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  • APTA Letter on SNFs and Productivity Published in NYT

    APTA has spoken out in The New York Times (NYT) about recent reports that skilled nursing facilities (SNFs) are taking advantage of Medicare billing policies, stating that the allegations underscore the need to replace volume-based payment systems with systems tied to value.

    In a letter to the editor published on October 8, APTA President Sharon L. Dunn, PT, PhD, OCS, responds to a September 30 NYT article titled "Nursing Homes Bill for More Therapy Than Patients Need, US Says." That article focused on a report from the Office of the Inspector General (OIG) of the US Department of Health and Human Services alleging that Medicare payments have "greatly exceeded SNF costs for therapy for a decade."

    For APTA, the OIG report and related media coverage are directly related to the pressures being placed on physical therapists (PTs), physical therapist assistants (PTAs), and other providers to meet productivity demands that can sometimes run counter to actual treatment needed.

    "The provision of physical therapy services should be driven by patient need and the clinical judgment of the licensed physical therapist," Dunn writes in the letter. "Productivity goals that drive services toward economic incentives continue to be an issue that policymakers and professional associations have a joint responsibility to meet."

    Much of the criticism of SNFs is centered on the use of ultrahigh therapy hours in billing practices, which CMS estimates provides facilities with an average of $66 a day in payments over costs. A recent related analysis from the Wall Street Journal found that the use of ultrahigh therapy has increased from 7% of patient days in 2002 to 54% of patient days in 2013.

    In the APTA letter to NYT, Dunn also describes APTA's collaborative efforts to address volume-based versus value-based care, and how the association's Integrity in Practice campaign aims to provide PTs and PTAs with resources to support care based on patient need and clinical judgment.

    'We are committed to making sure that the correct incentives are invoked in care delivery, in a manner that maintains our patients' trust," the letter states.

    The issue of productivity pressures is at the heart of an effort by APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA), which collaborated to produce a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)." For more on productivity, check out "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.


    • One factor to consider: patients with higher acuity level are being discharged to SNFs rather than rehab facilities these days. So many patients who "would have gone to rehab" in 2004 are now not qualifying for hospital based inpatient rehab, and are going to SNFs due to policy changes by payors. This could explain a large percentage of the jump in ultra high frequency days since 2004.

      Posted by Nechama Karman, PT on 10/9/2015 6:14 AM

    • I have worked in SNF's and agree that there is often an element of management and/ or company pressure for PT and PTA professionals to work with patients for a longer duration than the client can actually physically tolerate. Many newly admitted SNF patients are relatively acute and can only tolerate a shorter duration of treatment.The possibility of breaking treatment into smaller multiple single day treatment sessions is one potential way of broaching this challenge that I know has been utilized, But, I believe it is not the PT or PTA professional that is the culprit. It stems back to acuity and the coding of patient acuity that SNF's are required to meet. I do not purport to have the actual facts and details related to this process but I do know it has caused many a frustrations in therapy departments.

      Posted by Kaethe Flynn on 10/14/2015 10:09 PM

    • Thank you Dr.Dunn, This is a serious issue for our profession on many levels. Sincerely, Vicki Wilkins PT DPT GCS OCS

      Posted by Vicki Wilkins on 10/14/2015 11:01 PM

    • Patients of all kinds coming into SNF's (as well as your local PP Out Pt. are increasingly medically complex with layers of pathologies and pharmacology on their records. Pt.s are d/c from acute care earlier due to policy/cost decision making by the same critical thinkers finding unintended consequences will exist. High therapy minutes are appropriate for the very fragile that take increased time for vitals management, positioning, orienting to therapeutic interventions, rest and resume. Research is indicating success with combined interventions at high levels of intensity & frequency and duration and that means high minutes and often more skilled staff. Also, those pts at higher levels of ability with goal to advance to return to community also make sense for high minutes based on what we know about neuroplasticity and intervention to recapture high level motor control programs and return home in shorter time frames. The left hand of current science and the right hand of treatment intervention and reimbursement need to work together. Too often the emphasis on cost management, which is appropriate at any time, is limited by it's integration of current science driving treatment intervention. Policy/financial people and those that deliver hands on care are often speaking different languages and see each other as the "bad guy" in need of control. It's neither. We have to manage our finances or go bankrupt in our lives. Financial personnel have injuries, strokes, TBI, pain like everyone else and want excellent treatment for themselves and their families when that happens. The APTA is in a position to bring about a common language. Thank you and keep speaking up.

      Posted by Jane L Stroede, PTA on 10/15/2015 3:10 PM

    • This is a bigger problem than most people realize. When people other than therapists are making decisions about therapy, the stage is set for fraud and abuse. But until physical therapists develop the backbone to say "No" to these fraudulent practices, they will continue. And until state medical boards respect the decisions of the therapists in these facilities, many therapists will never have the courage to refuse outside pressures to overbill and over treat.

      Posted by Mike Ward, PT, DPT on 10/15/2015 7:01 PM

    • Excellent article in Dec. issue of Reader's Digest on pages 39-41 on "A Case Against The Clock" Weel worth the read!

      Posted by Gerald Pica on 12/6/2015 11:59 PM

    • Could you please provide any (if any) standards of care on Productivity esp in an acute care settings. variables such as ancillary services which often delay our hands on time. And then on SNF unit non community based, We have a lot of extra paperwork which is non- productive time according to administration yet mandatory

      Posted by sherry M Bales on 12/5/2016 4:17 PM

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