Associations representing therapists have urged the CMS to intervene as skilled-nursing facilities lay off and cut the pay of thousands of therapists nationwide in response to the new patient-driven payment model.
The CMS scrapped the resource-utilization group model, which reimbursed SNFs according to the number of therapy hours and encouraged potentially unnecessary therapy services, the agency said, and replaced it with PDPM on Oct. 1. The budget-neutral model aimed to eliminate that incentive by basing pay on the needs of the patient and care quality, similarly to bundled payments.
Skilled-nursing chains have terminated or "transitioned" many of their therapists. Those who remain have been asked to boost their productivity and quickly cycle through patients as well as increase their use of group and concurrent therapy rather than one-on-one sessions.
The new model allows SNFs to conduct up to 25% of a patient's therapy in group sessions, but documents shared with Modern Healthcare show some facilities are making that ratio a requirement.
While PDPM changed Medicare payment methodology for SNFs, it did not change the value of physical therapy services or patient needs, said Sharon Dunn, president of the American Physical Therapy Association.
"Reducing PT and PTA staff 48 hours into this model reflects poorly on the commitment to patient access and quality of care. And CMS is watching," she said in prepared remarks.
The APTA, the American Occupational Therapy Association and the American Speech-Language-Hearing Association issued a combined statement Thursday detailing that they warned the CMS that Medicare beneficiaries may be harmed if they do not have access to the medically necessary skilled therapy that they need.
"I expect CMS to be closely tracking patient outcomes and to take action to address inappropriate behaviors or policies they see as negatively affecting patient care," the APTA told Modern Healthcare. "Patient plans of care didn't change overnight so staffing shouldn't be significantly changed overnight either."
The AOTA shared that sentiment, adding that mandating group and concurrent therapy without regard for professionals' clinical judgment is inappropriate.
The CMS is working on a response but did not provide one prior to deadline.
Critics say the layoffs prove that SNFs have been inappropriately boosting rehabilitation services. SNFs would log unnecessary therapy hours even for extremely sick patients who wouldn't benefit from the services, they argue.
"The use of magical minutes to drive profits has gone away," said Christine Ribik, an occupational therapist who has worked at multiple SNFs in the Washington, D.C., area. "The push for therapy was not based on patient need; it was based on corporate greed."
Therapists are critical of the push for more group and concurrent sessions because they claim they aren't as effective. It's a means to boost profits, Ribik said. The CMS has continually said that it wants individual therapy to represent the majority of therapy services.
The Medicare Payment Advisory Commission said that SNFs have provided on average less than 1% of total care in group and concurrent therapy.
The American Health Care Association, which represents long-term and post-acute providers, said that PDPM represents a shift to value-based, cost-effective care that incorporates nursing and rehabilitation to ensure the best care.
"This will mean changes in care," the AHCA said in a statement. "The most important measure of the success of PDPM should be resident health outcomes and the quality measures that CMS reports."
With the new payment model, patients' needs are tailored using five clinical case-mix adjusted components: nursing, nontherapy ancillary needs, occupational therapy, physical therapy and speech language pathology. A sixth component is the adjusted daily rate over the course of the patient's stay. But there are some issues with case-mix calculations that the CMS is trying to hammer out, experts said. The CMS said Friday that it will have an update next week.
MedPAC has pushed for a unified payment system for all post-acute providers, which it hopes would eliminate perverse incentives and streamline the reimbursement process. But in the meantime, the wave of unemployed therapists will likely outweigh the demand for their services, SNF executives said.
Management assured Melanie Lunn in late September that layoffs weren't coming, said Lunn, a physical therapy assistant who was let go by Genesis HealthCare on Oct. 1.
"I was told not to worry; don't panic," she said. "But in the eleventh hour (Oct. 1), they went through laying people off."
Skilled-nursing home operators experienced a similar upheaval in the late '90s when it implemented the prospective payment system. Industry observers said that transition resulted in even more cuts compared with what's happening now, although some were rehired about six months after the implementation.
Major changes are on the horizon for several healthcare sectors. Home health will make a similar transition next year as the CMS substitutes a volume-based model to one that relies on patient characteristics. CMS Administrator Seema Verma wants to revamp the 340B drug discount program by cutting Medicare Part B reimbursement to hospitals that get deeply discounted drugs from pharmaceutical manufacturers.
In addition, the agency proposed a new consolidated payment structure for evaluation and management services that would amount to a rate cut for clinicians, although it has since walked back that provision.