What You Need to Know
As part of overall efforts to move Medicare payment away from fee for service and toward a structure that holds providers accountable for patient outcomes and costs, the Centers for Medicare and Medicaid Services (CMS) has made significant changes to the home health and skilled nursing facility (SNF) payment systems. The SNF Patient-Driven Payment Model (PDPM) began October 1 (the start of fiscal year 2020), and the Home Health Patient-Driven Groupings Model (PDGM) (.pdf) begins January 1, 2020.
Both of these payment systems align payment with patient characteristics, conditions, and needs, and eliminate the connection between reimbursement and the volume of therapy services provided—time spent and number of visits. This change makes it ever more important to show the value and cost-effectiveness of physical therapist services within SNFs and home health care. At the same time, what doesn't change is the coverage criteria or documentation requirements associated with the skilled therapy service coverage under PDPM and PDGM. More important, there is no change to the care needs of SNF and home health patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies. That some providers may choose to reduce PT and PTA staff reflects poorly on the industry's commitment to patient accessibility and availability, safety, and quality of care.
APTA created these brief summaries to give you the facts about the impact of the 2 new payment models in a format you can share with others.
Under both models, ICD-10 codes form the basis of reimbursement, making it crucial for SNFs and home health agencies to be accurate in their coding. To help you identify appropriate ICD-10-CM codes, APTA offers resources on identifying the correct codes for ICD-10-CM.
You'll find information that can help you improve your practice to show value and minimize waste on APTA's Best Practices page of the association's Center for Integrity in Practice. Read about the Choosing Wisely initiative, the crucial role of the practitioner's clinical judgment, using evidence-based practice, the Physical Therapy Outcomes Registry, and more.
Preserving Access to Services: Demonstrating Your Value
CMS' goal is to improve payment accuracy for patients in HHAs and SNFs. In the new payment systems, the connection between therapy utilization and payment is eliminated. With the therapy utilization no longer being connected to payment, it is imperative that you are able to understand and demonstrate the value your services bring to your facility or agency—and, of course, to your patients.
To demonstrate the value of your services to the health care system and determine how your individual and group performance may affect payment within these new payment models, you should be making care decisions based on evidence, using the most appropriate tests and measurements for each patient.
APTA has developed handouts that list the wealth of research on various areas of physical therapist services that demonstrate the value, impact, and benefits of physical therapy in health care. You can use them to advocate to employers, peers, and the general public. Select studies have been chosen through comprehensive searches of the health sciences literature.
More Tips for Conveying Your Value
To convey your value to your agency or facility administrators, you should know your outcome and cost data at the facility or agency levels. It is critical that you understand what discipline-specific data is being gathered and how it relates to quality reporting. Additionally, you should:
- Examine your facilities' quality metrics and performance and determine how you impact various metrics, including falls, pain, and readmissions.
- Consider how you contribute to your patients' quality of life and overall outcomes and communicate that to your Administrator.
- Explain how you will identify opportunities to collaborate with other care disciplines, improve the team's overall communication, and bring value to the entire care team.
- Explain how you may proactively address changes in the plan of care, increasing efficiency and reducing overall costs.
- Consider a self-assessment of your skills and consider how you can support your facility in meeting the challenges that lay ahead.
- APTA has partnered with the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely® campaign to provide specific, evidence-based recommendations that encourage both patients and physical therapists to make wise decisions about the most appropriate care. The list of 5 APTA recommendations and citations can be found in the downloadable list of "5 Things Physical Therapists and Patients Should Question." Visit the Choosing Wisely website for more information.
For guidance on acquiring this data and working with your agency or facility administrators, please visit the APTA Quality webpage.