MANAGED CARE ENROLLMENT IS EXPLODING ACROSS THE COUNTRY. WILL PDPM CHANGE THAT?

The Future of Managed Care What’s on the horizon for managed care is starting to look really appealing to some in the post-acute sector. Hold on. Did we really say that? The Bipartisan Budget Act of 2018 contains provisions that will allow for telehealth and Medicare Advantage Plans to address social determinants of health, not able to be addressed in quite the same way under traditional Medicare benefits.


Medicare Advantage plans are at an all-time high and continue to grow. With low cost medications and a new focus on potential benefits seemingly not tied directly to healthcare, these Medicare Advantage plans continue to attract seniors and their families.

​2010 – Fee for Service 75%             Medicare Advantage 25% 2018 - Fee for Service 49%             ACOs 17%             Medicare Advantage 34% These benefits could include transportation to the grocery store, home air cleaners, carpet cleaning for those with asthma or allergies, meal deliveries and things that will help keep consumers from needing more costly medical care.


PDPM & RUG-Based Plans While the new payment system, Patient Driven Payment Model, begins on October 1, 2019, RUG-based managed care plans will eventually be required to adopt the PDPM payment model. The Centers for Medicare & Medicaid Services, CMS, has indicated that the MDS will not support RUG-IV calculations indefinitely. Humana is the first to say they will follow in the steps of the feds with the PDPM model. It is yet to be determined if other plans will follow.

In any case, it is easy to focus on the new payment system detracting focus from other payor’s impact on the overall payor mix. Experts predict that managed care will continue to grow and Conveners’ expectations for focused care, measureable outcomes, and evidence-based practice will not change. Conveners are at the table asking questions and helping to direct care. Using standardized assessments to show progress or risk helps decision making in regards to the patient’s transition and hand off to the next most appropriate setting. 

​Success Under Managed Care  Managing care is all of our responsibility. Wecan be most effective in knowing the patient’s needs and discharge plans at time of admission. This means clear and accurate information from our acute partners, the families and the patient. Additionally, it means creating a clear clinical pathway that the entire IDT follows and uses to guide daily care conversations. And lastly, using methodology to assess risk along the pathway for return to hospital, or challenges that need to be addressed while under our care or in the next setting.  Inviting all parties to the table, from the acute partner to the patient and their caregivers, to discuss the trajectory of care will eliminate silos and encourage clinical conversations that will drive the most effective clinical care.

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