-ifs, it’s easy to lose sight of the facts.

Below are five myths and misconceptions about PDPM to ensure your facility and staff are prepared when the new payment model goes into effect on October 1, 2019.

Myth: PDPM is the same as value-based care.

While PDPM and the term “value-based care” stem from a similar spirit, they are two distinct concepts:

                                                               i.      Value-based care refers to the general practice of delivering holistic, personalized treatments to optimize resident or patient outcomes. PDPM fits under the topical umbrella of value-based care, but not all value-based care aligns with PDPM.

                                                             ii.      PDPM is a specific Centers for Medicare & Medicaid Services-led reimbursement model that only applies to skilled nursing facilities.

                                                           iii.      The ideology behind value-based care is that resident outcomes should determine reimbursements for facilities. Under PDPM, resident results will influence, but not define, reimbursements. Despite PDPM’s shift away from the existing RUG IV model, services themselves will still factor into payment rates for each care episode. This point leads us to an alternative view on PDPM. Industry expert Steven Littlehale makes a hard distinction between PDPM and value-based purchasing by claiming that PDPM is still “really all about volume.” He also challenges the sentiment that PDPM itself is the coming of a new era, positioning it as a blip on the long-term radar of reform. PDPM is just one progress point, he implies, along the IMPACT Act’s journey to achieve a “unified post-acute care payment system (U-PAC).”

Myth: PDPM will automatically cause most SNFs to lose money.

This myth presupposes that the RUG-IV model was ideal for SNFs. But even if facilities adopted the practice of augmenting therapy to increase reimbursements, that doesn’t mean it was their best option. It is possible that SNFs have been heavily documenting residents’ supposed therapy requirements while still providing, but not fastidiously recording, clinically complex care delivery. In this case, PDPM will boost reimbursement rates for SNFs – as long as providers understand how to code for and classify residents’ needs under the new payment paradigm.

Myth: PDPM deprioritizes therapy.

PDPM does aim to discourage SNFs from using higher therapy RUG levels just to reap financial rewards. However, if a resident genuinely requires treatments like PT, OT, or SLP, then CMS will still reimburse SNFs accordingly. Section O, an addition to the MDS per PDPM, will require SNFs to track the cumulative therapy minutes for each resident’s stay. A significant drop here in therapy utilization may raise a red flag to CMS, which could result in reduced payments.

Myth: SNFs should max out group and concurrent therapies under PDPM.

On one hand, PDPM promotes more individualized treatments for residents, which could necessitate outside-of-the-box therapy modes. But even though therapy minutes won’t define payment classifications under PDPM, the new regulation caps group and concurrent therapy allowances at 25%. Anything over that could result in penalties. This proposed limit intends to discourage SNFs from inappropriately using group/concurrent therapies as a cost cutter. 

Myth: The MDS coordinator role will lose importance.

Some have predicted that PDPM’s lighter assessment requirements will stamp out the MDS coordinator role, but this isn’t the case. It is true that PDPM reduces the number of required MDS assessments from five to two (with a third optional one), but in turn, the proper execution of these assessments will get more difficult. Where subpar coding could sometimes slide under the RUG-IV model, it won’t under PDPM.

MDS coordinators will play an integral role in conducting hands-on assessments and documenting the details that spur reimbursements. Instead of disappearing, the MDS coordinator role will evolve into a more dynamic job function which requires collaboration to corral and record key data points.

Tad Druart is the Chief Marketing Officer of Cantata Health.