Early Data Shows PDGM’s Regional Winners, Losers 

The impact of the Patient-Driven Groupings Model (PDGM) doesn’t appear to be universal.

In fact, each home health care agency’s performance under the model seems to depend on a few somewhat uncontrollable factors, new PDGM data suggests.

“CMS created a model that was based on all claims nationally, but depending on where you are and the types of patients you’re seeing, I’m expecting we’re going to see some real winners and losers,” Chris Attaya, vice president of product strategy at Strategic Healthcare Programs (SHP), said.


Attaya shared those insights during a recent webinar hosted by BlackTree Healthcare Consulting, during which he and BlackTree Managing Principal Nick Seabrook shared PDGM performance data from the first few months of the year.

So far, PDGM’s winners and losers appear to be regional.

For example, the data shows that for the first five months of the year, the Southwest had the lowest average case-mix weight for non-Low Utilization Payment Adjustment (LUPA) episodes of any region in the country, at 0.997. Meanwhile, the Northeast saw the highest average case-mix weight of 1.179.


Under PDGM, case-mix weights help determine how much agencies get paid by the Centers for Medicare & Medicaid Services (CMS). Specifically, they’re used to adjust providers’ base payment amounts for each 30-day unit of home health care. 

There are 432 possible case-mix adjusted payment groups under PDGM. A higher case-mix weight generally generates a higher payment adjustment, while a lower case-mix weight usually means a lower reimbursement rate.

Case-mix weights for each unit of care are determined by five different factors: admission source, timing, clinical grouping, functional impairment level and comorbidity adjustment.

Timing appears to be among the most important of those when it comes to case-mix weight, Attaya said on the webinar, pointing to data to back up his claims.

“It’s pretty correlated,” he said. “The early-late against your case-mix weight is the biggest reflection of how well you’re going to do in terms of the case-mix weight.”

In other words, regions that saw a lower percentage of early cases were also likely to see lower case-mix weights, the data suggests.

Case and point: The Southwest — which has the lowest average case-mix weight — saw the lowest percentage of early cases, at 27.6%; the Northeast — which had the highest average case-mix weight — saw the highest, at 51.5%.

Similarly, the home health industry has also seen regional winners and losers in terms of LUPA rates, Home Health Care News previously reported.

Like case-mix weights, LUPAs impact agencies’ reimbursement rates. If an agency doesn’t provide the appropriate number of visits determined for a patient in a period of care, they can be hit with a LUPA and, in turn, receive lower reimbursement. Under PDGM, there are 432 different LUPA scenarios, with visit thresholds ranging from two to six.

Since the coronavirus hit, home health agencies in states with a higher number of cases generally saw higher LUPA rates for the first few months of the year, according to the data presented during the webinar.

That includes states like New York and Washington, hit early and forcefully by the virus. Both saw LUPA rates well above the national average for the first few months of the year.

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