‘Pendulum Swung Too Far’: Therapists Raise Concerns Over Layoffs, Clinical Changes Under PDPM

It’s four months into the Patient-Driven Payment Model (PDPM), and despite some industry analysts pointing to early gains for nursing homes, many occupational, speech, and physical therapy advocates continue to criticize layoffs and changes to resident care patterns.

On the operational side, the initial PDPM returns have been positive: For instance, 67% of nursing homes saw daily increases in Medicare per-day rates in November, according to the latest analysis from Zimmet Healthcare Services Group and its affiliated data firm, CORE Analytics.

But on the ground, the shift from a minutes-driven system to the new PDPM — with its incentives for group and concurrent therapy services — has been met with uproar from therapists who claim they’re being undervalued.

Some clinicians believe they’re caught in a bait-and-switch — with bad medical decisions as a trade off for higher reimbursements and the bottom line. What seems to be some recent relief from squeezed margins for operators could also result in lower outcome scores — leading to increased visits to the hospital, some therapists say, potentially wiping out any financial gains through readmission penalties.

Two therapy associations opted to find out exactly how therapists and administrators are faring with PDPM to date, and nearly 5,000 respondents didn’t paint a positive picture.

Thousands of responses poured in, suggesting that fewer minutes and potentially inappropriate therapies lead to more complications for residents — while more therapists are being laid off and facing underemployment and increased work pressures, resulting in a serious morale problem.

The American Occupational Therapy Association (AOTA) and the American Speech-Language-Hearing Association (ASHA) collected about 600 and 4,435 responses to their surveys, respectively, and shared the feedback with SNN last week.

“One of the intentions of the new program is to do some correction and fine tuning of over-utilization, but we feel the pendulum [has] swung too far,” Sharmila Sandhu, AOTA’s vice president of regulatory affairs, said.

AOTA’s survey questions focused on the impact of reimbursement changes under PDPM and notable shifts to daily practice patterns — or lack thereof. Approximately 600 self-reported e-mails came in from October 1 until February, a figure that did not include a multitude of phone calls.

Mandated group/concurrent therapy

About 48% of occupational therapists (OT) claimed a nursing facility was mandating the provision of group or concurrent therapy in place of individual therapy, regardless of the patient’s functional level under PDPM, Sandhu said.

“Our biggest concern is that we don’t believe that…therapist[s’] clinical judgment should be overridden by policies,” Sandhu said.

In addition to evolving clinical practices, about 50% of OTs and occupational therapy assistants (OTAs) reported being laid off or experiencing a reduction of working hours under PDPM.

“We didn’t ask this question, but a significant number of members reported layoffs or decreased hours or services. They voluntarily offered their company names, so we have some information,” she said.

With reduced therapy time and layoffs, the fear among therapists is “increases in falls … [and] readmissions to the hospital that are potentially preventable,” Sandhu said. “And those are quality measures that these skilled nursing facilities … will be judged upon. And so it’s important to note that CMS is watching that as well.”

Although the goal is to get the patient healthier and back home as quickly as possible, many therapists like Sandhu insist that the timeline and care must be enacted safely and thoroughly before discharge.

“It’s important that they receive the just right amount of therapy,” she said.

A complicated shift

When the federal government first introduced PDPM, the stated goal was to reduce providers’ temptation to offer unnecessary therapy services solely for financial gain. Under the former Resource Utilization Group (RUG) system, there was a direct connection between the number of minutes provided and the nursing facility’s eventual Medicare paycheck. Meanwhile, the government made several high-profile accusations against companies they believed were building their therapy strategies around profits and not patients.

With PDPM, therapy shifted from a revenue driver to an expense for operators to manage while figuring out the complex new Medicare reimbursement math. In the immediate wake of the change, both confirmed and anecdotal reports of therapy layoffs roiled the industry, and a variety of voices cautioned operators against jerking the wheel too far in the other direction.

“I think it’s really short-sighted that these companies are doing this, because they know CMS is watching, and they know if they have a dip in outcomes or dip in utilization, CMS is probably going to audit them,” Kara Gainer, director of regulatory affairs for the American Physical Therapy association, said in October.

Mark Parkinson, president and CEO of the prominent nursing home industry trade group the American Health Care Association, offered blunter warnings in conversation with SNN that same month.

“If we don’t do better, we should be crushed by CMS,” Parkinson said. “If therapy declines and outcomes decline, we deserve whatever penalty we get. But if therapy minutes decline and outcomes improve, we shouldn’t be criticized, in my view.”

Three stories of potential harm

Sandu shared three narratives from concerned therapists after occupational therapy minutes were reduced.

In one case, a therapist claimed that residents were sedentary and experiencing function declines due to a lack of sufficient therapy services.

“They are at higher risk for rehospitalization,” the therapist said. “They fail at home because they are too weak and de-conditioned and [become] a fall risk.”

Another reported that patients who had received 65 minutes of therapy per session prior to October 1 were now only logging 20, prompting concerns about their ability to safely re-integrate into the home setting.

“[This] will result in them needing significantly more caregiver/family support than if they received medically necessary therapy, in my clinical judgment,” the therapist wrote.

Another anecdote came from a therapist pushed to bring together two different kinds of patients in a group and conduct similar activities. One patient was very ill and had non-verbal problems; the other was higher-functioning and needed to work on different skills, Sandhu said, citing the survey.

The American Speech-Language-Hearing Association (ASHA) fielded a larger and more formal survey to more than 16,000 speech language pathologists (SLPs) who listed their primary or secondary employment setting as a nursing home. The survey was conducted in December; the results were collected last week and went out to 4,435 clinicians and administrators, Monica Sampson, ASHA director of health care services in speech language pathology, said.

Aside from standard demographic questions, the heart of the survey focused on changes in employment and clinical care as a result of PDPM.

When asked how PDPM impacts a clinician’s employment status, 551 administrators and 3,411 clinicians responded, with 38% reporting reduced employment hours overall despite no official change in employment status — while 39% reported an increased productivity requirement for clinicians, and 21% observed a change in how productivity was calculated.

For administrators in the employment category, 40% responded that expectations of increased productivity requirements were the biggest impact since PDPM, and 21% indicated a change in how productivity was calculated.

Similar group/concurrent pressures

In addition, 42% of respondents said they were mandated to provide some kind of group treatment sessions not based on their clinical judgment, according to Sampson, while 35% received a directive to provide concurrent service regardless of the individual therapist’s recommendations.

ASHA received more than 100 pages of narrative information during the survey process, which illuminated trends post-PDPM. This included how SLPs were employed and utilized in the face of layoffs and employment changes.

“It kind of hits home to feel like, these are my colleagues and peers on the field, and they’re very real implications,” Sampson said. “Things like: I can’t pay my mortgage, I lost my insurance, I didn’t get enough heads-up about this so I could find another job. People who work in SNFs and in gerontology in general are passionate about that age group. So while people do indicate that [they’ve] made transitions to other settings, or looking to make a transition, that’s not what [they] want to do, but it almost feels like they’re forced to do.”

In further commenting about the narrative trends, no one company was particularly problematic in implementing PDPM strategies in relation to therapy and patient care, Sampson said — but the overall changes pointed to a major reduction in therapy services.

More specifically, clinicians reported a trend of high-acuity residents not receiving enough individual care in the first few days, when it could be most needed.

For example, one therapist said that “all her new admissions were getting 14 to 16 minutes of treatment for 50% of her caseload,” Sampson said, which is an indication of a need for more quality treatment and time, she added.

In one case, a patient with Parkinson’s disease was in need of more treatment time and increased comprehensive therapy, according to one therapist, but resources were not allocated, and the patient developed aspiration pneumonia as a result of reduced services.

Speech language pathologists offer swallowing treatments for patients with diagnoses like Parkinson’s, which involve chronic conditions that can impact safe swallowing.

“Her concern is … that her recommendations for care are not being complied with,” Sampson said. “And this is somebody who says she has 10 years of experience. She’s working on her board certification in swallowing and yet that clinical judgment is not being followed.”