After nearly two years of planning, the long term and post-acute care profession has embarked on its Patient-Driven Payment Model (PDPM) journey. Now that therapy is not the primary driver of reimbursement for skilled nursing facilities (SNFs) anymore, before one could say Interim Payment Assessment (IPA), thousands of therapists have job uncertainty. To come to grips with this somewhat expected, yet sobering reality, the burning question—what drives PDPM—needs to be answered first. 

When introducing RCS-1, and then PDPM, the Centers for Medicare & Medicaid Services (CMS) realized that the therapy-centric, resource utilization groups (RUGs) based prospective payment system (PPS) was flawed and obsolete. Now, the main goal of PDPM has been to reimburse SNFs based on patient characteristics and complexity of care.

Since therapy would cease to be the prime driver of SNF reimbursement under PDPM, most expected the therapy utilization to drop. However, CMS has declared that it reserves the option to audit providers when therapy is underutilized. So, what does all of this mean? How much therapy is the right amount? And who decides what is right?

Firstly, PDPM means just that. It is a payment model driven by patient characteristics and complexity of care. It goes without saying that the care of patients in SNFs, in general, ought to include therapy. The goal for patient stays in SNFs is to optimize their functional status while providing all the necessary clinical and nursing care, so that they may transition to their homes or to other care settings at an opportune time.

Granted, there will be patients who do not benefit from therapy as they may be too weak or too sick, but even they need to be reevaluated periodically to assess their candidacy for therapy.

If providers do not do a good job in recognizing patients’ needs and stint therapy, one thing is bound to happen. CMS will audit and recover payments from those who are not providing adequate therapy to their residents. CMS has ready access to resident characteristics and therapy minutes provided through minimum data set (MDS) assessments. A quick audit could be accomplished by taking the various payments for physical, occupational, and speech therapy categories under PDPM—for individuals or a group of patients—and comparing them to the prevailing cost of actual therapy minutes provided, and/or prior utilization patterns under RUGs. 

If patients are demonstrating a high potential for improvement through their characteristics and functional scores, but are receiving suboptimal therapy, one may expect claim audits and survey citations. Under PDPM, CMS pays SNFs to provide therapy based on the anticipated need, as calculated by clinical characteristics and functional scores documented on MDS assessments, and not any longer by therapy minutes. 

In the absence of a published formula, how does one determine what is the “right” amount of therapy for each patient? Obviously, that has to be a collaborative determination by the clinical team and therapists, based on the patient’s characteristics and medical necessity. The clinical documentation should always be supportive of such a decision, and of any subsequent changes to utilization of therapy services. 

Adhering to the 25 percent cap on group and concurrent therapy may not be sufficient to prevent audits if patients are provided group or concurrent therapy while not meeting inclusion criteria for such options. If a patient truly does not need much active therapist engagement, consideration should be given to the use of Restorative Nursing Programs, which should enable quicker improvement in functional scores and perhaps a shorter length of stay, while providing an audit defense against stinting—if documented clearly along with medical necessity.

Will there be a shrinkage of the therapy workforce in SNFs? Yes, there likely will be, but it should not be a knee jerk response to a change in payment models, rather based on determination of need and utilization patterns. Since those standards are still being established in the industry under PDPM, across the board workforce reductions are premature and are bound to raise red flags for audit from regulators.

Until a decision to reduce the workforce is obvious and unavoidable, perhaps asking the therapists to focus on the patient rather than the minutes every week is the right thing to do. Therapists could collaborate with nursing staff to revamp the Medicare Part B therapy program for long term care residents, while training SNF nursing staff to be effective partners in Restorative Nursing Programs.

So, what drives PDPM? Is it the patient, or the payment? While initial reactions, such as changing therapy staffing in some centers, appear to suggest that payment is driving the change, the patient is the driver of the PDPM bus. Payment, no doubt, fuels the PDPM bus. 

If the journey is planned well—by charting a good path with accurate initial MDS assessments, there should be enough fuel to arrive at the destination. CMS acts as the gas station, and if providers encounter unexpected detours due to changes in patients’ conditions, IPAs will provide the additional fuel needed to get home. But it behooves providers to remember that gas stations can top off fuel, but not change drivers. The driver, for PDPM, is definitely the patient, and anyone who does not agree will be asked to get off the bus.