The Patient-Driven Payment Model (PDPM) was specifically designed to reimburse skilled nursing facilities based on the condition of the patients that they treat, rather than by the minutes of therapy provided to those patients.
As part of the change, the Centers for Medicare & Medicaid Services (CMS) included a 25% cap on group and concurrent therapy services for patients, service types that had been mentioned in the months prior to the implementation of PDPM as a potential area for operational savings.
But one of the concerns that the agency expressed about the changes was that the decision to use group therapy would be required by employers, rather than driven by clinicians — a concern shared by the major therapy associations, according to Ellen Strunk, owner of Rehab Resources and Consulting, Inc., on a Wednesday webinar hosted by Optima Healthcare Solutions, part of the Pittsburgh-based Net Health.
A survey from a post-acute care workgroup — consisting of the American Physical Therapy Association (APTA)–Geriatrics, the Home Health section of the APTA, and the health policy administration section of the APTA — seemed to suggest those concerns have some validity, at least in the early going.
The survey, which had more than 1,700 total respondents, found that of those who worked in a SNF, about 60% to 65% said their utilization of concurrent and group therapy had increased, Strunk noted.
“Unfortunately, of those responding to the post-acute care workgroup survey, more than half said that those changes were mandated by their employers,” Strunk said on the webinar. “Twenty percent said that their provider only encouraged the use of more concurrent or group therapy.”
Later in the discussion, she did add the caveat that the survey did not distinguish who was responding to what question, and so some of these answers could have come from home health therapists. It’s also not clear what the distribution of therapists by discipline was.
But the bigger picture has to be considered, Strunk said.
“Remember, there is a patient at the center of this,” she said. “So if treatment minutes or visits are declining, then we ask why. When we change our model of care, there are going to be some changes. What we as therapists have to be mindful of is whether those changes are appropriate.”
In 2018, CMS indicated that it would be monitoring therapy levels closely, including the levels provided in the months prior to PDPM taking effect, given the shift in incentives with the change in payment. But it also indicated that it would be keeping an eye group and concurrent therapy proportions as well.
There may be various explanations for the changes in group and concurrent therapy provision — which, as Strunk noted on a previous webinar, is not something SNFs should shy away from if it’s clinically appropriate.
One thing to consider is that it could be beneficial for patients, Rita Cole, director of clinical services at Net Health, said on the Wednesday webinar.
“Clinically, it could be good for patients,” she said. “For providers, they are going to be receiving less reimbursement under PDPM, they need to find ways to still deliver the same amount of therapy and achieve the same outcomes of care. Of course, the reality is that for some patients, the amount of therapy delivered prior to PDPM was not reasonable, and providers may have had to downsize their staff.”
Data does indicate that group and concurrent therapy minutes have increased since October 1, 2019, and in a survey conducted by Optima, 39% of respondents reported currently providing group and concurrent therapy at levels between 1% and 10%. A quarter of respondents indicated that group and concurrent therapy was used between 11% and 20% of the time.
However, 41% of providers with less than 50 facilities reported less than 1% for group and concurrent therapy as part. of the survey.
Optima’s post-PDPM survey had 590 respondents — 45% of which represented in-house therapy providers, 38% were contract therapy providers, and 17% indicated they were both in-house and contract therapy providers.
In terms of organization size, 42% were associated with one to nine facilities, 28% were associated with 10 to 49 facilities, 14% were in the range of 50 to 100 facilities, and 17% were in the range of 101 facilities or more.
Strunk noted that the requirements for group and concurrent therapy were set by Medicare in 2012 and have not changed. But the documentation regulations are more specific to support group therapy; concurrent therapy “is not something necessarily that can be planned,” Strunk said.
“In order to verify that group therapy is medically necessary and appropriate, you should include in the patient’s plan of care an explicit justification for using group, rather than concurrent or individual therapy,” Strunk said. “So it’s your decision-making for that.”
That said, she noted that how medical reviewers will tackle this remains to be seen. She has only seen one result of a review of actual PDPM documentation, where a Medicare administrative contractor looked at about 13 charts for services delivered between September and November of 2019.
“Unfortunately, 11 out of those 13 did not support medical necessity,” she said. “They did not provide more specifics about what types of things they felt didn’t support medical necessity, so we don’t know how they looked specifically at documentation for group therapy.”