In addition to providing CMS with reports of inappropriate practices by HHAs and SNFs, the organizations are now taking concerns about PDPM and PDGM misapplication directly to physician and consumer groups.
From the moment new payment rules governing skilled nursing facilities and home health agencies were rolled out, APTA, and the professional associations representing occupational therapists and OTAs and speech-language pathologists have been battling some employers' willful misapplication of the rules. Now the organizations are taking that mythbusting effort directly to physicians and consumers.
This week, APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association released two joint letters and a consumer "fact sheet" that exposes how some SNFs and HHAs inappropriately use the new systems — known as PDPM for SNFs and PDGM for HHAs — to reduce patient care, cut therapist hours, and sometimes eliminate entire jobs. "PDPM" stands for "Patient-Driven Payment Model"; "PDGM" stands for "Patient-Driven Groupings Model."
In a joint statement announcing release of the letters, the organizations write that "Preserving access to therapy services is critical, particularly as postacute care organizations prepare for the expected surge in patients recovering from COVID-19."
The consumer-focused letter, sent to numerous patient and consumer advocacy groups, cites examples of HHAs and SNFs reducing therapist hours, requiring therapists to perform services outside their scopes of practice, ignoring or modifying physician orders and plans of care, misinforming therapists about which treatments are allowed under the payment systems, and failing to provide maintenance therapy, among other practices.
"Our associations stand committed to ensuring all patients retain access to medically necessary therapy services and ensuring all stakeholders understand the impact these business-driven decisions can have on patient outcomes," the organizations write, adding that "Medicare beneficiaries and their caregivers deserve to know the facts about Medicare coverage in SNFs and HHAs to address the inappropriate practices."
To that end, APTA, AOTA, and ASHA created an accompanying fact sheet that explains, in easy-to-understand language, the most common mistruths patients and caregivers are being told. Among the messages that the organizations point out as false:
- Medicare limits the amount of therapy that can be received.
- Medicare dictates what forms of therapy a therapist can deliver.
- A portion of SNF therapy treatment must be provided in a group setting.
- Medicare only pays for therapy services that improve a patient's condition.
- Medicare does not pay for certain diagnoses.
- Medicare does not cover home health services unless the patient is discharged from the hospital or institutional setting.
- Medicare won't reimburse for any home health care services that exceed a total of 30 days of service.
"Many SNFs and HHAs are using these payment systems in ways that support patient access to necessary care, but some are purposefully providing misinformation," said Kara Gainer, APTA's director of regulatory affairs. "We believe the facilities and agencies misusing the systems are outliers, but it's still important that all patients are aware of their rights."
The fact sheet includes steps patients can take if they believe a SNF or HHA has inappropriately restricted access to therapy services, including links to consumer advocacy groups that can help pursue the issue.
The letter directed at physician groups is aimed primarily at home health and warns that "some HHAs are making care choices for patients based on the perceived financial incentives … rather than the actual needs of patients of patients or the plan of care."
"We recognize that CMS only implemented PDGM on January 1, 2020," the letter continues. "However, we anticipate that as patients raise concerns with their physicians and outcomes data becomes available, the failure of some HHAs to provide the care that has been ordered as medically necessary for the patient will require your attention."
APTA, AOTA, and ASHA have been supplying CMS with a steady stream of examples of inappropriate practices by SNFs and HHAs since the new payment plans were introduced. For its part, CMS says it has been tracking SNF and HHA utilization and outcomes data, but has yet to release any findings, describing any release as "premature" at this stage.