Feature: All together now
Group therapy still plays an important role, experts say.
Long-term care therapy providers have undergone a long episode of rehabilitation of their own in recent years. And many feel they've evolved into a stronger, more resilient profession as a result.
The injury came after periods of billing practices that government regulators viewed as problematic. What ensued was a near tsunami of government regulations and reimbursement policies aimed at transforming care delivery across all types of long-term care settings.
The biggest changes yet to come are a result of healthcare reform, which promises to make care more accessible and affordable while pressuring providers to avoid costly care and hospital readmissions. According to the American Physical Therapy Association, nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days — approximately 2.6 million seniors, at a cost of more than $26 billion every year.
Many view this as a prime opportunity for therapists to be part of a larger effort to help patients heal faster and transition safely to lower levels of care.
Other recent regulations have had a positive effect, according to Garry Pezzano, senior vice president of Clinical Practice for Genesis Rehabilitation Services. For example, the 2004 “75% rule,” requiring 75% of patients in long-term acute care hospitals and inpatient rehab hospitals to have one of 13 specified conditions before it could qualify for payment, has better steered patients into the most appropriate settings.
“So we're actually seeing Medicare guidelines/regulations affecting some of that population,” Pezzano says. “It really is out of necessity in meeting the patient's needs but from a regulatory standpoint and reimbursement standpoint, these kinds of changes have made it necessary for us to re-think our practice.”
Meanwhile, most therapy providers are not big fans of the current reimbursement environment. The APTA, for example, called it a “flawed fee-for-service payment system” in its 2012 annual report. In its own recent “Blueprint for Reform” report, Kindred Healthcare asserts that “current silo-based post-acute delivery and payment systems are unsustainable for the long term.”
Other government measures such as the OIG's fraud prevention system targeting so-called excessive billing practices led McKnight's “Rehab Realities” blogger Shelly Mesure to ponder the specter of “an atmosphere of fear-based rehab services vs. clinical decision-making-based rehab services.”
One of the most sweeping changes came in 2010, when new regulations changed the way billable group and concurrent therapy minutes were calculated. The policy created stricter documentation rules for group therapy.
“Therapy providers used to be able to treat up to four patients in a group and divide the time equally. The new rule, however, requires four patients at a time, which isn't always practical,” says Pezzano, who also serves as president of the National Association for the Support of Long Term Care.
Pezzano and other therapists contend a problem is that patients in group therapy must share common diagnoses or conditions for such therapy to be most effective.
“Being part of another patient's therapy is where the clinical value comes in,” he explains. “But with the new rule, it's much more difficult.
“What we really need to do is move much more quickly toward a pay-for-performance model,” he adds. “We're all working toward being patient-centric, facilitating smooth transitions and preserving Medicare dollars. We can't get there by making arbitrary rules about cutting payments.”
Other providers have different views about the changes. The rules hit many providers hard in terms of billable hours, according to Kristy Brown, CEO and founder of Centrex Rehab, a non-profit Minnesota-based provider.
The rules also have served as a wake-up call.
“These changes have truly brought focus back to the patient, which is where it needed to be,” Brown says. “We interpret regulations without any gray areas and do not look at workarounds or how to make therapy we provide fit a regulation.”
While the rules affected her own firm's revenues, Brown says her company is “very focused on quality of care. In my estimation, if you provide quality of care, your name will get out there and you will be able to attract business.”
The rules have had a positive impact, agrees Neely Sullivan, director of education for Select Rehabilitation.
“Since the changes were implemented, therapy policies and practices have evolved to ensure that patients are receiving the best care possible, and that appropriate reimbursement is attained for the services provided,” says Sullivan. In turn, the changes have forced providers to become more efficient, vigilant, transparent and better at documentation.
Meanwhile, providers have re-thought the most appropriate situations for individual or group therapy.
“Before CMS changed the structure of therapy delivery, we would use concurrent and group therapy as a means to encourage participation, as a platform to boost competition and what I call a patient's ‘inner athlete,'” says Holli Benthusen, an occupational therapist and regional director of business development and client relations for Select Medical Rehabilitation Services.
The new rules, she maintains, have prompted therapists and providers to “start leaning in the opposite direction and change their therapy delivery techniques.”
Leigh Ann Frick, senior vice president of rehabilitative services for Heritage Healthcare, believes the new rules have had a freezing effect on therapists' decisions over the best form of therapy to provide. Like her peers, she believes there are appropriate reasons for both individual and group therapy.
“It's unfortunate that reimbursement parameters are so complicated that they potentially impact the clinical therapists' decisions,” she says. “A therapist should have the ability to make clinical decisions based on the needs of the patient and provide those services accordingly, but that autonomy is slowly becoming more restrictive.”
Still, practitioners believe group therapy can play an important role. For example, it may be beneficial to see a patient concurrently or in a group to ensure generalization and maintenance of skills as the patient approaches discharge, says Kathy Simpson, vice president of clinical operations for Hallmark Rehabilitation.
“This is true for all disciplines, as a physical therapist may be monitoring how the patient is performing their exercises, an occupational therapist may be training ADL skills such as meal preparation, and a speech therapist may be monitoring communication skills with peers,” she points out.
“Patients with similar diagnoses and degrees of disability are often great candidates for concurrent or group therapy,” adds Jeanna Conder, senior director of clinical operations for RehabCare. “Many patients succeed when they can identify with others in a similar situation.”
Conder defends the provision of individualized treatment as “a consistent mode of therapeutic delivery.” While the rules have forced therapists to be “more cautious when delivering concurrent and group therapy minutes,” there are still valid and viable reasons to pursue them. “The focus of treatment should always be on the needs of the patients and how best to improve their quality of life.”
Brian Boekhout, a vice president at Wellness Services and EnerG by Aegis, agrees.
“Group sessions absolutely have a place — be it socialization, an opportunity for participants to mirror one another, motivate one another, effectively cope with loss or a medical condition — these things bring a lot of benefit to skilled rehab,” he says.
Other forces of change
No doubt, the reimbursement and regulatory arena continues to shape rehab therapy. But there are other forces of change.
One is the patient population, which is living longer outside of nursing homes and other settings.
“In Genesis alone, about 60% of the patients we treat in long-term care are discharged home,” says Pezzano. “Ten years ago, that was not the case. We have patients who are having stays in a SNF for as few as five days.”
Another is the focus on integration and patients' continuum of care, and safely transitioning them from acute, to skilled, then rehab, assisted living or home.
Centrex, an integrated therapy network, is affiliated with an accountable care organization.
“Any facility or organization we go into to provide therapy, we do our best to give them the tools they need to become one of the preferred providers for the ACOs,” she says.
In addition, consumerism has fueled greater expectations of positive resident outcomes, providing challenge and opportunity. Simpson says Hallmark's rehabilitation practices “have had to evolve to meet our customer's needs and our strategies have focused on providing the best, most intense rehabilitation that we can to achieve the best outcome with a shorter length of stay.”
The move toward evidence-based, outcomes-driven care, therefore, is uppermost in the minds of rehab therapy providers, they say.
“As an industry, we've gotten better at collecting information on clinical outcomes,” Pezzano explains. Genesis has a trove of patient outcomes data, and the challenge going forward is finding a way to include that information on Medicare and Medicaid claims. While Genesis uses the information for quality improvement and to motivate its own patients, Pezzano believes CMS would benefit greatly from it.
Like any business today, rehab therapy providers have begun diversifying and expanding into niches — in part to shore up lost revenues but also to enhance their value. Some have developed specialty units around diagnoses and conditions, or episodic care for short-stay residents, Pezzano says.
Boekhout observes that EnerG by Aegis is an integrated wellness product.
“We're seeing the need for care extenders, other ancillary departments, coming forward with a more integrated model of delivery and the therapist spending time, that are absolutely critical to transitioning to other areas,” he says.
Centrex recently launched its EverActive™ Senior Wellness Clubs, which are a personal passion for Brown.
“I'm trying to move from treating the patients after an injury or incident to helping them after they heal to lead long, productive and healthy lives,” she says while channeling the “triple aim” first articulated by Donald Berwick, M.D., the former head of the Centers for Medicare & Medicaid Services: improving individuals' experience of care, improving the health of the population, and reducing the per capita cost of healthcare.
Unfortunately, there's an acute shortage of all kinds of therapists. The APTA predicts a physical therapist shortage of nearly 28,000 just seven years from now.
It doesn't help that new physical therapists are required to complete a three-year doctor of physical therapy program. The APTA even foresees the day when PTs will be board-certified specialists. Some believe this has fueled wage inflation.
The median salary among the nation's 184,000 physical therapists is $80,000, according to the APTA.
Pezzano says he also is troubled by rules that say time spent supervising students is not billable, which may dissuade companies from on-the-job training.
The crosscurrents of reimbursement and regulation can create a turbulent river that providers must carefully navigate.
“The most critical piece is transitioning,” says Pezzano. “That's really the challenge and the opportunity we have. With the push toward integration, we need to take this precious therapy time we have and use it in a very effective way, and that means getting the patient to the next level of care and ensuring the handoff is safe and smooth.”
Another near certainty is ever-increasing regulatory scrutiny, Brown says. “One thing providers are bound to face more of is audits. But in order to prevent having to give money back, we make sure our therapists are 95% or better compliant with Medicare and Medicaid standards. If we can't support the skills for the services we delivered, then what are we in it for?” n