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2020: What lies ahead for payers and PACs?

Between PDPM, PDGM and new IMPACT Act discharge planning requirements going into effect, it’s been a busy few months for the post-acute space. With so much change, what might 2020 have in store for payers and post-acute providers? As 2019 quickly draws to a close, our thought leaders share what trends they expect to see in the new year.

Tom Martin, Director of Post-Acute Analytics

PDPM will bring more change than RUG ever did

In July 2018, CMS finalized the Patient Driven Payment Model (PDPM), which replaces the Resource Utilization Group, Version VI (RUG-IV). While the RUG-based model was often criticized for basing reimbursement on the volume of therapy services provided to the patient, PDPM, which went into effect on October 1, 2019, classifies patients into payment groups based on specific, data-driven characteristics. By more closely correlating reimbursement and a unique patient’s needs, PDPM better aligns payment rates with the costs of providing care and increases transparency to enable patients to make informed choices.

Both PDPM and PDGM (the Patient-Driven Groupings Model) are new payment models that aim to fix the misaligned provider incentives prevalent in traditional Medicare fee-for-service models. There’s reason to be generally optimistic about both new payment models as they should result in more equitable reimbursement for providers. Though early PDPM results show that most providers are experiencing boosts in reimbursement, it’s still premature to draw conclusions regarding potential winners and losers out of this new program. Ultimately, despite remaining uncertainty, we can expect to see more significant revenue shifts under PDPM – whether up or down – than we did under the RUG system.

Quality measure success will continue to live outside your four walls

Publicly reported CMS quality measures for QRP, VBP and Five Star are no longer solely based within a provider’s care setting, but instead across different care settings. In 2020, we expect to see a continued trend: in order to improve in any quality measure that’s publicly reported by CMS, you need to know what’s happening to patients outside your four walls. Key to success across these programs is understanding what happens to your patients after you’ve discharged them out of your care.

Matt Gagalis, Head of Payer Market Development

Payers will expand value-based care and risk-based arrangements for Medicaid

Value-based care and risk-based arrangements aren’t going away over the next 12 to 14 months. In fact, we expect these to be a priority for Medicaid plans in 2020 and beyond. Medicaid patients, by definition, are difficult to track and contact – patients move frequently and can lack consistency in addresses and phone numbers. In 2020, payers will prioritize technologies that effectively capture a patient’s whereabouts and status, whether visiting an emergency department or being admitted to the hospital. Solutions that provide these insights will be increasingly valuable as payers cannot drive critical quality measures without knowing the location of their patients within the care continuum.

Readmissions and member experience will continue to be thorns in payers’ sides

Over the past twenty years, readmissions have been difficult for both payers and providers to successfully address. Though the CMS Hospital Readmissions Reduction Program has received the credit for declining readmissions, evidence suggests that the reduction has actually been driven by an overall decline in all hospital admissions. While advances in telemedicine, in-home care and real-time data availability have shown promise, payers must implement these solutions to achieve notable change in readmissions in 2020.

We also anticipate continued health plan focus on member experience and satisfaction, where payers have historically struggled to move the needle. While Stars Ratings and other quality initiatives have delivered strong outcomes in areas like medication adherence and preventive care, member experience is still a pain point for payers. In order to remain competitive, payers must expand strategies to improve member experience.

Learn how CarePort’s suite of tools can help payers, post-acute providers and health systems better manage care transitions and coordinate care.

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