Weighing the Promise and Perils of Skilled Nursing Ventilator Care Under PDPM

Among the many unknowns of the new Patient-Driven Payment Model (PDPM) is its effect on the types of patients coming into the skilled nursing facility.

But one place to watch resident patterns is around the addition of ventilator services and care to facilities — especially if they haven’t offered those options before.

Respiratory therapy — along with ventilator care — provides considerable financial benefits for SNFs under the new Medicare model. For one thing, ventilator and tracheostomy care automatically place residents in the highest reimbursement case-mix groups for the Nursing component of PDPM, Melissa Sabo, chief operating officer at Gravity Healthcare Consulting, told SNN earlier this year.

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“Everybody’s interested in it, because once you start going through the numbers, the reimbursements are just unbelievable,” she said.

But if SNFs are looking to add ventilator care services, they have to look beyond the Medicare reimbursement they receive. Patients who require this level of care are placed indeed in the highest payment group under the Nursing component of PDPM: Extensive Services. But patients in need of such care are also likely to end up remaining with a facility well past the 100 days covered by Medicare, Gregory Pino, the co-founder and president of Dynamic Respiratory Services, told SNN.

That means facilities need to be thinking about how their state reimburses for such patients under the Medicaid system.

“What should be considered is that most likely, 30% of all ventilator admissions are going to turn into long-term patients,” Pino explained. “So obviously if you’re not already in the ventilator business and you’re considering opening a unit because of the opportunities under PDPM, you have to consider the fact that 70% to 80% of your patients are going to be long-termers under Medicaid. You have to balance out that short-term spike in reimbursement to the long-term reimbursement.”

Incentives to provide vent care

The new Medicare reimbursement system is designed to pay SNFs for the needs of the patients they serve, essentially incentivizing them to take on residents with more medical complexities — with the goal of rewarding providers for caring for their needs, rather than for minutes of therapy offered. There’s also the matter of the changing state of the typical Medicare resident: Patients are getting discharged from the hospital in a much sicker state than in years past, and facilities that can meet their needs can be hard to come by.

Residents who require long-term ventilator care, especially those in need of hemodialysis along with it, can be hard to place, Angie Roberson, the president of the American Case Management Association (ACMA) told SNN over the summer.

Pino put the number even more starkly, estimating that less than 10% of SNFs offer ventilator services. The reasons can vary by state, but the two major factors are state regulations on staffing and certificate of need (CON) programs, in addition to the question of Medicaid reimbursement.

“If you’re a state like New Jersey, who awards ventilator beds based on a certificate of need program and also requires that you have 24/7 staffing, that means you’re going to have to at least have 10 to 11 beds in order for that facility to have the opportunity to be profitable,” he said.

Pino is familiar with New Jersey, given that he owns another company — New Jersey Respiratory Associates — which was founded by his father and manages respiratory services for SNFs in that state. Dynamic, on the other hand, offers the same service on a broader scale, and also has a PDPM-specific program to help facilities develop respiratory therapy modalities.

PDPM could make facilities more likely to take some of those patients, a possibility Toby Edelman, a senior policy attorney at the patient advocacy group Center for Medicare Advocacy, acknowledged to SNN.

“What’s going to happen to admissions may be positive,” she said. “People with vents … mostly go to LTACs.”

While ventilator care is a respiratory service, it’s important to make sure that it’s distinct from respiratory therapy, since the requirements for setting up ventilator care are extensive and can vary by state. It’s often a matter of months, Dennis Nowak, CEO at the respiratory therapy consultant Titrate, LLC, told SNN.

“Most states require you to be certified to be able to take a ventilator patient,” Nowak, who ran a company called TransCare in the mid-1990s that provided respiratory therapy to SNFs and followed that with work in the field of durable medical equipment and home care, said. “Then you have to be appropriately set up to care for that patients. You have to have the staff trained and you have to have the equipment and suppliers and whatnot.”

Pino agreed, emphasizing that facilities can’t “one day snap their fingers” and add ventilator care, given all of those challenges.

But Edelman is concerned that some facilities may be trying to add the service without doing the proper due diligence. She mentioned two different stories she’d heard post-PDPM that made her worried — though she also stressed that they are in fact anecdotes. One incident involved a one-star facility on the candidate list for the Centers for Medicare and Medicaid Services’ (CMS) Special Focus Facility program announcing the provision of ventilator care. Another involved a facility moving patients to make room for ventilators.

But she’s also not sure how pervasive the problem is, and the Center for Medicare Advocacy is specifically seeking more information on such care in SNFs — especially in light of an investigative report by The New York Times that found widespread drug-resistant infections for SNF residents on ventilators. The possibility of bad actors simply reacting to incentives in the new system is one she finds alarming.

“It’s common knowledge that nursing homes really look at financial incentives pretty closely and respond to them,” Edelman told SNN. “On the one hand, we’d like to see people on vents have a place to go and not go out of state, but we want to make sure the facilities are doing a good job.”

PDPM’s effects still unfolding

Respiratory therapy and ventilator care need to be considered separately under PDPM, since while they fall under the same component of nursing, they land a patient in different groups in terms of reimbursement level, Vincent Fedele, chief operating officer at CORE Analytics, stressed.

While a ventilator care diagnosis will put a patient into the top-paying Extensive Services group of the Nursing component, respiratory therapy will put a patient into the second-highest-paying category — Special Care High — if certain conditions are met.

“The challenge has been that you need seven days of respiratory therapy within the look-back period in order to code that on the [Minimum Data Set],” Fedele explained. “The reference date for the initial Medicare assessment under PDPM has to be by Day 8. So there’s not a lot of wiggle room in there, and respiratory therapies must be initiated upon admission in order to get those seven requisite days within that look-back period. There’s a pretty narrow window.”

CORE Analytics is a data service affiliated with Zimmet Healthcare Services Group, which drew on that service’s PDPM findings to produce a report giving some highlights on the early weeks of the new system.

There has been an uptick in capture of respiratory therapy since October 1, specifically for post-operative respiratory therapy. But a condition such chronic obstructive pulmonary disease (COPD) with shortness of breath while lying flat will score a patient in the Special Care High category — and it’s easier to get the documentation for the COPD condition than it is to start respiratory therapy services on admission, Fedele noted. While other conditions would support the need for respiratory therapy, the timeframe mandates are a challenge for providers capturing it, he said.

Many providers are waiting to see the results from PDPM before jumping head-on into respiratory therapy in part because of those challenges, at least in Nowak’s experience.

“You have to cross all your T’s and dot all your I’s, and make sure that you’re submitting your claims appropriately in order to get paid appropriately,” he told SNN. “So [providers] are still a little nervous about it.”

Still, Dynamic’s PDPM program currently serves about 150 buildings in roughly 10 states. It was specifically aimed at helping facilities develop respiratory therapy modalities in a short timeframe, because while most people think of respiratory therapists with respiratory therapy, “the scope of practice of a respiratory therapist is fully in the nursing scope of practice,” Pino explained.

“The respiratory therapy modalities that are under PDPM that qualify that patient for Special Care High are typically modalities that nurses provide, regardless of patient setting,” Pino told SNN.

That means that SNFs have options when it comes to providing the care, even though the impact of respiratory therapy will likely not be visible to SNFs for a while: Pino estimated about four to six months for the financial and outcomes effects to materialize.

But one thing is certain: SNFs can’t add the services haphazardly.

“One thing that will not change is the need to be constantly overseeing respiratory,” Pino said. “It’s a program that can’t sleep, because the requirements are so strict to capture it. It’s a seven-day-a-week, 24-hour-a-day program that needs to constantly have oversight.”

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