In July 2018, the Centers for Medicare & Medicaid Services (CMS) finalized a new case mix classification model, the Patient Driven Payment Model (PDPM), which will be used under the Skilled Nursing Facility Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay (https://go.cms.gov/2S2lrRR
). Beginning October 1, 2019, PDPM will replace the current case mix classification system, the Resource Utilization Group, Version IV (RUG-IV).
Many informative articles have been published to date explaining the roles of the nurse, physician, and other health care professionals in a SNF to operationalize this new billing model. An opportunity to focus on optimizing medications to achieve improved patient outcomes with prudent spending and potential cost savings exists, and the consultant pharmacist can play a key role in driving this change.
MDS and Medications
Reimbursement for medications included on the initial Minimum Data Set (MDS) assessment is provided for the duration of a patient’s stay in a SNF as long as it is documented accordingly. This new payment model is designed to reimburse the SNF to “do the right thing” for medically complex patients. Thorough and appropriate documentation of a patient’s medical condition upon admission is paramount to selecting drug therapies that maximize reimbursement and improve patient outcomes. The new PDPM allows SNFs to move away from considering medications only as a cost center where the focus has been to purchase the “cheapest pill” and move toward including medications as an important factor in the care process to achieve optimal patient outcomes.
The MDS that is completed upon admission and updated at intervals during the stay drives the reimbursement “score” and dollars. Under PDPM, payment is determined through the combination of six payment components. Five of the components are case mix adjusted, including the physical therapy (PT) component, the occupational therapy (OT) component, the speech-language pathology (SLP) component, the non-therapy ancillary (NTA) services component, and the nursing component. NTA carries a threefold multiplier for the first 3 days of an admission to help offset the costs related to medications and complex medical conditions.
Additionally, there is a non–case mix adjusted component to cover utilization of SNF resources that do not vary according to patient characteristics. Medication costs are reimbursed under the NTA component. For the NTA, the initial “score” is determined by adding the numeric value of all of the 50 possible conditions and treatments (see the Supplementary table
online) that are applicable to the patient on admission. This sum correlates to a case mix group, which correlates to a case mix index. The SNF’s base rate for the NTA component is then multiplied by the patient’s NTA case mix index to achieve the patient’s NTA rate. On day 4, it is reduced to the original rate to calculate the payment for the remainder of the SNF Part A stay.
It is imperative that the consultant pharmacist review the initial diagnosis codes that are entered on the MDS to ensure the medication therapies correlate with the diagnoses. This should be reviewed as part of the patient’s admission Medication Regimen Review (MRR).
PDPM Assessment Schedule
The initial MRR completed upon admission will differ from the monthly MRR for a subacute or long-term care patient. Facilities would benefit from investing in this consultant pharmacist service for medication management because it provides an additional resource and medication expertise for a thorough and precise patient assessment for the initial MDS.
Older patients are often prescribed a disproportionate number of medications, resulting in polypharmacy. This leads to reduced medication compliance, increases the risk of adverse drug effects, and may lead to adverse events. There is considerable evidence of inappropriate as well as excessive prescribing for older patients. Although there are risks, medication outcomes can be improved through deprescribing.
The concept of deprescribing
first appeared in the health literature in 2003 (J Pharm Pract Res 2003;33:323–328), when Michael Woodward, MBBS, of Austin Health in Heidelberg, Australia, outlined its principles as:
Reviewing all current medications
Identifying medications to be ceased, substituted, or reduced
Planning a deprescribing regimen in partnership with the patient and the prescribing clinician
Frequently reviewing and supporting the patient
Deprescribing for patients in a SNF can be initiated by the consultant pharmacist in coordination with the admitting and monthly chart reviews or when a patient is discharged or readmitted to the facility. The consultant pharmacist should participate in an interdisciplinary care team meeting to discuss individual patient recommendations. The reasoning for recommending the discontinuation of any unnecessary medications may also be shared with the patient, if appropriate. The nursing staff can be educated about whether a drug should be tapered or simply stopped, what tapering regimens are most effective, and what parameters should be monitored, how often and for how long (PLOS One 2016;11:e0161248).
Studies have shown that 47% to 79% of nursing facility residents receive systemic antibiotics each year, and it is estimated that many of these antibiotics (between 25% and 75%) are unnecessary or inappropriate. Overuse of antibiotics contributes to antibiotic-resistant bacteria, adverse drug events, drug interactions, colonization of bacteria or secondary infection from resistant organisms, and complications that can be attributed to senseless use of antibiotics (Consult Pharm 2017;32[Suppl A]:10–16). Since 2017, federal regulation §483.80(a) mandates an infection prevention and control program (IPCP) and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use in all SNFs.
Intravenous (IV) antibiotics can be costly, but they are often a necessary part of a patient’s medication regimen in SNFs. As it pertains to a facility’s antibiotic stewardship program, a consultant pharmacist may recommend switching to an oral version of the same medication after a certain amount of days on IV to complete the prescribed course of therapy. This is commonly referred to as an “IV to PO switch,” and it provides the same therapeutic outcome. In most cases, oral medications are easier to administer, are better tolerated by the patient, and are less costly. Under the new PDPM, switching to a less costly oral antibiotic when appropriate may result in significant cost savings, and the SNF will continue to receive the higher NTA rate driven by the IV antibiotic ordered on admission for the entire Part A stay.
Part A Formulary
Most SNFs have a formulary that is developed in conjunction with the vendor or in-house pharmacy comprising a list of preferred medications used by that facility. Under the new PDPM model, SNFs should reevaluate their current formulary and make updates as necessary. The consultant pharmacist can review and evaluate the medications on the formulary and provide clinical expertise regarding appropriate medications.
Optimizing medication management strategies such as discontinuing unnecessary medications, deprescribing, antibiotic stewardship, and Part A formulary management is essential to minimizing adverse events in patients, improving patient outcomes, and reducing unnecessary medication costs. Consultant pharmacists are the medication experts who possess the knowledge to provide optimal medication management.
Over the last several decades, the pharmacy profession has seen new prescribing terms evolve such as e-prescribing and deprescribing. I have created yet another new term to describe the action consultant pharmacists will perform in response to the 2019 PDPM reimbursement model: opti-scribing. Opti-scribing by consultant pharmacists will ensure that the health care team in a SNF documents medication orders and responds appropriately, chooses the most effective medication therapy to achieve the intended outcomes, and minimizes adverse events for the patients while maximizing the reimbursement to the SNF.
Dr. Manzi has been a licensed pharmacist since 1990 and a Board Certified Geriatric Pharmacist since 1998. She is currently a clinical advisor for CVS/Caremark, coordinating with account teams and health plans on the details of their pharmacy benefit offerings, formulary implementation, medication utilization management, and MTM as well as providing clinical information and geriatric expertise. Any opinions in this article are that of the author and not of CVS/Caremark.