It is a simple ask.

It is the right ask.

Show me your therapy minutes.

The COVID-19 pandemic appears to have provided a bit of a pause to the anticipated review and audits we all anticipated seeing associated with PDPM.

The pandemic, of course, came at a time when the industry also saw the largest shift in the industry’s reimbursement model since 1998.

It’s a pandemic, that if anything, has only shown the need and benefit of skilled physical, occupational, and speech therapy services in skilled nursing facilities. Therapy and nursing teams alike play a crucial role in the immediate and long-term recovery of patients.

The headlines prior to PDPM were real, and raw, and should not be brushed away as secondary to COVID-19. 

For those who do not remember the headlines, here are a few notable pieces:

Therapy ‘Armageddon’ predicted; billing minutes to be ‘extinct’ soon?

Brace for rehab pay shifts, expert warns” 

Gut shot: Therapy providers called on the carpet over productivity goals” 

Scarier than the headlines were the “rumor” mills of internal conversations occurring across the nation:

  • Automatic decline in minutes to occur Oct. 1, 2019, in the range of 20% to 30%
  • “Phased in” minute decline
  • Therapist staff reductions 
  • Creative conversations associated with metrics tied to group and concurrent services

All conversations with seemingly justifiable reasons for shifts, “I mean, the RUG system assigned random volume minutes, so now we can do what the patient needs …”; and “Therapy is a cost center now and you don’t cut staff you will lose your shirts in the new model.” 

Leading up to and following the shift to PDPM, providers were advised to anticipate audits from program integrity, including payment that result from changes in the coding or classification of SNF patients vs. actual changes in case mix; changes in the volume and intensity of therapy services provided to SNF residents under PDPM compared to RUG-IV; and compliance with the group and concurrent therapy limit. 

While the industry is beginning to see more review activity related to clinical accuracy (good news!), we have yet to see activity related to volume shifts between the two payment models.

One recent study that reviewed federal Payroll-Based Journal (PBJ) staffing data did note entrenchment of about 5% for therapists and 10% for aides following PDPM and stated a preliminary look at another database has shown “sizeable” reduction in therapy minutes, which could be an even bigger indicator whether outcomes may suffer.

Outcomes and the alignment to volume of services also was noted in the recently published TOPS study

The research, commissioned by the American Physical Therapy Association and the American Occupational Therapy Association, used newly published data from the Centers for Medicare & Medicaid Services that was collected from January 2015 through December 2016.

Key findings of the “Therapy Outcomes in Post-Acute Care Settings” study:

  • Physical therapy and occupational therapy provided a functional benefit to most patients, with evidence of significant rehabilitative value across 1.4 million Medicare cases.
  • TOPS detected positive value in physical therapy and occupational therapy provided in PAC settings for rehabilitating and preventing the decline of core ADL function in beneficiaries.
  • Increased therapy intensity is positively correlated with increases in measured functional status in patients within the PAC settings studied following discharge from initial hospitalization.
  • Thirty-day readmission rates to acute-care hospitals following a PAC episode decreased after therapy and appear to have varying threshold effects within each setting. Readmission rates help to reflect whether patients are receiving appropriate levels of care following discharge from the hospital, and these findings indicate that patients who receive physical and occupational therapies during their initial PAC episode are less likely to be readmitted and more likely have better outcomes, such as survival, functional ability, quality of life, and participation in daily living.

Findings specific to each post-acute care setting include:

  • Intensive therapy stays within an inpatient rehab facility tended to demonstrate significant rehabilitation through measures of functional independence.
  • Residents in skilled nursing facilities demonstrated a positive relationship between therapy intensity and functional change. Some clinical conditions treated in those facilities showed clear increasing benefits from greater therapy, particularly joint replacement therapy.

In closing, you will note there are many sources of information related to volume of care. Exciting and forthcoming research to guide us as we aim to provide the highest level of quality care in the future. 

With that said, I would still advise providers to keep a keen eye on those therapy minutes. We have enough evidence at this point to tell us there is a direct correlation between volume, outcomes, and risk for rehospitalization.

Best to not be surprised, best to prepare accordingly.

It’s a simple ask. It’s the right ask.

Show me your therapy minutes. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).