PDPM didn't reduce therapy outcomes

Therapy leaders are hailing results of a new study showing outcomes were not harmed during the first five months of the Patient-Driven Payment Model. 

At the same time, they caution that deeper examination is needed under non-pandemic conditions. And they reject any notion that therapy was overapplied under the previous Medicare reimbursement system.

“Overall, I think it’s really positive to see a study that highlights the changes that occurred around a regulatory shift weren’t detrimental to patient outcomes,” said Tracy Fritts, vice president of quality and outcomes for Consonus Healthcare. Her company provides rehabilitation, pharmacy and consulting services in more than 700 facilities nationwide. “I’m super excited to see that. It’s a question we were all asking. I think (the study) had a lot of purpose and solid methodology.”

Investigators found that despite a 13% drop in therapy minutes, outcomes were not significantly harmed. A Brown University investigative team led an in-depth look at outcomes related to PDPM’s onset. It was the biggest change to the long-term care Medicare reimbursement system in at least a generation.

Reviewed PDPM outcomes a ‘starting point’

Researchers analyzed records from more than 200,000 patients. About 50,000 applied to the five-month period after PDPM replaced RUG-IV. That was before the pandemic started and providers drastically altered therapy routines.

“It’s a great starting point,” Fritts said of the study, which appeared in the Jan. 7 issue of JAMA Health Forum. “There are probably some things that could be done to firm (results) up.”

She said it would be beneficial to examine therapy utilization over an entire episode rather than the first week. Experts also called for a look at outcomes beyond activities of daily living, hospital readmission rates and length of stay.

Jennifer Bogenrief, JD, is assistant director of regulatory affairs for the American Occupational Therapy Association. Her group would like to see more than the initial MDS assessment used as a pivot point about longer-term outcomes. It would also like to see more done with risk adjustments.

“We agree with the (study authors) that future study is needed,” she said. “AOTA supports the patient-centered approach to care delivery in SNFs envisioned by PDPM, and we strongly believe that therapists must be allowed to use their clinical judgment to determine the mode and amount of therapy that an individual patient needs to reach their goals.”

Worn out RUGs

Both critics of the RUG-IV system and therapists that practiced under it now denounce the former system because it determined provider reimbursements solely on the amounts of therapy delivered. Analysts assert that led to irrationally high therapy amounts that peaked around cut-off points for new pay levels.

“Too often, the payment models influence the way facilities treat their patients, when ideally, therapists should be free to use their clinical judgment to determine the appropriate level of care based on the patients’ needs,” Kate W. Gilliard, director of health policy and payment for the American Physical Therapy Association, told McKnight’s Monday. “While this study focused on only hip fracture patients in the SNF setting, other [pre-PDPM] studies like the Therapy Outcomes in Post-Acute Care Settings (TOPS) Study indicate that benefit from rehabilitation services extends to several other clinical populations across all post-acute care settings.

“We are encouraged that many facilities appear to be re-aligning therapy with patient needs,” she added. “However, the TOPS study also suggests that patients who receive the least therapy have poorer functional recovery and higher risk for readmissions after discharge.”

That is a point that the therapy association leaders and researchers agree on. Future monitoring must assure reductions in therapy don’t become detrimental to patient outcomes.

Better focus needed under PDPM

Any future studies also must look at a broader range of patients, said Sarah Warren. She focuses on Medicare for the American Speech-Language-Hearing Association. Warren said it was premature to draw some of the conclusions found in the JAMA article.

A sample size of more than 50,000 patients is needed “to understand the true impact” of PDPM’s implementation, she asserted. She worried that stroke, Alzheimer’s and COVID-infected patients, among others, were not strongly enough represented. 

“The variety of outcomes for SNF patients that we should consider are much broader than falls, pressure ulcers, and hospital readmissions — factors CMS cited in rulemaking for FY 2022,” Warren said. “There are no measures associated with communication, cognition or dysphagia.”

One industry expert told McKnight’s that implications from the study authors, and others, that therapy minutes were artificially inflated under RUG-IV are off base.

“I would argue instead that therapists were nimble and worked very hard to fine-tune their skills to be able to achieve the same goals with reduced therapy time and resources,” said Melissa Brown, COO for Gravity Healthcare Consulting. “In a value-based world, therapists should be lauded for their achievements under PDPM, rather than scolded for typical practice under RUG-IV, which was also successful in achieving outcomes.”