PDGM Under The Rainbow
July 20, 2019 | United States
The general idea with PDGM is that CMS is going to start paying for value, not volume. In theory, they are paying you to increase a patient’s ability to perform independently at home. However, the reality is that clinicians often score a patient’s initial abilities much higher than they should (affectionately called “Rainbow Charting”) resulting in a modest or outright lack of improvement in key functional areas.
The problem is that each clinician scores patient ability based on their own understanding of the OASIS. This is often flawed due to a failure to grasp the full scope and purpose of the assessment, and how to properly identify and score downgrades. Given the cloudy language of M00 items and the general lack of standardized process with OASIS, this puts agency Star ratings and reimbursement at even greater risk under PDGM.
While the new Section GG is allowing for better overall scoring symmetry, we are finding that those items are subject to the same level of error and subjective determinism as the M00 items.
Based on years of OASIS discharges and follow-ups across several agencies from coast to coast, I can tell you that inaccurate SOC scoring results in the average agency top-line revenue taking a hit somewhere between 3% and 8% on traditional Medicare reimbursement. (For more guidance, poll your primary discharging therapists).
Under PPS, this has mostly been obscured by Service Utilization which paid more based on the number of therapy visits. However, now that visit count is shifting to a net cost under PDGM, many companies are about to feel the pain - and feel it bad.
SOC clinicians and discharging clinicians are oftentimes different people with different philosophies of care. RN’s more frequently start cases, but typically use verbal inquiry to assess the M1800-M1860 questions, meaning they are blind to inaccurate answers. And patient’s often overestimate and overreport their ability at first contact because they don’t want to be seen as incapable.
For instance a nurse asks a patient, “are you able to bathe yourself?” The first thing that goes through the patient’s mind is “if I say no, someone is going to see me naked”, so they say “Sure, no problem there!”
At discharge, the clinician may accurately respond that the patient is now independent in the task. However, since the patient was rated incorrectly as independent from the beginning, this now makes it appear to CMS there was no improvement in this area, and therefore as an organization you were not effective.
This is not an outlier. It is occurring every single day and at every agency. With the previous revenue buffer now going away, agencies without a clear and objective process for measuring, spot-checking, and validating clinician OASIS understanding and scoring may find that they simply cannot sustain an adequate service provision for patients.
While many companies utilize SHP to review chart notes and correct inaccuracies, this is blind to the reality on the ground. Without laying eyes on the patient and truly seeing a clinician’s ability, it’s impossible to validate scoring accuracy at the time it occurred. Conventional OASIS training solutions are just as blind to this clinical reality because they focus on formulas and guidelines rather than clinical approach.
Agencies have to accurately screen and train their clinicians on an ongoing basis to determine who’s an accurate scorer and who’s isn’t. OASIS understanding is an evolution, not a one-time fix and forget. If you don’t correct the problem at the level of process and reasoning using a field-based context that clinicians can relate to, the training will not succeed long term. This is something any seasoned clinician will tell you.
ClinicalHQ was founded on the principle of delivering real solutions to the actual problems on the ground. Our tech, training, and testing solutions were born out of hard learned lessons from decades of industry experience and process failures. Let us show you how our platform can deliver the real results that your agency needs. You can request a demo from our website here.
Authored by Jon Mancil, Founder, ClinicalHQ.