Listen to full episode of ASHA Voices: How Will January’s Home Health Changes Affect Services?
(Music – ES_Forest Pond With Stars – Polar Nights)
This is ASHA Voices. I’m J.D. Gray.
When changes in how Medicare paid for services hit skilled nursing facilities in October, we heard stories from members who experienced job loss and changes in their pay or status.
What will happen when similar changes hit the home health industry on January first?
We speak to two experts. They say that while home health reimbursement is changing; your value and your skills aren’t. And advocating for your clinical judgment, and your patients’ care, will be ever more critical.
Sarah Warren: “We’ve got to always be saying: If you want quality care, you want to avoid negative outcomes. We want to protect your bottom line. We can’t make up volume by overburdening the caseload.”
Listen in as we discuss how to show your value under the new Patient Driven Grouping Model, or PDGM.
That’s coming up on ASHA Voices. I’m J.D. Gray.
(Music – ES_Typewriter Song)
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Whether they help with cognition or swallowing, speech-language pathologists in home health settings deliver treatment to people where they live. On January 1st, more changes are coming to how care is reimbursed under Medicare.
You may remember in October the patient driven payment model, or PDPM, overhauled Medicare reimbursement at skilled nursing facilities. Now health care providers in home health are preparing for a comparable payment overhaul coming from the Centers for Medicare and Medicaid Services, or CMS. It’s called the patient driven grouping model, or PDGM.
What does this mean for SLPs and clients in this setting? After PDPM went into effect, we heard reports of SLPs losing their jobs, receiving a decrease in pay, or experiencing a change in job status. Will the implementation of PDGM be different?
To help answer those questions and discuss PDGM, I invited Jenny Loehr and Sarah Warren to speak with me.
Jenny is an SLP. Shas a 15-year career in home health and trains field clinicians for a large health-care company that provides inpatient and home-based care.
And Sarah is the director of healthcare policy for all things Medicare at ASHA. We spoke together at the 2019 ASHA Convention. To begin our conversation, I asked Sarah, what some of the most significant changes we can expect to see under the new system are, and how they are different from what was there before?
Sarah Warren: So I think the primary change you’re going to see is the way that therapy services are paid in home health. We’re really moving away from paying based on the number of visits, to paying based on the patient characteristics. And then there’s some really unique elements of the home health payment system that are going to factor into your payment as well, that never factored into payments. Such as the source of admission, and the length of the payment episode or the payment periods.
J.D. Gray: Jenny, have you anything to add?
Jenny Loehr: Yeah, I mean, it is a very different model. Traditionally was therapy based prior, and now, as Sarah said, it’s clinically based and really dependent upon diagnosis. And as Sarah mentioned, there are other little factors that are going to bump a reimbursement a little bit, but it just puts us in an a completely different approach to patient care.
Warren: Yeah, I mean it’s not the number of visits you provide, it’s these clinical groupings, and there’s 12. And two of them specifically tie to therapy, but CMS has made very clear, and we’ll talk about this I think more, that regardless of what clinical grouping the patient is assigned, if they need therapy, they should be getting therapy.
Gray: Okay. So why is it that we’re seeing these changes?
Warren: There’s a lot of reasons, for the changes. One, we’re moving away from a volume-based system, where the amount of therapy or amount of services just generally you provide, drove the payment. And I think that there was some concern among policy makers that paying based on the number of visits you provided as a home health agency maybe provided misaligned incentives and drove some home health agencies to provide as many visits as possible. Not because that’s what the patient needed, but because it increased the reimbursement, and they felt like they really needed to address that.
Loehr: Right. Over utilization is a big problem. And decisions that CMS makes, and has made in the past, has essentially altered our behavior in the healthcare industry. So we see that happen. They make a decision, they make a change, and then all of a sudden we see different behaviors. But I think that’s a big one is over utilization and fraud.
Warren: They saw an increase in utilization without a corresponding increase in patient complexity. And you always have this push pull between payment and practice. You really want practice to shape payment, but you see these instances where there’s a change in the way payment is distributed. And that drives the practice. And so we really want to really always be trying to develop a payment system that’s reflective of clinical practice.
Loehr: Yeah. And that’s what PDGM is. It forces us all to really look clinically at the patient, and hopefully develop that right. Just right plan of care for the patient based on the diagnosis and comorbidities.
Gray: So we’ve talked a little bit about all the different factors affecting payment—among them duration of care, comorbidities, level of function. Let’s talk about this one, the clinical categories. How do these work?
Loehr: Well, there’s 12 different buckets. I call them buckets just to make it simplistic, different buckets for a diagnosis of a patient, right? And so you have a patient that has a broken hip, they’re going to go into the musculoskeletal bucket. You’ve got a patient who’s had a stroke, they’re going to go into the neuro bucket, etcetera. So there’s 12 different buckets. And within each of those buckets is a set amount of money that is given to provide care for the patient. So as Sarah mentioned before, previously it was therapy driven and we were paid for the amount of services that we provided. Now you’ve got a set amount of money. You decide how you want to spend that.
Warren: And I think the way that CMS developed these clinical categories was based on historical claims and OASIS data. And the OASIS is the assessment tool that’s used under Medicare in the home health setting. And so what we found was, while we have a role in almost all, if not all, of the 12 buckets. Because of the historical claims data, therapy is really only giving an additional pay bump in 2 of the 12. But as I mentioned, CMS has stated numerous times in various policy documents that it doesn’t matter if, in which of the 12 clinical groupings you’ve been assigned, as the patient needs therapy, then they’re supposed to be getting therapy .
Gray: But how does that work if it can’t be paid for under that bucket. You just add a bucket?
Loehr: So no, you don’t add a bucket. I wish we could add a bucket. No, and Sarah’s correct. You know, there’s nothing in the regs, nothing in any of the documents that states that if you’ve got a wounded patient that’s got dysphagia, that we cannot provide services to them. You’re just given this amount of money.
Because number one, it’s the best thing for the patient. Number two, we still have to think about outcomes and star ratings, which there’s incentive for agencies to continue to keep their star ratings up, and there’s penalties, possible penalties, for those agencies that lose their star ratings. So it’s kind of this, I don’t know, weird dance that we have to do. You still have to provide that. So there’ll be some incentive in the long run for an agency to be successful, even though the reimbursement wasn’t there necessarily for the therapy visits.
Warren: I think the other thing to consider in terms of, you know, there’s not a separate therapy payment, is in the quality element of it. Is if that patient comes into the home health episode and they have a fall or they develop aspiration pneumonia, that’s a cost that the home health agency has to eat. And so I think it’s working hard to make sure that you develop efficiencies in care, and effectiveness in care. And maybe providing some therapy even though there’s not a therapy payment, because you recognize, one, that’s clearly in the best interest of the patient. And two, from a financial consideration standpoint, it may be better for your bottom line.
Gray: Not very long ago we brought stories to this podcast about changes that went into effect for skilled nursing facilities under PDPM. And we heard from SLPs whose jobs were cut, their hours were cut and their job status has changed. We heard stories of questionable care, and expectations, and now about three months later, and we’re seeing another change in post-acute reimbursement under Medicare. This time affecting home-health. These wounds are still fresh for many of the SLPs. And I’m wondering what’s the prognosis for this change in home health?
Warren: Well, I think we have to be cognizant of the PDPM experience, and recognize the impact that could happen on our members’ employment. We can’t ignore that. I think the challenges in PDGM in some ways are a little bit greater, frankly, and I think we need to be honest with about that. You know, with the over-utilization that we saw in the previous payment system, it would not be unexpected to see layoffs or reductions and hours, you know, changes in your employment status, essentially. It’s hard to predict exactly what that’s going to look like at this point—you know, put a number on it.
And I think the other thing is we’ll see, to some extent, an overreaction on the part of the industry that does not help someone who’s lost their job for one month, or three months, or six months and that ultimately gets it back. But we will see some reinstatement of employment over time as home health agencies gain experience with the system and realize that maybe they acted too quickly.
Loehr: Yeah. I think, well said. I mean history repeats itself for those listening who lived through the PPS era. There was, you know, we lost a third of the workforce at that time. Same kind of scenario, just different reimbursement model. But we corrected, and CMS corrected. I mean, I think there’s going to be, there’s a lot of knee jerk reactions. I’m hearing a lot.
I can’t say enough that it’s not Medicare’s stance. They’re not telling any agency how many visits need to be made, but there’s a lot of preemptive behavior going on right now, right now as we speak. And it’s not January 1 yet. You know, about cutting back on visits and, which is, it’s very unfortunate. There’s so much myth out there, and it’s really causing a lot of confusion, and a lot of frustration, and a lot of fear.
GRAY: We’re going to take a quick break. When we come back, we’ll address some of those myths. And, we’ll talk about how to demonstrate your value under this new system, and the importance of proper coding.
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Gray: We now rejoin the conversation I had with ASHA’s Medicare health care expert Sarah Warren, and with a 15-year home health care vet who teaches speech- language-pathologists how to work in the field at a large home health company. I asked both guests to go through some of the myths they are hearing around PDGM. Sarah Warren’s voice will be the first one you hear.
Warren: We could go through a lot of the things that people are hearing, and let’s be clear too. It is our obligation to do what’s in the patient’s best interest, and we weren’t necessarily doing that under the previous payment system.
If you can really say that the evidence supports one visit or seven visits, that’s what you should be doing. So I think we need to be clear that we should be always providing evidence-based care regardless of what the payment system looks like. But I think first and foremost, the two myths that I hear a lot is that you can only provide therapy to a patient that comes into one of those two clinical buckets that triggers payment. You can provide therapy to any patient who walks in your door, who has a therapy need that’s medically necessary. What does that mean? If that person needs your skills, a clinician, if that person can improve or maintain a level of function, they should be getting therapy services, and that’s required under law.
And I think the other thing that Jenny highlighted too, is that Medicare is dictating the number of visits. Medicare is not dictating the number of visits. They’re expecting you to evaluate that patient and develop a comprehensive plan of care that addresses all their care needs, that’s based on that patient’s clinical presentation. And so when a company is saying you only get one visit a week or whatever that magic number is, they’re factoring the business consideration into those kinds of administrative mandates.
Loehr: Right. I do understand it. I mean we all understand that health care right now in the United States is a business, and these agencies are doing what they feel like is best to keep the electricity on, to keep the paychecks coming. But when it comes down to dictating what kind of care somebody’s going to get, you’re dancing on a legal fine line right there. Because that is a decision that should be made by the therapist, the clinician, the speech-language-pathologists, and the physician, not the person who is running the agency. So that is like the number one myth is that agencies are saying, you know, “SLP, Medicare says you can only do so many visits.” And that is definitely not true at all.
And the agencies that understand PDGM well, and have used the tools to run the numbers and look at the 35,000 feet up in the air down big picture, understand that if you provide the care, and the right care, to the patient, you’re going to come out ahead in the end. It can work that an agency can be fairly profitable if they’re doing the right thing. And I mean that’s what this whole system is designed for. It’s patient-centered. So it’s going to force us all to take a closer look at what the real needs are for the patient and develop just that right plan of care.
Warren: I think there’s some very specific myths built into the way this home health is structured. So under the old payment system, and now the PDGM for home-health, you always had a 60 day episode of care.
But under a PDGM now you have two 30 day payment periods within that 60 day bucket. So it is possible that there could be some misunderstandings, either intentional or unintentional about how those 30 day payment periods work and how that dictates your clinical practice. So, for example, because the payment goes down during the second 30 day payment period, you may be told to front-load services or discharge patients within that first 30 days because that’s all Medicare is going to pay for, and and similarly, or maybe not similarly, but if you have a patient who really could be discharged within that first 30 days clinically appropriately, I think this will be less common, but it could definitely happen that you keep that patient on beyond 30 days just to collect that second 30 day payment. I think the more likely scenario is trying to get those patients out the door within the first 30 days because they don’t want to eat any costs in the second 30 days.
I think you could also see someone in the old system if they “Didn’t need a lot of visits.” I’m doing the air quotes thing here, if they didn’t need a lot of visits, they probably could have potentially not been admitted to Home Health. And so what I think SLPs potentially experienced in Home Health settings in the past, not all SLPs, but some who worked in that setting, you could see, I could see some being told, okay, you get four patients on your caseload and you’re just going to do tons of visits with those patients.
Now I think what’s going to happen is you’re going to get like one or three visits with the patient and so how are you going to make up that volume? You’re going to take on more patients. And I think that has implications for SLP burnout. I think it has implications for patient care and the quality of that care. So, we’re going to have to really continually be monitoring: do you see a ton of discharges right at 30… The magic 30-day window? Do you see going to 75% institutional admits and 25% community admits?
And we’ve got to always be saying: If you want quality care, you want to avoid negative outcomes. We want to protect your bottom line. We can’t make up volume by overburdening the caseload.
Loehr: Right. And I think that you brought up a great point. I mean the change and then the caseload, your projection that you see that’s going to happen, which I also see happening is going to affect the bottom line because of the quality. And once again, if the quality goes down, then you’ve got patients who will be re-hospitalized and you also are going to affect those star ratings. People need to understand star ratings are still there, they’re not going anywhere. We still have to be mindful of meeting our outcomes, et cetera.
Gray: Sarah what should SLPs do if they see something that they feel is a violation of Medicare regulations or ethical standard?
Warren: I think that’s a great question. I think first and foremost, if you feel like whoever your supervisor is, your director of rehab or whoever that person is, is saying to you, you have to discharge all your patients within the first 30 days. I think first and foremost you need to go and clarify with that person, is this seriously the instruction that you’re giving me? Because the feedback when I work with leadership in the home health industry in the skilled nursing facility industry is they do have concerns that maybe sort of middle management for lack of a better way of saying it, have a fundamental misunderstanding of what the expectation is. So I think rather than calling the police and running through the building with your hair on fire, I think you do need to clarify that expectation.
And I think then you need to bring them the facts because if you have a frontline supervisor who’s saying, well Medicare says you only get five visits, we have resources on our website that directly refute that.
If you’ve really exhausted every avenue to work that out internally, then I think you do need to consider are there other sort of oversight bodies that you should be reporting that to? Whether that be the state survey agency or the department of health or whatever regulatory body within the state.
Gray: Okay. Let’s talk about how SLPs can demonstrate their value in this new system. What can they do to make things better for themselves and their clients? Jenny?
Loehr: Yeah. All right. Well there’s a lot of opportunities for SLPs. As we’ve been talking here, we’re going to have to be more efficient. It’s going to be more patientcentered care planning, kind of taking a step back and taking a holistic view of the patient, right? So we step outside of our silos as SLPs just, my silos starts around my lungs and goes up to my brain, right? And it’s just this little skinny silo. But I can step outside that, liberate myself and take a look at the whole patient, work shoulder to shoulder with my colleagues. I’m not saying step into the lane of the physical therapist or the occupational therapist or the nurse, but we’re going to have to be smarter and more efficient at getting to our goals.
And I think that as SLPs we’ll become super valuable, much more valuable in collaborating more with our partners out there on goals and functional goals. That’s one way I think that we can increase our value. I think another way, and I’ve been on the soapbox for a really long time, but we need to work at the top of our license. There’s a lot of SLPs out there that claim, I don’t take vitals cause that’s not in my scope of practice or I don’t do the OASIS assessment because that’s not in my scope of practice. And that that’s not true especially OASIS.
It’s cumbersome. Nobody likes to complete an OASIS assessment. But it is a privilege. But what’s happened is SLPs have said no it’s not in my scope. I don’t want to do it. Let’s just give it to the nurse to do. And that devalues you.
Warren: We’re partly here because we weren’t-… No one, the industry and clinicians as a collective group, was doing their due diligence in diagnostic coding and completion of the OASIS and that’s why we have PDGM as it exists. And we have in our presentations that Jenny and I do, I have a slide that says the future is ours to create and we have the opportunity to flip that concept on its head and understand how to code the OASIS, understand how to do diagnosis coding and build that data repository that we need to get you guys into more clinical categories.
Our advocacy is not stopping for our members on January 1st because PDGM went into effect and my job is done. My job is just starting January 1st as far as I’m concerned because I need to get more diagnosis coding in OASIS information to CMS that reinforces your value because you have as an SLP a ton of value in that setting and in all health care settings. But we’re obviously speaking specifically about home health.
Gray: What I’m hearing you say is that when someone’s coding, when they’re doing their billing, they need to think, this is not just going to my supervisor, the HR department, but this is also going to CMS and this is going to have an impact on the entire industry, not just my immediate position.
Warren: Yes, absolutely. And then I think from the value perspective, I mean we’ve alluded to it multiple times. We can identity… SLPs can identify people at risk for aspiration pneumonia. They can identify people at risk for a fall. They can identify people with a cognitive deficit.
Warren: So the value is you can identify these patients early and essentially save your agency money by either avoiding payment reductions for failing to meet various quality metrics or the cost of a patient who acquires something after admission to the home health episode. I think the other thing to think about outside of the Medicare quality reporting program and the star rating system, which Jenny talked about is, is that a lot of facilities and home health agencies kind of have in-house trainings for their employees.
Loehr: So home health agencies have to have QAPI program. The quality improvement programs. That’s as a Medicare regulation, I guess that’s the right word, but every agency has to have a system in place to monitor incidences or events or things that are happening so in order to improve performance overall and improve care. So some of the areas that home health agencies look at are incidences like are there falls? What kind of med errors are happening? What is the trend in infections? What’s the trend with rehospitalization? And so they have to have these QAPI meetings and generate data to report and they have to come up with performance improvement plans to mitigate and to improve.
And SLPs could be really valuable to this process, this performance improvement process. Because of the SLP mind if you see that, Oh, we’re seeing a lot of people with respiratory infections, perhaps they would say, “I’d like to look at some of those medical records and see if they might be related to swallow issues.” Or “Yeah, you’re seeing a lot of falls, well, what, what part can I play in fall prevention?” Et cetera.
Warren: Your value is greater than your visits. Value is not tied to visits. And that’s the mindset. And I think people are struggling with that. Your value was always more than that and it will continue to be more than that. And identifying where you can plug yourself in is going to be really critically important.
Gray: Jenny Leohr, Sarah Warren, thanks for joining me and thanks for this conversation.
Loehr: Well thanks for inviting me. I really appreciate it.
Warren: I really appreciate it as well and people should not hesitate to reach out to us. We really want to be here and be helpful to you, so please don’t hesitate to reach out.
Back Announce + Post-Roll and Credits
GRAY: Find more information about PDGM, including a breakdown of the changes that are coming on January 1, by going to ASHA dot org and searching “Medicare home health.” If you can’t find the answer you are looking for, send an email to “reimbursement-at-asha-dot-org.”
And if you have a story about your experience working in home health or if you were affected by PDGM, we want to hear from you. Leave us a voicemail at 301-296-5804. Or send us an email at podcast at asha dot org. We may use your story on a future episode of this podcast.
(Music: ES_Forest Pond With Stars – Polar Nights)
ASHA Voices is produced by the American Speech-Language-Hearing Association and comes from the team behind the ASHA Leader magazine.
Support for ASHA Voices comes from the ASHA Workload Calculator. Learn more by going to asha-dot-org and searching “ASHA Workload Calculator.”
Support for ASHA Voices also comes from the ASHA Continuing Education Registry. Learn how to earn and track C-E-Us at asha-dot-org-slash-C-E
Production assistance comes from Pamela Lorence. I’m J.D. Gray, and this is ASHA Voices.
(Music: ES_Hyperthymesia – Frank Jonsson 44100 1)
GRAY: We’ll be back on January 16 with more conversations about how we communicate and how communication changes our lives. Looking forward to next year, we’ll hear from researchers searching ways to reverse hearing loss. We’ll discuss how we talk about race with author Ijeoma Oluo *[Ee-joe-muh Oh-lue-oh]*. And we’ll talk about the role food and eating play in one’s life, while discussing dysphagia.
As you look forward to 2020, what are the issues and topics you want to learn more about? Write us an email. Let us know. You can reach us at podcast at asha dot org.
I’m J.D. Gray. This is ASHA Voices.