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Why a New Medicare Policy Could Cut Back on Physical Therapy

The new reimbursement model affects patients in skilled nursing facilities


Medicare changed its payment policy for physical, occupational and speech therapy in skilled nursing facilities Oct. 1, 2019, moving to a new system called the Patient-Driven Payment Model (P.D.P.M.). It dramatically altered how companies that provide these services are paid for treating clients.

I had a front row seat for these changes, since my 88-year-old father suffered a fall and two broken vertebrae last August. He was a patient at a skilled nursing facility — a nursing home that provides skilled nursing care — in western Massachusetts when the changes were taking effect and I was at his side at the time.

Our experiences underlined just how dramatic these changes can be for those in need of therapy. And I feel it’s important for others who might be in the same boat to know how they can potentially affect their own or a loved one’s care. People should know the steps that can be taken to prepare for dealing with this new system. Before recounting my father’s experiences, let’s take a quick look at what these changes entail.

A New Reimbursement Model

Under the old Medicare system, therapy companies were paid for the number of minutes their physical, occupational or speech therapists treated patients. The obvious financial incentive for providers was to deliver as much therapy as possible per client. Investigations of that system often uncovered clients being “over-provided” with therapy, to maximize reimbursements whether or not they were beneficial to the patient.

My father had been admitted to the skilled nursing facility prior to the adoption of P.D.P.M., but on Oct. 1, we experienced efforts to cut off his therapy and send him home.

Medicare sought to improve the system with P.D.P.M., which bases reimbursements on a patient’s diagnosis and medical needs.

Since then, therapists and professional associations, such as the American Physical Therapy Association, say some large therapy companies have reacted by laying off many therapists. They also say these companies began pressuring their therapists to do more group sessions rather than one-on-one sessions to maximize therapists’ time, regardless of patient needs. Medicare allows for up to 25% of patients’ therapy to be conducted in group settings.

My father had been admitted to the skilled nursing facility prior to the adoption of P.D.P.M., but on Oct. 1, we experienced efforts to cut off his therapy and send him home, despite his not having recovered from his injuries or using all his 100 days of eligibility for therapy under the old Medicare provisions. Because of his condition, he could not do group therapy.

He was to be cut from treatment on Sept. 23 by the company contracting for therapy in his skilled nursing facility, even though he still had more than 50 days of eligibility remaining.

Fortunately, we had kept a record of his therapy treatment from the beginning of his stay at the facility, so we prevailed and he was able to continue after the 23rd. However, rather than letting my father continue with the talented physical therapist he’d been working with, the company replaced that therapist with much less experienced physical therapist assistants.

We eventually chose to look for another skilled nursing facility for my father to finish out his therapy eligibility.

Advocate for Yourself or Your Loved One

So, what can a person do to avoid what happened to my father? First of all, ask questions — constantly.

Most skilled nursing facilities, or rehabilitation hospitals, are adjuncts of nursing homes, often farming out therapy to large, third-party companies. Sadly, many clients are not their own strongest advocates for care and can be exploited by less-than-scrupulous businesses.

Get to know the case workers assigned to you or your loved one and find out what your rights are regarding therapy. Take your own notes about therapy sessions: How long was the session, who saw the patient (make sure the person is a licensed physical therapist or a licensed physical therapist assistant), what was accomplished and were therapy “benchmarks” established so progress could be measured? Was the session in a group setting, and if so, is this appropriate for you or your loved one?

Keep organized copies of the “therapy notes” from each session; you are legally entitled to them. This was how we were able to keep my father’s therapy going.

Let the staff see you writing notes and taking an active interest in therapy. It is remarkable how much better your care can be if you are keeping a written record of treatment. Do not hesitate to question placing a patient in a group setting if you feel this will not be beneficial.

Most providers would prefer to avoid confrontation, so polite questioning can lead directly to better care.

Keep in mind that P.D.P.M. is uncharted territory for everyone, and there will probably be glitches along the way. You will be better able to navigate the new system and get the care you or your loved one deserves if you are prepared going in.

The vast majority of therapists have their patients’ best interests at heart and will do the right thing if allowed. Just understand that there are new pressures on them with P.D.P.M. and it may take a bit of work on your part to make sure you or your loved one receives appropriate therapy.

By John Gilman
John Gilman is a writer living in the metropolitan New York area. His primary field is the world of wine, about which he has written extensively. He recently began writing about health care, while attending to his father’s needs, learning a bit about navigating caregiving challenges and wishing to share his experiences.

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