Physician Groups Have Skilled Nursing Opportunity In PDPM — If They Take Action

April 11, 2019, Maggie Flynn, Skilled Nursing News - The clinical condition and medical complexities of skilled nursing patients will drive reimbursement under the new Medicare system — giving physician groups that serve skilled nursing facilities the opportunity to have a major impact on the outcomes and success of both the patients and the facilities they serve.

But it’s an opportunity they’ll have to step up and take, and many aren’t inclined to see the Patient-Driven Payment Model (PDPM) as something they have to worry about.

“Most physician groups that serve nursing homes are not looking at [PDPM] as their issue,” Sandeep Patel, chief medical director of the SNF division at long-term care services company Eventus WholeHealth, told Skilled Nursing News.  “They’re looking at it as a facility issue.”

Eventus’s services include primary care, mental health services, podiatry. and optometry for long-term care and assisted living facilities across North Carolina.  The Concord, N.C.-based firm also provides medical directorship at 18 SNFs.  In total, it serves more than 200 facilities in various capacities throughout the Tar Heel State.

Facilities are reaching out to groups like Eventus to navigate various initiatives related to PDPM, Patel said.  But generally speaking, nursing homes across the U.S. are not using physician groups for medical directorship, he noted. By and large, they’re using mom-and-pop physicians with an office practice.  That’s a model of care that is no longer relevant to the present-day SNF environment, given increasing levels of sickness and acuity in the patient population, Patel argued.

Rising patient acuity is also a major factor in PDPM, as the model drives reimbursement up for patients with more complex conditions and comorbidities.  The new system is the first step along a path to incentivizing SNFs to take on more such patients, who traditionally are hard to place and costly to care for in other settings, Robert Harrington, principal and cofounder of PAC Leaders, told SNN.

Like Patel, he believes that the old model for doctors and medical directors won’t cut it under the new system.

“As it relates to medically complex patients, SNFs are going to get paid for only what they can prove they did and only for the acuity level they can prove the patient had,” Harrington told SNN.  “And if it’s not documented, it hasn’t been done.”

PAC Leaders, a medical management company based in Alpharetta, Ga., was established in March, with a current presence in three facilities.  The company projects that it will be in 20 to 40 facilities by the end of the year, and Harrington said it sees opportunity in the demands that the PDPM model will put on SNFs — especially in terms of patient complexity and the education and training those patients require SNFs to have in place.

“in today’s world, where Dr. Smith who’s an internist or family doctor who practices in the SNFs and comes in a few times a month to see a few patients here or there, his or her level of documentation is not going to be adequate to maximize reimbursement for the skilled facilities,” he said.

Even though SNFs are working on training and education in advance of PDPM, they have no one on the medical provider side accountable to them to complete proper documentation, Harrington said.

“They don’t get seen for three to five days by the admitting medical provider, and yet the SNF has to — within that first couple of days — document the acuity and severity of the patient’s condition and all their comorbidities,” he told SNN.  “Right now, they have to train all their nursing staff to do that documentation, because they don’t have an alternative.”

Ideally, the patient would be admitted to a SNF and be seen in a matter of hours by the admitting medical provider, with a complete history, physical exam, and documentation of all the medical issues, Harrington said.  That would result in a more complete picture, and he believes adding medical management could take some of the burdens off of the frontline staff in terms of documentation.

Patel also thinks that SNFs will end up gravitating toward groups that have a plan for dealing with the medical complexity and need to assess patients quickly, completely, and accurately.

“Physicians and physician groups that want to remain part of long-term care and post-acute care, they’ll look not only to how they do the work, but how do they strategically partner with the facility,” Patel said.  “Not only to improve the facility financially, but to make sure the best patient outcome is met.”