Patient-Driven Groupings Model: An Opportunity for Physical Therapists (part 1)
Part 1: What's Changed, What Hasn't—and What Shouldn't
By Mahmood Iqbal, PT
When it comes to Centers for Medicare and Medicaid Services (CMS) changes, I have come to believe that there are 3 sides of the story: the CMS version, the providers' version, and the truth, which is usually somewhere in the middle. The Patient-Driven Groupings Model (PDGM) that will govern home health payment beginning January 2020 is a good example of what I'm talking about.
PDGM shook the therapy world when it was announced that the number of therapy visits will not be considered or weighed into each 30-day period pricing for home care within a 60-day episode. As usual, providers, fearful of losing money, started to lay off therapy staff without really understanding what CMS intended.
Most of us understand that therapy visit thresholds were used to determine the additional pricing to the base rate for a home care 60-day episode. Home health providers have paid particular attention to this fact, realizing that the number of therapy visits at certain thresholds adds value to the base amount of the home care episodic rate. Back when the therapy threshold was 10 visits, home care agencies tried to have a minimum of 10 visits to capture that dollar amount. When the threshold increased to 13 visits, that number soon became the norm of therapy visits for every patient. Later, the therapy threshold moved to 19 visits. Home care agencies started to add multiple therapy services to attain that number and discharged every patient after 19 visits.
So what did CMS do? CMS collected all of that information and analyzed the trends of home care agencies working to maximize their revenues unrelated to patients' needs or outcomes. Unfortunately, many therapists didn't push back against the providers' greed, as they were getting per-visit payments. Right or wrong, the data and studies have shown trends of such behaviors. From this perspective, it's no surprise that therapy thresholds were removed from the payment model.
I am not saying that every provider and every therapist was part of this trend. I'm saying that data have proven that therapy thresholds and their weight in episodic rate pricing resulted in a trend, and CMS responded to that trend. So now it's time to move forward. We can't change the past, but we can learn from it.
To understand the impact of the new home care rules on therapy we need to dig deeper into the details. I'm the CEO of a home care agency, but I'm also a PT, so I feel that I have a unique vantage point from which to see things: from the perspective of a provider as well as a physical therapist. And from my vantage point I see this to be tremendous opportunity for PTs to become an integral part of home health care and its future.
You might think that I'm out of my mind. But there's another side to the PDGM. Let me explain.
These things are continuing under PDGM for home care:
- Start of care, recertification or follow up (OASIS)
- Recertification visit within the 5 days prior to the beginning of the new episode
- Plan of care for 60 days with patient-focused outcomes based on patient diagnosis, and clinical and rehabilitation needs
- Face-to-face document requirement by the referring physician
These things are changing under PDGM:
- Patient will be placed into 1 of 12 clinical groupings, 6 main and 6 sub-clinical groups. under the clinical group of Medication Management, Teaching, and Assessment (MMTA)
- Payment changed from a 60-day episode to 2 30-day payment periods in an episode of care.
- Therapy thresholds are eliminated as a determinant of payment.
- The split percentage payment approach (Request for Anticipated Payment) will be phased out. In 2022, the RAP will be replaced with a Notice of Admission (NOA), with a late submission penalty for failure to submit the NOA within 5 calendar days of the start of care.
- The payment calculation will depend on the following 5 items:
1. The admission sources; institution or community
2. Early (first 30 days) or late (second 30 days) period of care
3. Clinical grouping model
4. Functional impairment level (low, medium, or high)
5. Comorbidities (none, low, or high)
It's inaccurate to think that the exclusion of therapy visit thresholds from the payment calculation means there are no anticipated patient therapy needs. Nursing visits, social worker visits, and home health aide visits were never part of the home care payment calculation--did that stop home care agencies from using nurses, social workers, and home health aides? No, it did not. The bottom line is this: Under the PDGM payment model, home health agencies are expected to provide the necessary services based on patient illness, patient clinical needs, functional limitations, and safety and hospital readmission risks; to make patients stable, better, and independent in their homes to prevent them from frequent readmissions to a hospital or an emergency room. This reality means that PTs still have an important role to play in any responsible home health agency.
If providers are under the impression that they will not provide therapy services when a patient's assessment suggests—and functional impairment would require—the services, then providers will create another trend for CMS to evaluate, and that evaluation could result in further cuts to Medicare payment under the homecare payment period. CMS will already be implementing a -4.36% behavior adjustment in the new payment model.
Here's what you will not find in the 2020 home health rule: any mention by CMS that therapy services will not be needed or provided for a home care payment period. Instead, here are a few statements that we have received from CMS on the question of the impact of PDGM on therapy:
"We disagree that the PDGM diminishes or devalues the clinical importance of therapy. The musculoskeletal and neurological rehabilitation groups under the PDGM recognize the unique needs of patients with musculoskeletal or neurological conditions who require therapy as the primary reason for home health services."
"For the other clinical groups, we note that the 30-day base payment amount includes therapy services, even if the primary reason for home health is not for provision of therapy. The functional impairment level adjustment, in conjunction with the other case-mix adjuster under PDGM, aligns payment with the cost of providing services, including therapy."
If you read these statements you will come to realize that while 2 clinical grouping models, musculoskeletal and neurological rehabilitation groups, will have higher therapy service needs, the other 10 clinical groupings (the more nursing-centered ones) will still require therapy services if there are functional impairments and/or other comorbidities that warrant therapy services to achieve optimal patient functional outcomes.
So is the PDGM the end of therapy in home health? CMS doesn't think so. And if home health companies are smart—and if they've learned anything from the visit threshold creep that contributed to the payment system we're about to begin in January—they would come to understand the 1 thing the PDGM can never change: the true needs of the patients in the agency's care.
Stay tuned for part 2 in this blog series, where I'll take a look at what PTs can do to demonstrate their value in PDGM.
Mahmood Iqbal, PT, is president and CEO of Home Health Care Solutions, located in Avon, Indiana.