Respiratory Therapy’s ‘Massive’ Skilled Nursing Opportunity Under PDPM

As providers continue to stare down the October 1 implementation of a new Medicare payment model for nursing homes, specialization remains at the top of many operators’ to-do lists — with respiratory therapy potentially emerging as a key revenue source.

Because the Patient-Driven Payment Model (PDPM) matches reimbursements with resident acuity, operators have looked to a variety of new specialties designed to attract more complex residents, from specialized cardiac programs to ventilator care to speech therapy.

Just about every one of Melissa Sabo’s clients at Gravity Healthcare Consulting have inquired about adding respiratory treatments to their repertoires as they prepare for PDPM, she told SNN.


“Everybody’s interested in it, because once you start going through the numbers, the reimbursements are just unbelievable,” Sabo, who serves as chief operating officer for the Cumberland, Md.-based post-acute and long-term care consultancy, said.

Ventilator and tracheostomy care, two types of respiratory services, automatically put residents in the highest reimbursement case-mix groups for the Nursing component of PDPM, Sabo noted, with other respiratory modalities also boosting a resident’s overall payment score in the Non-Therapy Ancillaries (NTA) category. In addition, being able to care for complex patients provides a length-of-stay advantage: If an operator can offer ventilator and tracheostomy services, Sabo said, it has a much greater chance of capturing all 100 days of Medicare eligibility for skilled nursing coverage, as not all operators in a given market typically can accept such patients.

“The ROI is just massive under PDPM,” Sabo said.


Edwin Frost, president of the West Deptford, N.J.-based respiratory provider Aeris Consulting & Management, said adding services like the ones his company offers represents yet another step in an overall trend that predates PDPM.

“Skilled nursing facilities over the past several years, and this has really amped up in the past five years, are being forced to take sicker and sicker and sicker patients — especially with many areas of the country losing their long-term acute care hospitals,” Frost said. “They don’t qualify for acute rehab, because those regs are very strict. There’s very little access to higher levels of care, intermediary levels of care, and they really have been forced to take sicker and sicker folks.”

But as with many other specialty services in nursing homes, PDPM will finally start to give credit to nursing homes for admitting and caring for these sicker patients, Frost said.

“They’re forced to take sicker patients, but the line items haven’t been available for them to say: This is how you can help pay for respiratory therapy,” he said. “It’s always been the cost of doing business, if you will, for skilled nursing.”

In order for a respiratory-focused operator to capitalize on the boosted reimbursement potential — which can be as high as an additional $1,200 to $1,800 per week, according to Frost — a SNF must successfully document a patient’s condition during a specified look-back period, generally seven days. In addition, the SNF must demonstrate at least 15 minutes of face-to-face time between a trained nurse or respiratory therapist and the patient for each day that he or she is in the facility.

As Sabo also noted, Frost emphasized that the benefit isn’t just a purely fee-for-service play: Given that cardio-pulmonary issues are a leading source of hospital readmissions, timely interventions from respiratory therapist could help operators prevent costly trips back to the hospital for residents — while also capturing a longer overall length of stay.

“Readmission rates start to go down, their marketability starts to improve,” Frost said. “Amongst patients and family members, when they’re in the facility, confidence levels increase.”

That need for dedicated face-to-face time could make contracting with a third party respiratory partner more attractive for operators down the line. For example, Frost noted that buildings have expressed interest in training in-house nursing staff to perform respiratory interventions, but given the time constraints, a single staff nurse could only see about 3.5 patients per hour. Furthermore, given the high turnover that most operators suffer, providers could train up a nurse only to have he or she leave.

At Gravity, Sabo typically recommends that operators choose a trusted partner when adding specialty services such as respiratory care, primarily to avoid potentially expensive compliance issues.

“That’s really the way to go under PDPM so you can successfully increase the services that you can care for without putting you at risk for audits, denial, survey,” she said, adding that most SNF operators already have enough on their plates without the added burden of proper specialty documentation and reporting.

In general, respiratory therapy companies provide a vast array of services, with contracts covering training, equipment, consulting, and audits to ensure compliance with the Centers for Medicare & Medicaid Services (CMS), Sabo said. Frost’s services, for instance, typically cost about a third of the total reimbursement that the provider will achieve from the respiratory care, leading him to estimate the return on investment at about 70%.

But Sabo also noted that operators may already be performing certain respiratory services for which they aren’t currently being paid, highlighting the importance of analyzing a building’s operations for potential reimbursement add-ons that can come without the addition of any specialty staff or partnerships.

“People are providing most of the services already that they might need in order to make the money,” Sabo said, specifically pointing to nebulizer treatments. “They’re either not documenting it correctly or not getting the right number of minutes. I think there’s an opportunity for people to take advantage of what they’r already doing.”

Still, despite the potential for payment boosts, Frost said he hasn’t seen as much interest in his company’s services as he expected heading into PDPM. Part of the issue, he said, is that operators in the skilled nursing space tend to be more reactive than proactive.

“Te general consensus right now, honestly, is most of them have their wheels spinning,” he said. “I don’t think they have their head wrapped around what all of these changes really mean.”

But Frost predicted an uptick in respiratory interest once providers begin to go over their fourth-quarter 2019 and first-quarter 2020 reimbursement figures and realize the money they potentially left on the table.

“Finally, the skilled nursing facilities are getting some cash to be able to reinvest and make a stronger program,” he said.

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