Renee Kinder
Renee Kinder

Slide 1 – Therapy and the Role of the MDS in Payment Reform, Quality, and Survey

Such was the intro slide to my presentation last week at Ohio Health Care Association annual meeting, on the Tuesday following the release of the Proposed Rule, which introduced the industry to the Patient Driven Payment Model (PDPM) on April 27.

I opened with, “Who’s here to learn about RCS-1?”

A few laughs, confused looks, and even a couple of “RCS-what do you mean by RCS-1?” comments in response.Take a deep breath, Renee, I think to myself. You’ve got this.

Yeah, right! Nobody’s got this three days after the proposed rule.

Deep breath … just reference your slides as you need and get through this presentation.

Slide 8 – Background: PPS Reform

Why are we here? And what do we know will not change under the proposed PDPM model?

Well, we know that something needs to change in the current system that reimburses care based on the volume of services; and that recommendations from the Office of Inspector General and MedPAC suggest that we move from a volume- to a value-based system that is based on patient characteristics.

Slide 19 – What will not change?

We know that the foundational definition of skilled need and the methods for accessing the post-acute care skilled benefit will not change.

As I begin to review the four factors below and am getting into my groove with the presentation, I see an “alert” come up on the computer screen — “Battery Low.” I reach down below the podium and jiggle the cord because surely this is a joke.

So, what do we know will not change with the aim to reform PPS?

We know that to access care in a SNF, all four of the following factors must be met:

•  The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 – 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;

•  The patient requires these skilled services on a daily basis (see §30.6); and

•  As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)

•  The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity

Slide 21 – PDPM Case Mix Areas for Physical Therapy, Occupational Therapy, and Speech Language Pathology

Another deep breath.

OK, Renee, you don’t have all of this memorized and you can’t talk off script like with RCS-1, so as much as you hate to do so, you are going to have to look at your slides.

And then, all at once, all systems down.

No computer. No audio/visual. No projector. Nothing.

I look out calmly (only on the outside) into the audience for a familiar face and say, “Looks like the system is down. Can someone get me tech support, please.”

I then look at the group and inform them, “Y’all, we have 84 slides total, we are on slide 21. Get out some paper and start taking notes.”

Some kind eyes looked at me as if to say, “Are you really going to try to do this?” and “We would understand if you don’t want to.”

But then, just like we have all accepted the fact that RCS-1 is done, people pulled out paper and pens and started taking notes welcoming the updates we are all seeing within the structure of PDPM.

What do we know about the structure of the PDPM?

PDPM is proposed to have six (6) case mix components

•  Physical therapy containing 16 case mix levels based on four clinical categories and MDS Section GG functional level scoring

•  Occupational therapy containing 16 case mix levels based on four clinical categories and MDS Section GG functional level scoring

•  Speech Language Pathology containing 12 case mix levels based on presence of acute neuro condition, SLP related comorbidity, or cognitive impairment & mechanically altered diet or swallowing disorder as documented in MDS Section K

•  Nursing containing 25 case mix levels based on clinical conditions, depression, number of restorative services, and functional measure.

•  Non-therapy ancillary containing six case mix levels based on diagnostic conditions

•  Non case mix

What changes do we see between RCS-1 and PDPM?

•  Physical and occupational therapy with more distinct versus combined case mix categories.

•  Potential incremental payment decrease occurring after day 20 versus after day 14 for physical and occupational therapy

•  Use of Section GG measures for functional status versus use of Section G

•  Modes of therapy capped at 25% for concurrent and group combined

•  New introduction of the Interim Payment Assessment (IPA) when specific criteria are met and the individual is not expected to return to his or her original clinical status within a 14-day period.

Soon after wrapping up this discussion, tech support arrived and re-booted the entire system.

I concluded my presentation with a bit more visual guidance for attendees, a few cheesy lines about an industry reset, and an acceptance that with the updates we see under PDPM, RCS-1 is now done.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Director of Clinical Education for Encore Rehabilitation and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs 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).