Patient Driven Payment Model (PDPM)

 

In 2018, the Center for Medicare & Medicaid Services (CMS) finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.

PDPM consists of the following five case-mix-adjusted payment components:

  1. PT: covers utilization of physical therapy (PT)
  2. OT: covers utilization of occupational therapy (OT)
  3. SLP: covers utilization of speech-language pathology (SLP) services
  4. Nursing: covers utilization of nursing services and social services
  5. NTA: covers utilization of non-therapy ancillary (NTA) services

Additionally, PDPM would maintain the existing non-case-mix component to cover utilization of skilled nursing facility resources that do no vary according to resident characteristics.

For more information about the PDPM patient classification: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

Calculation of Payment Under PDPM

Like the RUG-IV model, per-diem payment under PDPM would be determined by two primary factors:

  • base rates that correspond to each of the five payment components; and
  • case-mix index (CMIs) that correspond to each payment group.

Each resident would be classified into a resident group for each of the five case-mix-adjusted components. The base rate for each case-mix-adjusted component would be multiplied by the CMI corresponding to the assigned resident group. Additionally, separate adjustments would be applied to each resident’s PT, OT, and NTA payments depending on the day of the stay.

 

Determining Payment Under PDPM

Table 1 above shows the determinants of payment for each case-mix-adjusted component in PDPM. The non-case-mix component is not shown, as it is not dependent on resident characteristics. As outlined in Table 1, PT and OT payment would be based on the primary reason for SNF care and functional status at admission. SLP payment would be based on the primary reason for SNF care, cognitive status at admission, SLP-related comorbidities, and the presence of a swallowing disorder or a mechanically altered diet. Nursing payment would be based on clinical information from the SNF stay, functional status, extensive services received, viii Acumen, LLC the presence of depression, and restorative nursing services received. NTA payment would be based on the presence of comorbidities and extensive services received. PT, OT, and NTA payments would also vary based on the point in the stay.

AMDA PDPM Resources & Webinars (free to members)

PDPM White Paper

WEBINAR: Patient-Driven Payment Model (PDPM): An Opportunity for PALTC Clinicians

WEBINAR: The Quest for Quality: Red Flags in Skilled Therapy and the Changes Required by the Planned Transition to the New Patient Driven Payment Model PDPM)

Caring for the Ages Article: SNF Medical Directors and Clinician in PDPM Have Vital Role

CMS Resources