Little Known Changes in Medicare Payments to Providers May Result in Less Patient Care

Medicare is the primary insurer for Americans over the age of 65. While it covers acute illnesses and treatment, it provides little to no long-term care for chronic illnesses whether in the home or in a nursing facility. However, Medicare does pay for therapy (speech, occupational, and physical) in some circumstances.

On October 1, 2019 changes were made to how Medicare pays providers for skilled nursing services, including therapy, and these changes were effective on January 1, 2020 for home health agencies providing therapy and care under Medicare. These changes are known as the Patient Driven Payment Model (“PDPM.”) While the title sounds positive, many are still trying to understand how care may be affected. So far PDPM appears to have resulted in a reduction in therapy services provided to those who are vulnerable.

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Prior to enacting PDPM, Medicare payments for therapy and skilled services were calculated based on the time therapy was provided to the individual patient. This resulted in actual payment for time spent with a patient. However, under PDPM, a patients underlying condition is the basis for payment, and Medicare provides payment based on anticipated needs during the course of treatment. In other words, payment is calculated based on the average amount of therapy or care needed based on their condition. This new manner of calculating payment appears to result in less therapy. According to the Center for Medicare and Medicaid Services, this change was intended to be budget neutral but provide higher quality of care. Yet many Medicare recipients are finding this to not be the case.

Under PDPM, payments are calculated based on the patient-driven groupings model (“PDGM”). The model uses the patient’s underlying condition and the average cost of care provided over a 30- day period. Then 432 possible cases or mixed groupings are considered and factored which is then applied to the based 30-day calculation to further anticipate and address a patient’s needs. These 432 groupings are based on the source of admission (either institutional or community) based on the healthcare setting or the patient from the prior 14 days. Then Medicare examines twelve clinical groupings which include:

  • Musculoskeletal Rehabilitation Therapy
  • Neuro/Stroke Rehabilitation Therapy
  • Wounds – Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care
  • Complex Nursing Interventions Assessment, treatment and evaluation of complex medical and surgical conditions
  • Behavioral Health Care Assessment, treatment and evaluation of psychiatric and substance abuse conditions
  • Surgical Aftercare Medication Management, Teaching and Assessment (MMTA)
  • Cardiac/Circulatory Medication Management, Teaching and Assessment (MMTA)
  • Endocrine Medication Management, Teaching and Assessment (MMTA)
  • Gastrointestinal/ genitourinary Medication Management, Teaching and Assessment (MMTA)
  • Infectious Disease/Neoplasms/Blood-forming Diseases Medication Management, Teaching and Assessment (MMTA)
  • Respiratory Medication Management, Teaching and Assessment (MMTA)
  • Other Medication Management, Teaching and Assessment (MMTA)

Additional impairments such as bathing, the ability to dress, the ability to groom, toileting, transferring, are considered as well as the chances of morbidity or death are factored. The combined factors are then applied to the payments for the underlying condition in order to calculate the amount that will be paid to the provider for caring for the patient. Payments are re-calculated every 30 days. If the patient stops receiving services for 60 days and then receives services again, payments are calculated as a new admission. Payments are higher during the first 30 days and reduce thereafter.

Calculations under PDGM seem complex, but more importantly, are done without regard for an individual patient’s needs. Agencies providing therapy have a strong incentive to provide short- term rehabilitation assistance to patients but not long-term. Across the country, agencies and skilled nursing facilities have eliminated hundreds of therapist jobs and have terminated therapy services which have been provided to chronically individuals for long periods. Examples include terminating physical therapy for an individual with ALS which was desperately needed in order to maintain as much muscle strength and control as possible. The termination of therapy services has resulted in accelerated loss of muscle control which will likely require the patient to move to a nursing facility. Another reported example was the reduction in post-trach care speech therapy necessary for the patient to regain speech, language, voice, and swallowing. Prior to PDGM, the patient would have received approximately 45 minutes daily of therapy but post PDGM, the patient received 15 minutes. According to the therapist, that isn’t remotely enough time with the patient.

These changes in how payments are calculated are still relatively new and more time may be needed to determine how this affects healthcare as a whole. However, early reports indicate that PDPM and PDGM may be result in sub-par care for those with the greatest need.

Ask Kit Kat: Birds at the HRBT

Hook Law Center: Kit Kat, what can you tell us about birds nesting at the Hampton Roads Bridge Tunnel (HRBT)?

Kit Kat: Well, the HRBT is a bridge-tunnel system that connects Virginia Beach & Norfolk with Hampton and Newport News, VA. Currently, the bridge is undergoing a major expansion costing nearly $4 billion. It is the largest project undertaken by VDOT (Virginia Dept. of Transportation) and should be completed by Nov. 2025. Commuters are ecstatic, but there are implications for certain migratory birds who nest on the south island. Laughing gulls and the royal tern are two such birds. During construction, the south island has been paved to allow space to store construction equipment. So, Gov. Northam (VA) has made a plan to address the concerns of environmentalists and bird enthusiasts. Virginia and California are the only 2 states in the country that have made a commitment to birds when construction projects temporarily impact their nesting or areas of habitat. A recent act by the Trump administration has limited the response states need to make during construction projects that only “temporarily” change a specie’s habitat.

The plan put forth by Virginia includes adapting an artificial island at Fort Wool, a decommissioned military fort near the bridge, as a substitute during construction. The Virginia Dept. of Game and Inland Fisheries will lead the preparation of the island by clearing trees and underbrush, reducing predators, and sealing off vacant buildings. They may also dump top soil or sand to fill in low spots. Critics say it is a worthy plan, but does not provide as much acreage as the south island did. To address that concern, the plan also includes supplementing the area with stationary barges. Still, with all these efforts, some say the acreage will not meet the needs of the 25,000 birds who will return in March and April to lay their eggs and feed off the fish nearby. Fort Wool is about 5 acres smaller than the south island.

While not perfect, the commonwealth of Virginia is to be commended for reacting so quickly and composing a plan to address the situation. Furthermore, Gov. Northam has committed the commonwealth to restoring the south island to its original condition when construction is completed. (Joanne Kimberlin, “A big plan for the birds,” The Virginian-Pilot, Feb.15, 2020, p. 1 & 12)

Posted in Senior Law News