A new Medicare home health payment system that takes effect Jan. 1, 2020, reimburses for care based on patient characteristics, rather than on the number of therapy minutes the patient needs.
The new system, known as the Patient-Driven Grouping Model (PDGM), will likely affect the amount of speech-language treatment a beneficiary receives. It will also lead to changes in the ways speech-language pathologists demonstrate their value in this setting, their roles and responsibilities, and, in some cases, staffing levels.
PDGM payment is based on:
- Source of admission (community or institutional).
- Lower payment for the second 30 days of a 60-day episode.
- The patient’s assigned clinical category, based on primary diagnosis. Only two of the 12 categories—musculoskeletal and neuro rehabilitation—specifically drive payment for therapy services.
- Patient’s level of function (low, medium, or high).
Under the previous reimbursement system, the volume of services—such as speech-language treatment—triggered a separate payment. Under the new system, Medicare continues to expect that patients will still receive all the medically necessary services they need, regardless of whether the need triggers additional, therapy-specific payments.
As the Center for Medicare and Medicaid Services stated in its proposed 2020 PDGM rule:
“While these clinical groups represent the primary reason for home health services during a 30-day period of care, this does not mean that they represent the only reason for home health services. While there are clinical groups where the primary reason for home health services is for therapy (for example, musculoskeletal rehabilitation) and other clinical groups where the primary reason for home health services is for nursing (for example, complex nursing interventions), home health remains a multidisciplinary benefit and payment is bundled to cover all necessary home health services identified on the individualized home health plan of care. Therefore, regardless of the clinical group assignment, home health agencies are required, in accordance with the home health CoPs at § 484.60(a)(2), to ensure that the individualized home health plan of care addresses all care needs, including the disciplines to provide such care.”
What can I expect?
PDGM removes the financial incentive to provide more therapy visits and reimburses based on the value of care and patient needs. As a result, there will be shifts in roles, responsibilities, and staffing levels.
When a similar payment model went into effect for skilled nursing facilities on Oct. 1, 2019, ASHA received reports of layoffs, reduced salaries, reduced hours, transitions from full-time to on-call staff, and transitions from full-time to part-time or hourly positions.
PDGM may also lead to administrative mandates that change how you deliver care, especially in ways that are not in the patient’s best interests.
For example, administrators may:
- Discourage admissions to home health from the community, rather than from the hospital, because of reduced payment for community admissions.
- Direct clinicians to provide all therapy within the first 30 days or discharge a patient within the first 30 days, because payment decreases during the second 30-day payment period.
- Tell SLPs they may not provide services to patients in any of the 10 payment categories that don’t include a separate speech-language payment.
These types of policies or mandates violate Medicare regulations and may—when not in the patient’s best interests—violate ethical standards.
If you receive inappropriate directives, work within your organization’s leadership structure to resolve these issues. If that is not possible, consider reporting them [https://www.asha.org/uploadedFiles/Compliance-Reporting.pdf] to the appropriate oversight authorities.
How can I respond?
Your value in home health goes beyond individual visits. Target your conversations to the role SLPs can contribute to these types of efforts:
Improving quality and minimizing unnecessary costs.
- You can help your company improve its Medicare Quality Reporting Program score on some quality metrics—such as avoiding unnecessary hospital readmissions—which could avoid a reimbursement penalty.
- You can help save the agency money: For example, if a patient acquires a condition—such as aspiration pneumonia—after the home health admission, the agency is responsible for the related treatment.
- You can identify efficiencies in care delivery and address quality deficiencies your employer has identified, such as reducing the risk of falls.
Accurately completing of the Outcome and Assessment Information Set (OASIS). The OASIS items associated with the patient’s functional level are especially critical under PDGM. For example, item M1700 of the OASIS deals with the patient’s cognitive function. Accurate coding of reduced cognitive function justifies the SLP’s involvement in the plan of care.
Identifying patients with cognitive impairment. Accurate identification of these patients affects the agency’s Medicare “star rating.” This consumer-directed system rates agencies based on, among other items, patients’ improvement in ambulation, transferring, bathing, and other activities. Patients with cognitive impairment are not counted in those ratings because their cognitive status may prohibit improvement in those activities. Accurately identifying these patients removes their outcomes from the rating system, possibly boosting the agency’s star rating and making it more attractive to consumers.
Correctly coding diagnoses. Only two of the 12 PDGM clinical categories include the diagnosis codes associated with speech-language treatment, because historical claims data for the other 10 categories don’t include those codes. With the goal of improving other PDGM categories to include the codes—thereby reinforcing our clinical value and preserving access to care for patients—we must include the correct diagnosis codes associated with our services on claims. A more robust data repository of diagnosis coding can help change the PDGM criteria.
The viability of speech-language services in home health relies on changing the value proposition and accurate diagnosis coding that ASHA can use to advocate for improvements to PDGM. Let’s all work to identify the necessary improvements and participate in activities that help drive these improvements.
Sarah Warren, MA, is director of ASHA Medicare policy. email@example.com