Written by: Melinda Butler, OTD
OT’s Role with PDPM & PDGM
In recognition of National Occupational Therapy Month, I found it fitting to highlight how OT remains a pillar in the world of healthcare, even amidst the vast changes brought forth by PDPM and PDGM. While these novel payment models signify the biggest change in Medicare reimbursement in nearly 20 years, the role of OT as a vital part of the rehabilitation process remains the unchanged. Yet the implementation of these programs has rocked the world of therapy, leaving many OT professionals underemployed and frustrated; many seeking totally unrelated careers like the neighborhood coffee shop.
Implications for OT
These programs are designed to shift the focus away from therapy minute and visit thresholds as the primary driving force behind reimbursement; and shift the focus where it should be…on the patient. Hence the names: Patient Driven Payment and Groupings Models. However, removing incentives to maximize therapy, resulted in some providers seeking opportunities to reduce labor cost of therapists. All businesses have the right and responsibility to protect their investment by seeking ways to minimize cost, and maximize efficiency; but not at the sacrifice of quality patient care. Yet, many OTs/OTAs report:
- Mass layoffs or reduction of hours
- Companies requiring group and concurrent therapy
- Treatment sessions being limited to 15-20 minutes
- Provision of PT only, despite reported ADL needs
- OTs being limited to “simulated” ADL only
What Can OTs/OTAs DO?
Providers can be impacted financially by failure to provide all medically necessary services. There are several Alternative Payment Models (APMs) that are designed to ensure quality and efficiency, by holding providers accountable for achieving certain benchmark standards. One example is:
- Value-Based Purchasing (VBP)
- Greatly impacts revenue for SNFs and HHAs by rewarding providers with incentive payments based on the quality of care they provide to Medicare beneficiaries
- Primary quality measures: hospital readmissions, improvement and achievement, and patient reported satisfaction
- Financial incentives generated from a percentage of withholding from provider claims
- Providers who fail to reach targeted benchmark scores, do not receive the financial incentive
- Can result in millions of dollars per year in lost revenue
Other APMs examples include:
- Medicare Shared Savings Program (MSSP)
- Accredited Care Organizations (ACO)
- Comprehensive End Stage Renal Disease (ESRD) Care Model
- Comprehensive Primary Care Model
- Bundled Payments for Care Improvement
For more info on APMS: https://www.cms.gov/newsroom/fact-sheets/overview-select-alternative-payment-models
OTs/OTAs can advocate for their much-needed services by informing providers of the risk to revenue and referral sources. Objective information from evidence-based data and outcome measures is the most effective way to justify medical necessity of OT services. For example:
|“The patient needs OT to identify adaptive equipment (AE) needs for the bathroom.”||“80% of falls occur in the bathroom where OTs/OTAs address vital AE needs to reduce risk.”|
|“The patient really needs OT to improve ADL skills. Her husband can’t help her with bathing and dressing.”||“The patient scored a 40/100 on the Barthel ADL Index. This indicates 60% disability. The patient lives with her spouse who has mild Dementia.”|
|“The patient lives along so he really needs OT.”||“The patient’s closest relative resides out of state & patient scored a 40/56 on the Function in Sitting Test (FIST); indicating an inability to return home w/o asst.”|
There are governing agencies and programs that help protect the integrity of healthcare services. They can be of great resource as you advocate for the unique needs of your vulnerable patients.
- The OIG (Office of the Inspector General) https://oig.hhs.gov/
- MAC (Medicare Administrative Contractor) https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors
- Local professional licensure board https://www.occupationaltherapy.com/state-licensure-boards/
- AOTA https://www.aota.org/
So before you trade your scrubs for a barista apron, think back to what fueled your passion to pursue a career in OT and use that passion to advocate for your patients and your profession!
Happy OT Month!
Interested in learning more about this topic? Check out Melinda’s 2 hour online video course, “Successful Implementation Strategies for the Value-Based Purchasing (VBP), Patient Driven (PDPM), and Patient Grouping (PDGM) Payment Models,” here: https://summit-education.com/course/GPDPMB.1/#/onlinevideo/2-ceus.
Melinda also teaches a 6 hour course on “Functional Geriatrics” and it is available via online video or in person. To check out these courses, visit our website at https://summit-education.com/.
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