COVID-19 Scrambles PDPM Math, Particularly Around Therapy Minutes: ‘This Will Be a Complete Rebuild’

In the lead-up to the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, consultants, therapists, and the federal government warned operators over and over that therapy minutes would come under intense scrutiny in the months following the start of the new Medicare reimbursement system.

The model allowed for patients to receive up to 25% of their total therapy minutes in a group and concurrent setting, but prior to PDPM, the proportion of those minutes was very low.

As a result, the Centers for Medicare & Medicaid Services (CMS) indicated that it would be watching shifts in therapy quite closely both during and after the transition to PDPM.


“We do plan on monitoring that and seeing how much of a change occurs, along with changes in the patient population,” a spokesman for CMS said during a December 11, 2018 presentation on PDPM. “Because if we don’t observe changes in the patient population … that would suggest that payment incentives are continuing to have an impact on care decisions, as opposed to the needs of the patients. Then we’ll have to consider the scope of those levels, whether it’s at the facility level or the national level, and then consider what’s appropriate [to address that].”

Shortly after PDPM took effect, the chairman and CEO of Sabra Health Care REIT, Inc. (Nasdaq: SBRA), a real estate investment trust with skilled nursing properties, argued that good operators wouldn’t immediately spike their group and concurrent services — and echoed the idea that those who did would be caught.

“You’re not going to see the good operators go from 0% concurrent and group therapy to 25%, which is the max,” Rick Matros said during an earnings call on October 31, 2019. “You may see some guys do that out there, and I think they’ll get in trouble if they do that.”


Then came COVID-19, and whatever calculations might have gone into the 25% cap on group and concurrent therapy were shredded overnight.

Therapy is still a major focus under PDPM, even during the time of COVID-19, Hilary Forman, chief clinical strategies officer at the consulting firm HealthPRO Heritage — which also offers therapy services — said in a webinar held June 16.

But the pandemic has drastically altered therapy utilization.

“We were all worried in the fall about going over the cap,” she said. “And now we’re down to zero. So this will be a complete rebuild for us moving forward — again.”

Admission practices under COVID-19 have varied from place to place, with some SNFs forced to take in admissions while others were closed to them altogether, Forman noted. Isolation mandates meant the therapy gyms were probably closed, with therapy likely conducted in patient rooms, she said. But when it came to PDPM, that might have been a chance, in coding the Minimum Data Set (MDS), to meet the “isolation” criteria for nursing, she added.

In terms of other opportunities that COVID might have opened, SNFs that had been struggling to deal with the new normal under PDPM might now have a chance to redesign their workflows, Forman said on the webinar.

Of course, COVID might have exacerbated the challenges they were facing, Forman noted, but some opportunities for SNFs to look at care redesign do exist.

These opportunities for improvement might include, according to the presentation:

  • Early patient identification of IVs in the hospital
  • Breaking down existing silos in patient profiling and care planning
  • Making sure to determine nursing skilled services and rehabilitation
  • Providing a thorough review of the non-therapy ancillary component of PDPM

Clinical outcomes also remain the name of the game for therapy, and some of consulting firm CLA’s early findings were encouraging. Its data from on the functional outcomes from Section GG, taken from the MDS from before and after PDPM and COVID-19, highlight this — even if the amount of minutes provided aren’t exactly the same, Forman said. There are all kinds of reasons for the changes, ranging from telehealth to limited disciplines that could be provided.

But the emphasis on a holistic view of the patient is important.

“With all of the focus on whether or not we would deliver the right amount of minutes, if that minute would change, if the minutes would be delivered in group or concurrent, it’s fantastic to see at least in this subset of roughly about 400 sites, you can see that the outcomes over time improved,” Forman said.

Chart showing Section GG outcomes before and after PDPM and COVID-19. Source: CLA

Infection control measures, which had a significant cost for facilities in terms of staffing, obtaining personal protective equipment (PPE), and meeting testing requirements, also affected therapy, according to Forman.

“It did create some silver linings for the therapy community, and one was the ability for us to really redesign therapy delivery,” she said. “We were able to introduce telehealth into multiple sectors, not only in the skilled setting, but in our senior living.”

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