Medicare Payment Models Updated for 2020

As part of overall efforts to move Medicare payment away from fee for service and toward a structure that holds providers accountable for patient outcomes and costs, the Centers for Medicare and Medicaid Services (CMS) has made significant changes to the home health and skilled nursing facility (SNF) payment systems. The SNF Patient-Driven Payment Model (PDPM) began October 1 (the start of fiscal year 2020), and the Home Health Patient-Driven Groupings Model (PDGM) begins January 1, 2020.

APTA advocated to CMS on behalf of the physical therapy profession and our patients when the plans for payment system changes were first presented in 2017. Since that time, we’ve submitted comments and met in person with CMS representatives and federal legislators, both as an individual organization and as part of therapy organization coalitions. APTA strongly advocated for the inclusion of safeguards in PDPM and PDGM, including limitations on the amount of group and concurrent therapy that can be delivered (PDPM), and mechanisms to allow CMS to monitor and track therapy utilization and changes in patient outcomes.

Both of these payment systems align payment with patient characteristics, conditions, and needs, and eliminate the connection between reimbursement and the volume of therapy services provided—time spent and number of visits. This change makes it ever more important to show the value and cost-effectiveness of physical therapist services within SNFs and home health care. At the same time, what doesn't change is the coverage criteria or documentation requirements associated with the skilled therapy service coverage under PDPM and PDGM. More important, there is no change to the care needs of SNF and home health patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies. That some providers may choose to reduce PT and PTA staff reflects poorly on the industry's commitment to patient accessibility and availability, safety, and quality of care.

APTA has been working to keep the profession up-to-date with the evolution of the PDPM and PDGM through our news and social media outlets, webinars, phone-in sessions, and free, open access resources on the APTA SNF and Home Health Payment Models website. We are committed to helping the physical therapy profession better understand PDPM and PDGM, and educating employers and other stakeholders in developing responsible approaches to these new systems.

APTA created these brief summaries to give you the facts about the impact of the 2 new payment models in a format you can share with others.

• What You Should Know About PDPM (.pdf)
• What You Should Know About PDGM (.pdf)

Three of the APTA Sections - Home Health Section, Academy of Geriatric Physical Therapy, and HPA the Catalyst, have a number of other resources on their respective websites to help clinicians prepare and thrive in these new payment models. APTA also has the APTA Center for Integrity in Practice, which is a product of the American Physical Therapy Association's Integrity in Practice Campaign. It is designed specifically for physical therapists, physical therapist assistants, educators, and leaders to better understand fraud and abuse in health care and the impact they have on the profession of physical therapy, on individual clinicians, and on their freedom to practice. The Center for Integrity in Practice includes Upholding Integrity, Reducing Risk, and Best Practices resources. 

APTA also has been actively communicating with the press to highlight concerns surrounding the industry’s implementation of PPDM and potential inappropriate behaviors. Recent articles include:

• https://skillednursingnews.com/2019/10/cms-is-watching-changing-therapy-patterns-raise-concerns-about-skilled-nursing-audits-care-quality/
• https://www.modernhealthcare.com/operations/therapists-look-cms-aid-snfs-restructure
• https://www.mcknights.com/news/therapist-advocates-sharing-layoff-concerns-with-cms/

The new payment models do not change the value of physical therapy services or patient needs. PDPM and PDGM expect rehabilitation professionals will continue to furnish high-quality therapy services that are reasonable and necessary. CMS is closely tracking outcomes and therapy utilization, and actions such as mandating group therapy and inappropriately limiting medically necessary therapy services will draw the attention of the agency. APTA maintains an ongoing dialogue with CMS and we are sharing with them the feedback we’re receiving from physical therapists and physical therapist assistants regarding problematic reactions to PDPM. APTA will continue to carefully monitor implementation of the PDPM and advocate for appropriate changes as CMS evaluates the system during the first year of implementation. 

Questions? Comments? Concerns? All physical therapists and physical therapist assistants are encouraged to reach out to APTA at [email protected].