Clinical Group Assignment in Home Health Care for Medicare Beneficiaries With ADRD: A 2019 Pre-PDGM Simulation

BackgroundThe Patient-Driven Groupings Model (PDGM) assigns home health episodes to clinical groups using primary diagnosis codes. The implications of this approach for beneficiaries with ADRD, whose condition is rarely coded as primary, are unclear.ObjectiveTo compare simulated PDGM clinical group assignment between ADRD-highly likely and ADRD-unlikely episodes.MethodsUsing national 2019 Medicare fee-for-service data, we simulated clinical group assignment and compared primary diagnosis profiles before and after 1:1 propensity score matching.ResultsNine in ten ADRD-highly likely episodes carried a non-ADRD primary diagnosis. After matching on demographics, comorbidity, and functional and cognitive status, clinical group assignment differences between cohorts attenuated but persisted. Most strikingly, ADRD-highly likely episodes were nearly 12 times as frequently assigned to Behavioral Health, the group with the lowest average payment weight, and comprised 92.1% of all matched Behavioral Health episodes. Within clinical groups, primary diagnosis profiles differed between cohorts, suggesting distinct care needs.