The frequency of low-utilization cost changes (LUPAs) elevated for a lot of residence well being suppliers within the first 12 months of the Affected person-Pushed Groupings Mannequin (PDGM), which coincided with the COVID-19 disaster.
Partly, that’s as a result of there are way more LUPA variables to maintain monitor of beneath the brand new cost mannequin. At occasions, will increase have been additionally linked to residence well being sufferers unexpectedly declining scheduled visits due to COVID-19 fears.
To some, avoiding LUPAs by hitting a sure go to threshold might appear to be a comparatively easy course of. However residence well being suppliers within the weeds are telling a unique story.
“It’s in all probability one of many greater challenges beneath PDGM,” Nick Seabrook, the managing director of BlackTree Healthcare Consulting, instructed Residence Well being Care Information. “Below the Potential Fee System (PPS), we had a single threshold. We needed to handle 5 visits, and it was over 60 days. Now, you may have 432 thresholds to attempt to handle, and it’s over 30 days. I feel these two elements are what’s actually driving LUPAs up.”
King of Prussia, Pennsylvania-based BlackTree Healthcare Consulting supplies billing, OASIS and different companies to residence well being companies, amongst different post-acute care suppliers.
Residence well being corporations have been involved about LUPAs previous to the onset of PDGM, whereas the Facilities for Medicare & Medicaid Providers (CMS) really thought they’d be much less of a problem.
“One of many elements of that behavioral adjustment was the belief that we have been going to get higher at LUPA administration,” Seabrook stated. “However I feel that was a short-sighted view on their finish, simply understanding that it’s extra refined now than it was earlier than.”
EvergreenHealth Residence Care, a hospital-based residence well being and hospice supplier in Washington state, was hit laborious by LUPA struggles in 2020. It was one of many first suppliers within the nation to deal with COVID-19 sufferers, with the pandemic exacerbating PDGM’s ache factors.
Brent Korte, the chief residence care officer for EvergreenHealth, expects the difficulty to constantly enhance as time passes. However the struggles have taught each him and his group about what’s wanted to stop LUPAs.
“You want an up-to-the-minute understanding of the place every affected person strains up with LUPAs,” Korte instructed HHCN. “And we didn’t have that, and that was actually disarming. It brought about numerous additional work on our half, usually as a corporation. I feel we’ve realized a ton from it. Hopefully, we’re going to bounce into the remainder of 2021 with much more concentrate on really tackling PDGM versus being distracted solely by the pandemic.”
Not only a distraction
The pandemic hasn’t simply been a distraction from common residence well being challenges. It has had tangible results on LUPAs.
Sudden hospitalizations as a consequence of unplanned issues, staffing shortages tied to quarantine protocols and canceled visits due to sufferers’ anxieties can all throw a corporation’s LUPA-mitigation efforts out of whack.
If a missed go to is on a Tuesday, for example, even making up for it instantly the subsequent day may result in a LUPA within the new 30-day intervals. Moreover, entry to sufferers in amenities was additionally a problem in 2020, which made the scheduling course of harder.
“If we will’t see a affected person on sooner or later, and we now have to go in on the subsequent, it may set off a LUPA, and that’s been enormously [challenging],” Korte stated. “Our case hundreds have additionally grown, which implies our nurses and bodily therapists, particularly, have needed to [do more]. Within the meantime, the pandemic has brought about a deluge of considerably extra acute sufferers, sufferers who would in any other case have been admitted to expert nursing amenities.”
To Seabrook’s level, the behavioral adjustment from CMS didn’t replicate the truth that set in for EvergreenHealth, in addition to different suppliers throughout the nation. The adjustment was a proactive transfer on the company’s half — not reactive.
“We might have most well-liked that CMS, in a single regard, be reactive versus proactive in attempting to change our compensation,” Korte stated. “I feel for some suppliers, that behavioral adjustment in and of itself brought about a behavioral adjustment.”
Given the present acuity of its residence well being sufferers, EvergreenHealth hopes to decrease its LUPA price into the only digits by the tip of this 12 months.
“If we will meet our sufferers’ wants, understanding how sick they’re by way of the pandemic and the way we’ve had such a rise in acuity within the final 14 months, being within the single digits for LUPAs could be a fantastic aim to achieve,” Korte stated.
Discovering what works
So far as what’s labored, educating every clinician on LUPAs has saved EvergreenHealth’s head above water.
It’s one factor for an company’s leaders to know what triggers LUPAs and repair them, however with out top-down continuity, issues can fall by way of the cracks operationally.
“What actually works is ensuring that clinicians perceive their affect and perceive the coordination that it takes,” Molly McDonald, the scientific high quality coordinator for EvergreenHealth’s residence well being and hospice enterprise, instructed HHCN. “It’s greater than the one time when the affected person comes on service, attempting to plan that out. It takes fixed re-coordinating.”
In sure situations, a supplier gained’t know what a affected person’s HIPPS code is till 10 days in, which is now a 3rd of the way in which into the interval, Seabrook stated.
“After a supplier goes by way of their common QA course of and OASIS is accomplished, then the standard workers is reviewing the OASIS,” Seabrook stated. “They’re offering their suggestions to the clinician, the clinician makes their change, and now they lock the OASIS in and you’ve got that HIPPS code. You’re taking a look at that doubtlessly 10 days into the interval, and that HIPPS code goes to find out what that LUPA threshold is. You’re a 3rd of the way in which right into a interval earlier than you lastly discover out that threshold.”
COVID-19 continues to be affecting the LUPA downside all through the house well being sector. Because the disaster subsides, so will a few of the ache that comes with PDGM woes.
Nonetheless, LUPA administration will proceed to require diligence for suppliers to bolster their backside strains.
“The issue will get higher,” McDonald stated. “However we’re nonetheless emphasizing all the pieces that we did in relation to the COVID overlay of this and the significance of continued PPE, an infection management and vaccination pushes. This enables us to proceed to see sufferers of their residence and in amenities. If we don’t, that also is an actual downside in relation to the LUPAs.”