Regarding The New Medicare Payment System PDPM VRS The Current Medicare Payment system PPS RUG IV

Your Medicare Reimbursement and PDPM These are statements regarding the new PDPM system that originate from CMS, (Government regulator of Medicare) and provided by Sunlight Consulting. In this article we will critique the regulations and statements of CMS regarding PDPM. I will be adding comments as to the validity of the statements and claims made by CMS and Sunlight Consulting. • Regarding PDPM projected impact statement. (CMS STATEMENT): PDPM is Budget neutral. (False). PDPM is (NOT) budget neutral and was never intended to be. We will explain throughout this article. • Regarding the new PDPM payment system, concerning skilled nursing facilities rehab centers. (CMS STATEMENT) Note: therapy minutes and days therapy is delivered are not used for Reimbursement. (True) Therefore therapy needs, such as patient treatment minutes, patient treatment days, extended times of therapy sessions regarding PT / OT will not be factored into facility reimbursement. Furthermore, the amount of therapy patients require is unlikely to be provided under the new PDPM payment system for Medicare. Why? Expense, paying therapist, providing equipment, assistive devices and adaptive equipment is extremely costly and under the PDPM payment system will become a financial liability to the facility without proper reimbursement. Moreover, reimbursement for higher levels of therapy under the PDPM Medicare payment system will no longer be available to SNF rehab centers. In addition, the number of minutes and days of the therapy delivered will be have to be limited regardless of patents needs. Let me provide an example: major stroke patient’s require therapy 5/7 days weekly with extended therapy session to recover. Therapy will continue with skilled services for an extended period of time or until the patient has achieved enough strength, mobility, and range of motion to regain as much independence as possible to return home. Many stroke patients require cognitive retraining that plays a major role in their time of recovery. This is extremely costly to the SNF rehab centers and is currently paid for under the current PPS Medicare payment system. Note: at this time high levels of therapy continue to be reimbursed and delivered in SNF rehab centers. At this time skilled therapies are delivered by patient’s therapeutic needs. However, under the new Medicare payment system PDPM these higher levels of skilled therapy will not be reimbursed and will become a financial burden to all SNF rehab facilities. The Rehab facility will have no choice except to decrease therapy services provided or simply discharge the patient home as funding will no longer be available for these high levels of skilled therapy. • (CMS STATEMENT) PDPM system has its higher level of reimbursement in residents less dependent with activities of daily living and focuses more on the resident who needs some assistance. (True) In other words, residents with debilitating pathologies such as stoke, head trauma, Parkinson’s with PDPM there will be actually be less reimbursement for those who need it the most. Therefore, the SNF will have no choice but to limit therapies secondary to PDPM financial constraints. Which is what PDPM is all about decreasing cost. • (CMS STATEMENT) PDPM improves payment accuracy and appropriateness by focusing on the patient, rather than the volume of services provided. (False) The new PDPM Medicare payment system reimbursement plan does not focus on the patient’s therapy needs, its goal is to cut cost by limiting reimbursement for skilled therapies and decreasing documentation requirements. Note most patients that are admitted in skilled nursing facilities are admitted for and need skilled therapy. Therefore, buy limiting reimbursement for therapy, it will cut Medicare cost which is PDPMs goal. (not quality of patient care) (CMS statement) The Patient Driven Payment Model (PDPM) represents a marked improvement over the RUG-IV model for the following reason: improves SNF payments to currently underserved beneficiaries without increasing total Medicare payments. (False) This PDPM does not consider the patient skilled therapy needs regarding skilled Physical Therapy or Occupational Therapy, Patient equipment needs, assistive devices and falls well short of adequate reimbursement for the patient’s therapeutic needs. Note: therapy is the main focus of skilled services provided in SNFs rehab centers. In addition, is the very reason that most patients are admitted to SNF’s. Unfortunately for the patient and facility, the primary focus of PDPM is cutting cost and limiting patient therapy based on cost savings instead of patient therapy needs. • (CMS STATEMENT) No minutes are reported on the PPS 5day or IPA. (True) This is true because therapy minutes and days are not counted for reimbursement. Therefore, how much therapy the patient receives or does not receive will not impact the payment and hence does not have to be calculated on the MDS billing software. PDPM will result in a decreased number of minutes, and number of days that therapy is delivered to the patient. Unfortunately, the number of minutes, days and how much therapy the patient receives will be dictated by the financial constraints with the new PDPM Medicare payment system. This program written by Medicare regulators is designed to cut Medicare cost not to improve quality of patient care. Moreover, they have chosen to cut back reimbursement for skilled therapies. Why? because it is utilized so much in SNF rehab centers which and is an expense the writers of PDPM feel they can cut? In addition, I believe that this will increase the readmission rate to the hospital as patient just will not receive proper amounts of therapy to recover and return home safely. • (CMS STATEMENT) The total number of concurrent and group minutes, combined, should comprise more than 25% of the total therapy minutes. (True) This is to push group treatments (multiple patients treated all at the same time) in an effort to assist the SNF rehab financially by cutting the pay-roll cost of actual therapies provided in the SNF rehab facility. PDPM sees this as a token gift to the SNF rehab facility. The rule now regarding Medicare A PPS payment system is to not exceed 25% of total group minutes provided for each patient weekly. As the rule stands now under the PPS Medicare payment system it promotes individual therapy treatments and provides reimbursement for individualized high levels of therapies as needed and does not promote group treatment to cut government cost for Medicare reimbursement. • (CMS STATEMENT) PDPM programs reward health care providers with incentive payment for the quality of care. (True) & (False) claim. While some medical procedures and diagnosis codes do increase reimbursement under PDPM such as IVs and Ventilators, PDPM will not provide sustainable reimbursement for the delivery of PT and OT for patients that require high levels of skilled services. PDPM will force facilities to limit therapies though decreased reimbursement rendering it impossible for the facility to provide them financially. Moreover, note that PT & OT therapies are the number one reason that most patients are admitted to SNF Rehabilitation facilities. Therapies are the number one utilized skill in most short-term SNF rehab centers and provide the bulk of the individual treatment minutes for the patients under the current PPS the payment system. However, as noted therapies will be seriously limited under the new PDPM billing system. Skilled rehabilitation will be scaled back regarding quantity of days and minutes provided. The new Medicare payment system known as PDPM begins 10/01/2019. PDPM is a Medicare payment system that is a change from the current PPS Medicare payment system. Under the current Medicare PPS payment system, it is specifically designed to deliver the level of therapy appropriate to the patient therapeutic needs. Under the new PDPM Medicare payment system, it chooses not to recognize higher or lower levels of therapies delivered and does not factor them into the reimbursement for patient care. This system will not increase payment for the necessary higher levels of skilled therapies provided. Therefore, in time I’m sure higher levels of therapies will not be provided under the new PDPM payment system. Simply put PDPM Medicare reimbursement is not there for these skills and the SNF rehabs center will financially not be able to provide it. I’m sure the new PDPM payment system will save Medicare a bundle of money. However, in the end it will have a negative impact on patient’s health and how therapies are delivered. In short, this PDPM payment system was designed to save money not improve quality of care. Moreover, because of PDPM financial constraints it promotes early discharges putting the patient at higher risk for falls, injury and readmission to the hospital. • I am a director of Rehabilitation, I am obviously industry bias. However, I see the new PDPM payment system as a plan to decrease Medicare cost that is first and foremost harmful to the patient, devastating to the SNF rehab industry financially, as well as the careers of therapist and therapist assistants. Any comments please feel free to email dbragga25@gmail.com Or respond on David J Bragga blogs David J Bragga 5/16/2019