By now, most speech-language pathologists in health care setting have heard about major changes coming to the way Medicare pays skilled nursing facilities (SNFs), effective Oct. 1. The patient-driven payment model (PDPM) bases Medicare reimbursement to SNFs on a patient’s clinical presentation rather than on the amount of time they need treatment.
Here are the PDPM facts and tips—both financial and clinical—for SLPs in SNFs.
Know the facts
Medicare is changing how it pays SNFs, but not the longstanding requirement that only medically necessary services are reimbursed. The Centers for Medicare and Medicaid Services (CMS) does not regulate the daily decisions SLPs make on behalf of their patients. CMS also does not set productivity standards, dictate who can provide services—such as swallowing or cognitive treatment—or require the evaluation of every patient, either under the old system or PDPM.
CMS does expect providers to base services on patients’ needs and benefits of the treatment.
So, what does this change mean? First, the change emphasizes value over volume across the health care system. There is also interest in developing a unified post-acute care Medicare prospective payment system (PPS) that would create a single approach for reimbursing services provided in SNFs, home health, inpatient rehabilitation facilities, and long-term care hospitals—all of which now have different systems.
In fact, a payment model similar to PDPM, known as the patient-driven groupings model (PDGM), will be implemented in home health care on Jan. 1, 2020. The similarities between PDPM and PDGM might be an initial step toward a unified PPS.
According to policymakers supporting change, payment systems based on therapy minutes—like the one currently in place—may give SNFs the financial incentive to push the maximum allowable minutes of services for each patient, regardless of the patient’s needs. Historical claims data support this concern. Most patients received exactly 720 minutes of treatment—the minimum number required for the maximum reimbursement rate—indicating that service delivery was not based on individual patient’s needs. ASHA heard from members about pressures they experienced in SNFs to provide services, regardless of patient needs.
Know your value
Once PDPM begins to take effect, SLPs can move away from logging treatment minutes. Instead, you can demonstrate your value as members of an interdisciplinary clinical team.
SLPs play a critical role in identifying and diagnosing patients who need minor services as well as those with greater needs. Under PDPM, SLPs play a critical role in quality improvements, such as identifying patients at risk for a hospital readmission or aspiration pneumonia. Preventable health complications cost SNFs money. By demonstrating your role in avoiding quality reporting penalties and costly, preventable health care complications, ASHA members can strengthen their position in SNFs.
How to prepare
ASHA created a resource center to help SLPs prepare for changes with PDPM. You can understand all of the details about the new payment system with a series of free, on-demand webinars. ASHA developed a consensus statement in collaboration with our physical and occupational therapy colleagues regarding the importance of using clinical judgment and ensuring patient needs are the basis of service delivery. A second consensus statement can help you determine if and when to report behavior you think violates the law, payment policy and/or ASHA’s ethical standards.
By empowering yourself with the facts, knowing your true value, and voicing your clinical judgement, you enhance your position within SNFs to meet your patients’ needs.
Sarah Warren, MA, is ASHA director of Medicare policy. email@example.com