PDPM, Medicaid and the Future

We are now more than a year into PDPM. How’s it going?

If you are like most people, you are doing better financially with PDPM than with the RUG-IV, 66 grouper it replaced. In fact the data is pretty clear that almost everyone is doing better financially under PDPM.

Now we are starting to hear that some states are considering replacing state Medicaid plans with “PDPM style” plans. This is interesting for several reasons, but consider this:

  • There is no official data showing how provided therapy minutes have changed since the switch to PDPM. Common sense and anecdotal evidence suggest minutes have declined significantly. At least one national consultant has gone on the record saying minutes haven’t declined that much. CMS has been silent on this issue.

  • There is no official national data showing patient outcomes in SNFs. You would expect a year into this process we would start to see something, but so far… nothing. We really haven’t seen anything from the national consulting firms that collect this data either.

  • PDPM has most certainly not been budget neutral. Far from it. This we can tell from looking at published data and RESDAC. PDPM is more expensive than RUG-IV was.

  • The global pandemic has made it exceedingly difficult to determine how providers are responding to the new payment system. What changes are due to COVID-19 and what is just due to adjustments to PDPM? We won’t know for a long time IF the pandemic is brought under control with vaccines. What will the new normal look like? No one knows. This may be one reason why CMS has not made any rate adjustments based on therapy volume.

Why then, would states want to replace their current Medicaid plans with a system that costs more and whose efficacy has yet to be determined? CMS is obviously pushing for this to happen by complicating the state assessment process. That pushing appears to be working but how can we be sure we’ll end up with a better system? How can we be sure it won’t be more expensive and less effective?

Also keep in mind that many, but not all, states are reluctant to share any data regarding their Medicaid programs. This means we’re often flying blind collectively regarding these programs in large parts of the country.

This is no way to run a modern healthcare program. We can do much better. It seems like common sense that healthcare providers should have a way to compare their performance to that of their peers and that everyone should be using the same data for comparisons.

Data is the fuel for modern AI decision making machinery. We have mountains of this fuel in reserve, but we’re choosing to let our best tools sit still idle in many cases. That’s a shame.