PDPM and PDGM Updates

• By: admin
• On: 12/18/2019 08:52:08
• In: Payment

As part of overall efforts to move Medicare payment away from fee for service and toward a structure that holds providers accountable for patient outcomes and costs, the Centers for Medicare and Medicaid Services (CMS) has made significant changes to the skilled nursing facility (SNF) and home health payment systems. The SNF Patient-Driven Payment Model (PDPM) began October 1, and the Home Health Patient-Driven Groupings Model (PDGM) begins January 1, 2020.
Both PDPM and PDGM align payment with patient characteristics, conditions, and needs, and eliminate the connection between reimbursement and the volume of therapy services provided—time spent and number of visits. This change makes it ever more important to show the value and cost-effectiveness of physical therapist services within SNFs and home health care. At the same time, what doesn't change is the coverage criteria or documentation requirements associated with the skilled therapy service coverage under PDPM and PDGM. More important, there is no change to the care needs of patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies.
APTA has been working to keep the profession up-to-date with the evolution of the PDPM and PDGM through our news and social media outlets, webinars, phone-in sessions, and other free, open access resources on the APTA SNF and Home Health Payment Models website.

• Other resources include:
  • #PTTransforms blog: 2-part series on PDGM
  • PT in Motion News: Tips to navigate PDPM and PDGM
  • Center for Integrity in Practice: Product of the APTA's Integrity in Practice Campaign. It is designed specifically for physical therapists, physical therapist assistants, educators, and leaders to better understand fraud and abuse in health care and the impact they have on the profession of physical therapy, on individual clinicians, and on their freedom to practice.

Three of the APTA Sections - Home Health Section, Academy of Geriatric Physical Therapy, and HPA the Catalyst, have a number of other resources on their respective websites to help clinicians prepare and thrive in these new payment models.
APTA also has been actively communicating with the press to highlight concerns surrounding the industry's implementation of PDPM and potential inappropriate behaviors. Recent articles include:

• https://www.nytimes.com/2019/11/29/health/new-old-age-medicare-physical-therapy.html
• https://skillednursingnews.com/2019/10/cms-is-watching-changing-therapy-patterns-raise-concerns-about-skilled-nursing-audits-care-quality/
• https://www.modernhealthcare.com/operations/therapists-look-cms-aid-snfs-restructure
• https://www.mcknights.com/news/therapist-advocates-sharing-layoff-concerns-with-cms/

The new payment models do not change the value of physical therapy services or patient needs. PDPM and PDGM expect rehabilitation professionals will continue to furnish high-quality therapy services that are reasonable and necessary. APTA maintains an ongoing dialogue with CMS and we are sharing with them the feedback we're receiving from physical therapists and physical therapist assistants regarding their experiences with PDPM and PDGM. APTA will continue to carefully monitor implementation of the models and advocate for appropriate changes as CMS evaluates the systems during the first year of implementation.
Questions? Comments? Concerns? All physical therapists and physical therapist assistants (members and non-members) are encouraged to share their PDPM and PDGM experiences at advocacy@apta.org. Also, if you'd like to join the Post-Acute Care online community (Hub), please contact Kara Gainer at karagainer@apta.org.
 
Kara R. Gainer, JD
Director of Regulatory Affairs
American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314
703/706-8547