Preparing for the Patient-Driven Groupings Model
by Laurie Salmons

As home health providers know, low-utilization payment adjustments (LUPAs) can have a detrimental impact to an agency both clinically and financially. Clinically, it is difficult to obtain best patient outcomes with very few visits and financially, in some cases, a LUPA can be the difference between a $2,600 payment for an episode of care and an adjusted payment of $300.

The Centers for Medicare & Medicaid Services (CMS) has a triple aim for patients to have positive care outcomes, a positive experience of care, and a low per capita cost of care. Said another way, when LUPA episodes occur, these CMS goals are usually not achieved. Therefore, Medicare will pay the agency a per-visit rate instead of a full episode of care rate. Over time, this can add up to a lot of lost revenue for an agency.

In the Medicare Patient-Driven Groupings Model (PDGM) environment, the adjustment could be even more unfavorable.

LUPAs are just one of the contractual adjustments that currently make up the Medicare-certified home health prospective payment system. Home health agencies have had a five-visit LUPA threshold for some time now with four visits or less per episode resulting in a low-utilization payment adjustment.

PDGM, however, introduces Building a Better Management Team complex structure of visit requirement variables that Medicare home health providers will need to navigate. Like so many other aspects of PDGM, agency owners and managers should pay attention. LUPA management will become more challenging.

Under PDGM, LUPA thresholds will be based on clinical grouping and episode timing. New LUPA episodes, which will be evaluated annually by CMS, will range from two- to six-visit thresholds and vary across clinical groupings. There will be a different visit threshold for each of the new 432 home health resource groups (HHRGs). In addition, there will be a potential to have a LUPA in each 30-day payment period within the 60-day episode of care. Diagnoses that are high risk for hospitalization such as heart failure, COPD and diabetes are prone to LUPAs.

Figure 1 shares a summary of the visit thresholds and related number of HHRGs and top clinical groups, under the current PDGM guidance as provided by Medicare.


Figure 1Figure 1. Summary of the visit thresholds and related number of HHRGs and top clinical groups, under the current PDGM guidance as provided by Medicare. *Medication Management Teaching and Assessment (MMTA)

It is important that you prepare in order for your agency to be ready for the implementation of this new payment structure. This preparation includes conducting an intense review of your current LUPAs and understanding the impact that 30-day periods of care will have once PDGM is implemented in 2020.

1. Conduct an Internal LUPA Review

To understand factors that are currently causing LUPAs in the patient population in advance of 2020, your PDGM committee should randomly review a percentage of LUPA episodes with varying diagnoses each month for the next three to four months. The review process should include the following:

  • Was the episode front-loaded at start of care (SOC) and resumption of care (ROC) to potentially reduce the chance for rehospitalization? Front loading is usually at least three visits within the first seven days of care.
  • Does the patient’s clinical picture match the visit utilization provided?
  • Did the patient require more visits to meet goals and improve outcomes?
  • Was the LUPA a result of missed visits, staffing issues, patient refusal of care and/or scheduling issues?
  • Was homebound status confirmed correctly at SOC and was the patient-stated goal utilized to drive the plan of care?
  • Were the right disciplines added at SOC/ROC? Examples may include:
    • Occupational therapy ordered for respiratory and COPD cases
    • Physical therapy for functional issues, falls risk and safety concerns
    • Nursing for medication management, pain, self-management education needs
    • Medical social worker for depression counseling or family conflict resolution
    • Home health aides or other ancillary staff ordered to support care practice

From the findings of your internal LUPA review process, analyze your results and identify whether the LUPA could have been avoided. Investigate trends in avoidable versus unavoidable LUPA cases. Then, develop processes to correct avoidable LUPAs and educate your staff on these best practices for care.

2. Know the Impact of 30-day Periods of Care

It’s imperative to begin thinking about the management of PDGM 30-day periods of care. For example, for LUPA visits of two or less in the second 30-day period, determine if this low-visit count is impacting clinical outcomes. Then consider how moving those one or two visits into the first 30-day period would impact patient outcomes.

It’s possible that the first 30-day care plan with the additional visits might produce better outcomes and the second 30-day period may not be needed and a LUPA can be avoided. One way to analyze the risk for LUPAs within the second 30-day period would be to look at your organization’s 2017 data. This will give insight into which 30-day periods and what types of episodes would fall into LUPA categories in a PDGM environment. This type of impact analysis can help agencies understand their strengths and weaknesses moving forward.

Sometimes, a LUPA is inevitable, so it is important to consider the big picture as you think about your 2020 case-mix strategy. Under PDGM, with a 30-day period to assess and treat a patient efficiently, agencies front-load patients with three visits in the first seven days of care. Organizations should also, using the comprehensive SOC assessment, determine the need for additional disciplines and obtain orders quickly to support the patient’s needs. Remote patient monitoring will also be a vital tool to help manage the 30-day period.

Effective management of LUPA episodes has always been a challenge and yes, in the PDGM world, it just got trickier. Efficient Outcome and Assessment Information Set (OASIS) assessment, effective coding practices, strategic management of the episode and sending in the right discipline at the right time for the correct amount of time is key. Case management remains central, and seamless collaboration and communication has never been more important.