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[Blog Series] Preparing for the Patient Driven Payment Model (PDPM): Week 7

August 29, 2018
Reimbursement By Kay Hashagen, Senior Consultant

With the release of the Final Rule for the SNF Proposed Payment of PDPM, providers in the post-acute care arena,—specifically Skilled Nursing Facilities (SNF)—should review the way data is collected and measure the value of any therapy that is provided. So, in this final installment of our seven week blog series, “Preparing for the Patient Driven Payment Model (PDPM),” we discuss the importance of outcomes.




Patient Outcomes in the Pay-For-Performance Era

In the current RUG IV PPS model, since payment has been set to minutes of therapy provided, there has not been a significant focus on the outcome measurement for the Fee-for-Service (FFS) Medicare Part A population. However, regardless of the specifics of PDPM, providers should know that the pay-for-performance era is upon us. The percentage of Managed Medicare products related to Accountable Care Organizations (ACO) and Bundled Payments for Care Improvement (BCPI) programs has continued to expand. These plans focus on the needs of the patient rather than the volume of services. This has been a fundamental change for Medicare Advantage type plans.

This transition and change in focus will most likely lead organizations to focus on outcomes for FFS just like they do for managed care. The Centers for Medicare & Medicaid Services (CMS) appears to be pushing Medicare towards a payment structure that is focused on the patient condition. Reimbursement will focus on the patient needs; however, operators will start asking the question of how much care [i.e. for therapy] is required for each patient condition.

Under the proposed PDPM, SNFs will receive the same reimbursement for PT, OT and ST regardless of whether zero minutes or 500 minutes of therapy are provided. The reimbursement will come from the clinical diagnoses and the functional Activities of Daily Living (ADL) scores related to Section GG in the Material Data Set (MDS).

Many therapy companies and staff therapists are asking, “Will I have a job when the focus is on value and not minutes of therapy provided?” The best assurance for therapists is to demonstrate outcomes.

Measuring Outcomes in Rehabilitation

There are various ways to measure outcomes in rehabilitation. One author defines the Rehabilitation Measure of Outcome, or RMO, which can be understood in the context of the World Health Organization International Classification of Functioning, Disability and Health (WHO ICF):

The ICF describes the health condition within the domains of body structure and function (impairments), activity (limitations) and participation (restriction) interacting with the contextual personal and environmental factors.

The CMS changes to the PT and OT evaluations, which occurred in January 2017, follow the same parameters as in the WHO ICF. Use of outcomes that are tied to these focus areas will help track changes in function at the individual level. Clinician-assessed measures typically focus on changes in impairments and activities whereas patient-reported outcome measures help determine participation. There are many choices of outcome measures that relate to diagnosis, level of care, and patient-specific information. Therapists will need to demonstrate evidence-based practice as they utilize the initial evaluation components and incorporate appropriate standardized tests and measures into goals. By designing the Plan of Care to affect a desired outcome, and monitoring or measuring it with regular progress notes, the therapist should be able to demonstrate value.

 Value should be focused on:

  • being able to demonstrate a meaningful functional improvement,
  • monitoring medical status while progressing with rehabilitation [to reduce hospital re-admissions], and
  • demonstrating that the patient requires skilled intervention to achieve the outcomes and meet transition plans.

The days of hoping the patient will make progress because they have “potential” are gone. If the therapist is unable to demonstrate an objective functional change within the reporting period, then maybe the patient should not receive skilled therapy at this time. If the patient does not want to participate, that's their choice and perhaps therapy should be discontinued. Use of Restorative Nursing Programs will be more evident at times when the medical or cognitive condition of the patient does not warrant skilled therapy intervention. 

LW Consulting, Inc. would be glad to assist with more specific information on outcome measure implementation to demonstrate value. Contact us for help.

To recap our series from the beginning, check out week 1.


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