Streamline Your Reimbursement Bill Format for Quality Assurance with airSlate SignNow

Reimbursement bill format for Quality Assurance

[Music] okay well welcome tonight to how a Medicare reimbursement influences therapy specifically in post-acute care so it's going to be kind of a historical look back at some of the reimbursement models and how they've changed and how that kind of relates to even some of the things that we're feeling today in healthcare and how reimbursement has impacted the way that we provide care today so I'm Clary skrody right I'm an occupational therapist and health policy Consultants I'm also the founder and CEO of amplifiot so my advocacy background is that I'm the former director of practice for the Missouri Occupational Therapy Association I'm also the former advocacy and policy coordinator for aota for their Home and Community Health special intersection there's my contact information and then I'm also the incoming co-chair for the North Carolina OT Association for their advocacy committee so excited for that new adventure so I like to start this presentation with a quote from one of my favorite articles that I found from 1991 in ajot American Journal of Occupational Therapy titled how high do we jump it was written by Brenda Howard uh so this is back in the 1990s when reimbursement was really starting to change and I like this quote I think it reflects well with even what we might relate to today so it says the current environment of Cost Containment leaves occupational therapists quote caught Between the pressures of patients demands for quality care and the drive to contain costs which creates professional and emotional conflict and even though this quote is from 1991 I think it's definitely a quote that still resonates even with us today in 2023 that we often really feel caught in this tough situation between how do we provide quality how do we still you know relate to reimbursement how does that influence occupational therapy and what we do um so definitely something that I think still heavily impacts how we think about care and shows that we are definitely not alone in feeling that today so to kind of talk about how some things have changed it's always good to kind of talk a little bit about value-based care and lay some of the base ground of reimbursers or some of the major players that we have in reimbursement so we have Health and Human Services right or HHS which is the Department of the government underneath HHS we have the centers for Medicare and Medicaid services who are primarily going to be talking about today and we also have the centers for Medicare and Medicaid Innovation or cmmi which is also kind of recently somewhat rebranded to the CMS Innovation Center then as part of a big player in value-based care and quality measurement we have Battelle so Battelle is actually the new CMS quality contract that replaced the National Quality Forum so up until recently the National Quality Forum has been heavily involved in developing quality measurement and endorsing quality measures that cmsn utilizes throughout their Quality Reporting programs but now that contract has transferred to Patel that took over sometime in Spring of this year of 2023 it's still something that is transitioning but Patel as well as the National Quality Forum they're nonpartisan non-profit organizations that are consensus based so it's this idea that we have a committee of individuals who come together aota is part of some of those committees to discuss the quality measures and agree on whether or not they are something that should be endorsed or supported whether or not they're really necessary for care so Patel now has a role in that so obviously the development of quality measures is really important when looking at value-based care so before we kind of had value-based care we had more volume based care so this cost-based reimbursement and what value-based care is not um is this emphasis on high quantity of care so volume really incentivizes providing lots of therapy uh lots of services to make more money uh it's not driven by patient needs or outcomes it's really focused on just providing the most care all the time maybe it's right but so this is where you know your doctor would order a slew of tests an x-ray as well as an MRI and then multiple different services or for therapy or just incentivized to provide lots of different lots of services versus really trying to think about if we're providing high quality or a value volume-based care is primarily fee for service models so right the idea that the more you provide the more money that you make on the therapy world we really saw this like in rug levels is a really great example of volume based care also therapy thresholds that we used to have under um before pdgm and Home Health and the Medicare Part B is still our primary fee for service model so it's still our most uh value volume based care setting is Medicare Part B it also incentivizes at higher quantity and promotes utilization of the most expensive services so instead of maybe trying therapy first we might jump more to surgery or to other expensive tests versus Under value-based care really tries to incentivize trying potentially the cheaper but still effective option which can be a great place for therapy because we can be a lot less expensive than some surgical interventions uh but under volume based care is really just promoting providing a lot of care also to set our Baseline we'll review Medicare quickly so Medicare rights are only publicly available national health insurance program there are other national health insurance programs like Tricare or the VA but they aren't publicly available like Medicare is it's available to people over the age of 65 those with end-stage renal disease or those with a disability Medicare part A is our traditional or Hospital insurance it's generally free to individuals as long as they've paid into Medicare the appropriate length of time it covers inpatient hospital stays Inpatient Rehab facilities LTX Sniff and Home Health Medicare Part B is our outpatient insurance so this is one that typically has a monthly premium that's based on income so depending on how much money someone makes depends on how much they pay per month for Medicare Part B is technically optional but most people do have it it covers observation hospital stays durable medical equipment outpatient therapy and outpatient visits so there are still you know skilled nursing facilities can still build Medicare Part B but usually under that Outpatient Therapy umbrella Medicare Part D pretty simple right d equals drugs so it covers your prescription drugs and then Medicare Part C is also known as Medicare Advantage now it's estimated that approximately 48 of Medicare are eligible beneficiaries are enrolled in Advantage Plans so they're very prevalent and I believe is recently that they predict that it's over 50 either now or will be within the next year or so um so Medicare Advantage plans are very popular uh what's Difficult about them is that they're run by Private health insurance companies so once you've seen one Medicare Advantage plan you've seen that one Medicare Advantage plan so what I'll be talking about today applies to Medicare so traditional Medicare part A Medicare Part B well some of the repair Advantage Plans it's hard to say because they get to make their own decisions on how they spend their dollars as long as they cover at least the minimum of what Medicare covers but they can also Institute prior authorizations and all sorts of things so they may or may not follow all of Medicare policies all right so to rewind into the 1990s um CMS is starting to kind of pay attention to costs and outcomes right the cost of Health Care has really started to rise to get out of control and they're starting to think about okay how do we actually know that the care that's being provided is safe that it's effective useful that it's worth all the money so approximately 20 of all Medicare fee for service beneficiaries received hospital care and I believe it's supposed to be 19.99. 25 of those patients receive post-acute care services so um it was only about a quarter of them that actually went to pack Home Health was the most common post-acute care service and one out of every 10 beneficiaries received an average of 73 visits per year so if you think about home health as we know it today and getting 73 visits per year that would be quite a few um so the fact that one in 10 beneficiaries were receiving an average of 73 visits per year is pretty high so Home Health no longer looks like that now um the average visits we'll talk about in every 30 days is significantly lower so I'm just thinking about how much different some of these settings looked therapy charges were really going quickly this is something that they were starting to pay a lot of attention to because it was one of the fastest growing expenses especially in Post Acute Care like skilled nursing facilities and home health so between 1990 and 1996 skilled nursing facilities spending increased from 25.1 million to 40.2 million so nearly doubling therapy use did double essentially so it went from being 15 of those charges to 29 of those charges so therapy utilization was really increasing these settings but the one thing that these numbers don't include is Medicare Part B services so they anticipate that these numbers were even actually pretty sufficiently underestimated because this was only looking at Medicare part A versus it was a lot more common than to kind of provide Medicare Part B in addition to some of their part A Services because they weren't very well regulated Home Health Care between 1990 and 1996 increased from 1.9 million to 3.7 million dollars uh average of spending with an average of 36 to 77 visits per year so um 1 in 10 received 73 visits per year but that General average across the board was 36 to 77 so still quite a bit of therapy in terms of quantity and these episodes were lasting so episodes lasting longer than 165 days also grew by 43 and that made up 20 of all episodes so pretty much one in five episodes was longer than 165 days which that is well over you know the kind of normal three months or things like that like now we're lucky right if we get to see patients for 30 to 60 days imagine seeing them for 165 we're talking pretty much over a third of the year uh so that's a very long length of care in which you can see why increase spending was increasing so rapidly now this was coming from a article on um this is actually from the office of Inspector General um I forgot to update this citation but it's from the office of Inspector General in the 1990s where they were viewing skilled nursing facilities in California they looked at 24 sniffs Nation um some of them were 24 sips Nationwide and 218 Medicare patients and the quote was that the implementation of a prospective payment system for Medicare part A beneficiaries and a 1500 cap on Therapy Services for Part B beneficiaries creates an appropriate structure to control the cost of therapy services and then they express at the same time that they believe the cost formula is being used to develop the prospective payment system and Part B cap could also be significantly compromised by the volume of medically unnecessary services so through these studies they found that there was a lot of unnecessary therapy that was being provided in the skilled nursing facilities and through these audits um they're identifying that a lot of us due to poor documentation that it was over utilization of therapy services that they just weren't medically appropriate for individuals there was one patient that they talked about that had Advanced dementia and delirium and he was being provided with five hours of therapy a day that obviously was then not medically necessary if anything harmful so you can see kind of where their head was at that they really felt that therapy was something that they needed to control so Medicare and Congress right about this time is starting to pay attention they're starting to really think about okay how much this service is costing they'd already been implemented in the hospitals the diagnostic related groups that was implemented sometime in the 80s to try and start controlling costs and so it was in the 90s that they started paying attention to Post Acute Care so we saw the passage of a bipartisan budget or a balanced budget act that required the implementation of the therapy cap on Part B services and that was implemented in 1999 so they had that fifteen hundred dollar cap on Medicare Part B many of the clinicians who are working this during this time talk about how they were laid off um that overnight they had lost their job because everyone was so concerned right about the spending um and how that cap would Implement so that was a hard cap that over you could not provide over fifteen hundred dollars of therapy and Medicare would not cover that so that was the way that they were trying to control those costs um they also had simultaneous introduction of the prospective payment system at the same time so these were their new payment models they're moving away from that cost-based reimbursement so basically just paying the facilities for whatever they were billing for and move towards models that were more similar to the drgs that had already been implemented in the hospitals another reason why post-hute care spending was really increasing is that hospitals were kind of starting to buy up as well post-cute care facilities as a way to increase their revenue since they'd already had some kind of caps put in with drgs they were trying to then make more money by buying Post Acute Care Facilities so they implemented uh PPS and sniffs with along with the MDS in 1998 they implemented it in home health with the Oasis in 2000 in Inpatient Rehab they had the irf pie in 2002 and then also implemented in ltac as well in 2002. so we did not even have these standardized assessments really um until the late 1990s early 2000s so if you think about that in terms of the grand scheme of Health Care and the fact that Medicare is implemented in 1965. the fact that it took you know 40 years before we actually start thinking about okay how are we going to collect this data and standardized care and Healthcare is really interesting and how far we've come even in the last you know 23 years so all of this is still you know the grand scheme of healthcare a fairly new experiment so along with that we finally start to see right toward back towards that rise of value-based care so in 2007 we had the implementation of the triple aim or the discussion of the triple Aim so this is one of those first major moves towards value-based care it was first developed by The Institute for healthcare Improvement in 2007 and it was founded on pursuing these three pillars at the same time so while they'd been considered separately this was the first time that they really started talking about doing all three at the same time which was improving patient Health reducing per capita cost of care so the cost of care for each person and improving the quality of care and patient experience so like we said they'd already been kind of looking at okay how can we improve population health or how can we reduce per capita costs but they hadn't thought about how they can do those at the same time the triple aim really kind of LED in towards discussions and considerations then we saw the Affordable Care Act or Obamacare passed in 2010. so the Obamacare really implemented some of those elements of the triple aim and kind of forced on the government's hand in terms of moving more towards again value-based care and re redoing a lot of the payment structures uh so it passed in 2010 and improved HealthCare coverage especially around chronic disease management it also required the implementation of cmmi or the centers for Medicare and Medicaid Innovation and also required essential health benefits which occupational therapy is one of those essential health benefits then in 2014 oh we saw the triple aim revised into the quadruple aim uh they added one more pillar to this so we still have reducing costs we still have improving population health and patient experience but then we've also added in that Healthcare team well-being so even before the most recent pandemic they were still starting to pay attention to how exactly Healthcare well-being and what how important it is in terms of sustaining a high quality Health Care system so what are the goals of value-based care right we reviewed some of the goals of volume base so here are the goals of value it's all about providing the Right Care at the right time and also to the right patient so you'll often hear either these two at the same time or all three right care to the right time to the right patient focusing really on better outcomes and decreasing spending so that cost Effectiveness looking at whether or not the service you're providing outweighs the cost overall trying to improve patient experience more care does not always equal better focusing on the idea that patient needs should be driving care um really trying to improve communication between providers right so again reducing some of those repetitive Services by improving communication so that way you don't go to your primary care doctor they run a series of tests and then a few days later you go to cardiologists and they run a few more right trying to make sure that those Physicians are communicating or even therapy is communicating between clinicians right also trying to focus on improving Health Equity and health equality so overall trying to find that balance between value and affordability and of course it's always going to be that balance it's always trying to figure out where is that sweet spot because if we cut costs if we cut spending so much then we're also going to see that decrease in value right you can't just completely cut care at the same time sometimes if you provide more care the quality doesn't always rise at the same time with it so really trying to find where that sweet spot is and it's still it's always going to be an experiment of where can we both have better quality of care or at least the same while still reducing the amount that we're spending because we know here in the U.S we have some of the highest health care costs in the world but not necessarily some of the best outcomes so how is CMS thinking about quality well they have established numerous initiatives to work towards these value-based care goals um the first of which was creating the centers for Medicare and Medicaid Innovation which we'll talk about next uh they're also phasing out fee for service payment models so they've already been making progress towards this of transitioning towards value-based payment models CMS did mention at a conference a couple years ago that they plan to eliminate all fee for service models at some point um but they have quite a bit of work left to do towards that goal obviously we're still predominantly in a fee-for-service area even our current value-based payment models do still have those fee for service elements so they still have a lot of work to do but those are things to be thinking about as our Healthcare looks to change they've also introduced the patients over paperwork initiative so this was a goal of looking at how can they reduce burden improve efficiencies and care and improve the patient experience so one of the main ways that patients over paperwork helped occupational therapy is that we used to have to collect g-codes so you'd have to report the G Codes but CMS didn't audit of their documentation and found that they're collecting all these data through g-codes but then nothing was being done with it it wasn't going to quality measures it wasn't going towards payment it wasn't really capturing good information on how a patient was performing and so they eliminated the requirement to report on those g-codes so that's an example of a time where patients over paperwork has impacted therapy and it's still something that aota and other associations use in their advocacy to try and reduce that paperwork burden and make sure that it's really effective they also have meaningful measures which is pretty similar to the patients over paperwork they're looking to identify the highest priority for Quality measurement and Improvement so making sure that the measures they're using are meaningful and really kind of trying to cut down again on the number of quality measures because sometimes having so many quality measures you're just collecting a lot of data but then you're not even able to respond to it and it ends up just being a time in a financial burden on the facilities reporting it so really looking at are the quality measures that they have useful are they measuring what they're supposed to and if not can we eliminate them the Quality Reporting program is again something we're going to get into here in a bit but this was the Quality Reporting program is basically what they call their current quality program generally so the qrp so when they establish what quality measures they want facilities to submit is underneath their Quality Reporting program and that's where you're going to find information on what what the quality measures are that are currently utilized they've also developed Financial incentives to reward adopting best practices so one of the most common ones that we see in PAC is value-based purchasing programs so right this idea of using money to incentivize people to provide better care so undervalue-based purchasing programs you receive a financial bonus if you provide higher quality care or you receive a penalty if you provide low quality care we also see something similar in mips for outpatient now CMS does have a National Quality strategy so they have eight priorities that they've established they just redid their priorities in 2012. they're very similar to the priorities that they had previously but they have added in a couple new ones as a result of the pandemic so they're really looking at how they can embed quality into the care Journey so CMS has really put an increased emphasis on not just thinking of each individual section as its own Healthcare entity but thinking about how the patient is moving through those versus looking at each setting specifically right so really trying to think about that Continuum of Care how is the patient progressing how are they moving along they added in this one in 2022 advancing Health Equity especially based on some of the inequities that the covid-19 pandemic highlighted we knew that those inequities were there but CMS has put a much stronger focus into addressing them with some of the new items that they've added to the assessments right around literacy Transportation race and ethnicity that's all part of their National Quality strategy of trying to improve Equity because their opinion is if they can measure it then they can change it but if we don't have any data on it it's hard to know where to apply the right intervention they're also looking to promote safety and ideally achieve zero preventable harm they want to Foster engagement to improve quality and build trust so really trying to build that engagement between patients and caregivers they want to strengthen resiliency in the Health Care system this is another new one that they added after the pandemic obviously for because of some of the issues that we've had recently so really trying to look at how can we improve our health care System how it functions how can we reduce burnout so these are all things that CMS is actively looking into they're really trying to embrace that digital age and improving those Innovations and technology so trying to move away from paper chart audits and claims and moving more into integration and advancement of Technology Through Fire and interoperability those sorts of things so CMS is really trying to modernize the care that they provide and how they assess quality and then again increasing quality measurement alignment to try and promote that coordination of care so trying to instead of having you know measures for Sniff and measures for home health and measures for the hospital how can we kind of have one standardized list of quality measures that are measuring what we want them to um without also providing overdue burden so because it's difficult then to compare if every single setting has different quality measures it's different than even to compare the settings that's just a nice graphic of CMS strategic pillars they're very similar to the Quality strategy um but just kind of another visual representation of how they're thinking about quality they also have what they've recently announced is the universal foundations so this was actually just announced a few months ago it's still very much in the early stages uh but they're looking to at what quality measures they can utilize to follow a patient's lifespan so all the way from Pediatrics into adults there are some key areas that they've identified such as Wellness chronic conditions behavioral health care coordination so basically that measure is readmissions hospital readmissions um the idea being right if you have high quality care coordination then there shouldn't have to be a readmission and then the person-centered care which they're using caps currently and then Health Equity which they're utilizing some of those new items on the admission assessments for Equity so those are the key areas that they've identified again this is not something that they're necessarily currently implementing they're still requesting feedback they're doing educational webinars about but this is something that's coming down the line of those Universal Foundation right so along with aligning those quality measures they do have new new Health Equity and social determinants of Health that they're collecting you've heard me reference a few times so they have added these elements to um The Oasis and it's coming to the MDS in October it's already in the earth Pine LCDs but these items are race ethnicity Transportation preferred language the need for an interpreter social isolation and health literacy so these are all questions that obviously Falls very in line with what we assess as therapy practitioners but by collecting this data they're going to hopefully be able to provide some interventions to address those now on to the CMS Innovation Center or also known as cmmi so again this was founded in 2012 as required as part of the Affordable Care Act and their main job is to produce alternative payment models or apms so they're really kind of an experimental area uh so they can these can apply to a specific condition to a care episode or a population it really depends on what they're looking at but some examples of alternative payment models that have become popular our accountable care organizations that's a huge one are acos right this idea of how can we have these groups and systems collaborate and be responsible for care so they kind of provide capitated payments and it's where the primary care doctor has worked with the Specialists and they take responsibility for that individual patient's care so those are very popular we have the comprehensive joint replacement program so or cjr this is where again it's a bundled payment based on a patient's clinical condition for their care episode so if they have a total joint replacement CMS essentially says okay we'll give you you know let's say thirty thousand dollars and it's up to you how you spend that so that's why we've seen a reduction a lot of times in therapy utilization especially in like hip replacements and really trying to look at what's absolutely necessary to provide because they're no longer longer again getting paid for every service that they provide it's kind of that bundled payment hospital at home is another really popular one especially during the pandemic and is continuing on so this idea where you provide Hospital level care in a patient's home start out as an experiment and has been growing value-based purchasing again also is something that was trialled by cmmi so we'll talk about it for Home Health in a little bit uh but they trialed it first in nine states found that it was both cost effective it saved money improved patient care and so then they implemented it nationwide so it's always interesting to look at CM uh The Innovation Center's website and see what kind of payment models they're testing out a lot of them have to do with post-acute care and therapy this is again another one of their Graphics around their quality initiatives so very against similar to what CMS has overall they're looking at that Health System to achieve Equitable outcomes through quality affordable and person-centered care they're then also looking at how they can drive accountable care so they're really putting an emphasis on how can clinicians start taking responsibility for care instead of saying it's the patient's problem how can they be held you know responsible for managing that patient's health looking at Health Equity supporting Innovation affordability and then partnering to achieve system transformation so very similar to what CMS is focusing on but with some small tweaks to fit the Innovation Center now here's some more details in the Quality Reporting program because we're going to dive into some of the quality measures for Post Acute Care so data is used to assure Quality Health Care for Medicare beneficiaries these measures are developed again in collaboration with CMS and nqf and other organizations so like I said Battelle is stepping into that um that contract but nqf is primarily the one that you're still going to see is those nqf endorsed measures some of their initiatives are quality improvement pay for reporting public reporting so right on care compare and value-based purchasing program the data for Quality Reporting program is primarily collected through claims assessment instruments chart abstractions and Registries so this is also something that they're trying to standardize and move more into those electronic quality measures where they're collecting the information instead of having you to submit a claim and then upload it to these dashboards that it would just be able to automatically pull them from the claims that are submitted through this fire language so again we're quite a few years away from that actually occurring but that's something that they're trying to work towards and these quality measures are often publicly reported through care compare all right any questions before we could dive into Post Acute Care okay so post-acute care um it is a designated section of care facilities under CMS they consider post-acute care to be consistent of the long-term care hospitals or LTX Inpatient Rehab facilities or Earth's skilled nursing facilities or sniffs and Home Health so Within These settings we do have some standardized quality measurements and one of the main ones is potentially avoidable events you may also hear these called potentially preventable events the idea is that if we have high quality of care and better access to care that these expensive Health Care events could be prevented so they are utilized in All post-cute Care settings as required by the improving Medicare Post Acute Care transformation act or impact Act of 2014 the impact Act is responsible for a significant amount of change in reimbursement pdpm is from the impact Act pdgm is from the impact act as well as the unified Post Acute Care payment model which we'll talk about at the end again stemming from requirements of the impact Act so what are these potentially avoidable events um so these are quality measures that they look at the all-conditioned risk adjusted potentially preventable hospital readmissions so your readmission rates then they have a second one based on 30-day post-discharge readmission measures so they have two readmission measures that they check in All post-key Care settings we then have skin integrity or changes to skin integrity so basically your skin breakdown whether or not someone has new pressure sores um or skin issues from when they were admitted to when they discharged the incidence of major fall and then also Healthcare Associated infections and you'll hear these often called Hospital acquired infections in the hospital um so they have very similar measures around many of these items but after the hospital they're called Health Care Associated infections so we have caudi which is the catheter Associated UTI C diff MRSA surgical site infections and then central line Associated bloodstream infection so if you've ever wondered why facilities are so eager to remove indwelling catheters one they're associated with higher risk of UTI but also because they are scored on the number of catheter Associated UTIs that they have in their patient population so if you don't have an indwelling catheter it's hard to get a Coty so we do have some standardization right under the impact act they are requiring to improve standardization of care and we do have some standardization between ltch irf and sniff so ltech Earth and sniff have the exact same quality measures across the board and it's actually a fairly decent short list so we have individual with a care plan addressing function this is basically whether or not section GG was completed and scored um I do believe that this is a quality measurement measure that is eventually being phased out as it's capped out but it's currently still in effect a percent of residents with one or more major Falls or major injury right we're going back to those hospital or those Health Care Associated issues uh drug or potentially preventable issues there we go the drug regimen review and follow-ups and medication management changes to skin integrity the main ones that impact therapy are these change in self-care change in Mobility discharge self-care and discharge Mobility score these are based on 10 section GG items so section GG right being our standardized assessment in cms.com payments that score both self-care and Mobility we also have transfer of health information to Patient providers so actually trying to track how information is being communicated so is it being sent through fax was it handed to the patient you know via did they print it out was it sent through an EMR and actually tracking whether or not that information is being handed off so when the patient discharges from a sniff are they being given a copy of their medication list and is that copy of their medications also being sent to the Home Health agency that's taking over their care this will be implemented as of October 1st of 23 in skilled nursing facilities so this year we also have discharged a community so really trying to incentivize them to go home so this is often why Inpatient Rehab facilities do not want patients to discharge to sniff because it would go against this quality measure they're really trying to get them into home so that could be assisted living it could be independent living it could be into their independent home it just means not discharging into an institution like sniper the hospital and then again looking at those Hospital associate Health Care Associated infections these are the 10 section GG items that are utilized in the self-care and Mobility score now if you're wondering why the self-care items are so short because it's only three right eating oral hygiene and toileting hygiene it's because ltac has a shorter version of section GG so these are the items that overlap aota and occupational therapy practitioners have been advocating to CMS to increase the number of items in the self-care item as quality measure because can we really say someone's function has improved and we're only looking at eating oral hygiene and toileting it's not even looking at dressing or bathing but because of that lack of overlap and ltac it makes it difficult to have standardized quality measures and then in Mobility we have seven items you're set to lying lying to sitting on side of bed sit to stand chair to bed transfers toilet transfers and these are walk or wheel 50 feet with two turns or walk or wheel 150 feet so if someone's normally a wheelchair user these would be assessed with wheelchairs now in home health they for whatever reason still have their own quality measures um I did recently ask someone who works with CMS why Home Health has their own quality measures and they said they weren't sure and asked if they had any plans to transition them and they said they also were not sure so we'll see uh they have but these again are very similar where they're really heavily focused on again function so Improvement in bathing ability to get in and out of bed to ambulate take medications correctly right there are a lot of these at therapy especially occupational therapy can have a really positive impact on and so these are really great opportunities to advocate for our care we have timely initiation of care and this is focused on making sure that you get out within the first 48 hours which is something unique to Home Health again we see that transfer of health information so we do have some standardization discharged to community um right with an admission and discharge functional assessment drug regimen review those total normalized composite changes so there are some standardization but not full standardization and these items these total normalized composite change in mobility and self-care these are for value-based purchasing which I do have that list later on so how does value-based care impact us as rehab professionals so payments are focused more on patient factors versus service provision so we saw the elimination of drug levels in 2019 the elimination of therapy thresholds in home health uh right because there's a lot of concern over how those are really based on volume so the more therapy that was provided the more money that they would make um so we saw those fully eliminated in the last couple years we also had change in expectations from payers and employers right how we are paid for our services influences the type of services that we are supposed to be providing so if they are reimbursed based on value then your employer is going to want you to produce a value of care versus if we're reimbursed based on volume they're going to want volume so it really changed how they view therapy so an increased emphasis on function and Mobility so we had self-care and Mobility quality measures implemented section GG was fully implemented and then we do have functional level payment factors in Earth Sniff and Home Health there's also opportunities for therapy to support the care team through accurate scoring on admission and discharge assessments because of these new especially functional level payment factors therapy can have a big impact on accurate scoring which can lead to better and more accurate reimbursement because if a patient is being scored routinely as too functional then the facility is not going to receive accurate reimbursement to cover the services that the patient needs CMS does reimburse more for patients with a higher functional impairment because patients who are not moving away around as well generally need more services right just like patients with more comorbidities also generally need more services so the reimbursement is adjusted in order to try and accommodate that but if the data isn't accurate if the scoring is not accurate the reimbursement rates aren't going to be accurate most likely you're probably participating in some sort of alternative payment model even if you don't know it they are so prevalent and across the board like even in home health right the value-based purchasing is part of some of those apms and then also we can really make sure that we're engaging in providing Innovative services so there is some freedom in these value-based purchasing models that opens us up to being able to be a little more Innovative with our care so therapy reimbursement we are predominantly now in value-based care models so in acute care uh inpatient and long-term care hospitals we have diagnostic related groups or drgs so this is under Medicare part A we have Inpatient Rehab facilities sniff under pdpm and Home Health under pdgm are all considered value-based care volume-based care models are pretty much anywhere that's still billing Medicare Part B because it is still very fee for service the more minutes of therapy provided the more money you make so your home mods outpatient long-term care et cetera all Medicare Part B still pretty much fee for service unless you're part of those alternative payment models so for long-term care hospitals we have Medicare Part A's who covers long-term care and it's reimbursed under the ltch PPS or the ltch prospective payment system uh it has for its Mission assessment it has the long-term care hospital continuity assessment record and evaluation or care data set or LCDs we have the Medicare severity long-term care diagnosis Related Group so again very similar to acute care it's still a reimbursement or a drg there are a couple different separate calculations that make them a little bit different but generally very similar to acute care and ltch the Medicare requires that the hospital has an average length of stay greater than 25 days so these are going to be your patients who are pretty seriously ill so they're going to generally have multiple comorbidities often they're going to be on ventilators they're really not mobilizing well which is why they have that decreased section GG form because they're generally just not able to complete many of the things that are on there so Medicare does actually require that pretty extended length of stay so they have to be there on average 25 days now there are payment adjustments just like in all the settings based on location area wages and patient characteristics they also have short stay outliers as well as high cost outliers for Inpatient Rehab it's also reimbursed under Medicare part A and the Inpatient Rehab perspective payment system or Earth PPS the admission assessment or the standardized assessment required by CMS is the Inpatient Rehab Facility patient assessment instrument or the Earth pie so this data collected helps classify these patients into groups based on their clinical characteristics and anticipated needs so it's prospective payment because you're getting that payment in anticipation of what the patient is going to require so Medicare does require for as part of their reimbursement model for irfs that it has three hours the patient receives three hours of therapy at least five days a week so Earth is where it's kind of interesting where it is still considered a value-based care model but it does still have that fee for service element because it is requiring a minimum of three hours of therapy so that still has some of that volume involved there also must be at least two therapy disciplines so you can't just have OT or PT or speech you have to have some combination of the three therapies or all three if you only need OT or you only need PT or you can only tolerate an hour of therapy a day you are not eligible to have coverage for Inpatient Rehab under Medicare part A patients do have a deductible and co-insurance for the benefit period for Inpatient Rehab but it's lumped in with their acute care so their Hospital deductible and then they also have a 60 rule so this is another thing where if you've ever had a patient you're trying to get them to Earth and they were told they don't have a qualifying diagnosis this is often what they're referring to generally it's the diagnosis that you would expect right that need a lot of therapy so your stroke your spinal cord injury multi-traumas femur fractures brain injuries right so things that you would kind of anticipate diagnosing to anticipate need those three hours of therapy a day so sixty percent of patients admitted to the Earth must meet these one of these 13 diagnoses now skilled nursing facilities there is a lot of concern over Fraud and Abuse all you have to do is peruse the office of Inspector General's website to see a lot of lawsuits with skilled nursing facilities especially under the rug system so they had something that was called hugging the rug right so we had these minute thresholds and based on where the thresholds were you would see that there would be a lot of patients right at that threshold and then it would drop off and a lot more patients at the next threshold and then it would drop off so there really wasn't any patients receiving the amount of therapy in between because there wasn't incentive so that's why they called it hugging the rug under the Skilled Nursing Facility PPS or the prospective payment system again right we now have what it's more commonly called the patient-driven payment model so the sniff PPS and pdpm are basically one and the same but they're more commonly called the patient-driven payment model now this was implemented October 1st of 2019 so we had a little bit of time before the pandemic started how payment is now calculated so there used to be only a few different categories but now there's I believe over a thousand different combinations so you have patient characteristics that are identified on the minimum data set or MDS at admission so the same thing as like the Earth Pi we have the mdfs and sniff there is an OT payment component which we'll get into it's based on their clinical category and their functional score so those same 10 section GG items and they must receive either daily skilled nursing or five days a week of skilled therapy they must also have an inpatient Hospital stay prior to being admitted to the sniff so that's that three midnight Rule now we did see a waiver for that under the public health emergency that waiver has since expired so it is now a requirement again that you have a three midnight stay however there are some acos that do have waivers for that so if you work for one of those acos your patients can still go to sniff without an inpatient Hospital stay so unfortunately though for most patients if they are on observation in the hospital they are not able to go to sniff sniff does have a value-based purchasing program so the law has authorized CMS to expand quality measures under value-based purchasing and they've also have technical expert panels that discuss how to evaluate volume or value-based purchasing the program has changed a lot I'll admit that it's not someone of my strong suits of knowing much about the sniff value base purchasing but it's something to know that is there right so that again that incentive system of the higher quality care they provide theoretically they can receive then a payment bonus versus they're providing really low quality care they can receive a payment penalty so here's more details on how therapy is paid for in skilled nursing facilities so even though pdpm kind of functions similarly to this idea of a bundle payment model it's technically a variable per diem payment system and what this means is that a steel nursing facility receives a payment for each day that the patient is in that facility so it's not just kind of a lump sum for the care they depending on how long their stay is depends how much money they receive so and it varies from day to day so for therapy and nursing the facility receives the same payment for the first 20 days and then the payment decreases every seven days after that so let's say for the first 20 days the patient receives or the sniff receives you know ten dollars a day obviously it's more than that but then starting after that it goes down to eight goes down to six so every seven days after that the reimbursement goes down obviously this aligns then too with how Medicare part A covers 100 of the first 20 days and then 80 percent of the last 180 um but this is also why a skilled nursing facilities try and get patients moving out and why then therapists also feel pressure to decrease the amount of time they spend with patients as they surpass those 20 days because the reimbursement is going down the reason reimbursement goes down so at least as far as CMS has Justified it is that a patient should be making Improvement right so they shouldn't receive shouldn't need the same level of care that they received at admission at discharge theoretically assuming that value-based care is being provided so reimbursement then go goes down with that non-therapy ancillary is another component of the pdpm payment and this is reimbursed more up front because this is prescription drugs so the reason this is paid up front is because right when you go to the pharmacy you normally collect you know 60 days of pills or 30 days of pills you wouldn't pay per pill per day so this is to make sure that skilled nursing facilities are still incentivized to take patients with prescription drugs um and make sure that they're still fully reimbursed for those prescriptions so if the patient discharges and they leave with 10 pills this sniff has already still gotten paid for that prescription so OT and PT they have their own case mix they're the same calculated the same aota did advocate for OTS to be separate from pts but unfortunately the claims data that just wasn't there to support them being different so the case mix index for OT and PT is based on the primary reason for therapy so that therapy diagnosis and also the GG items which I've had them coming up again but it's those same 10. the speech therapy case mix index is based on the primary reason for speech so it's a little more complicated to calculate it's based on the patient's cognitive status whether or not they have a swallowing disorder or mechanically altered diet and other related speech comorbidities so the way that CMS kind of visualizes it is they have like little dots that kind of grow and Shrink so if the OT and PT you know for one patient their case mix index might show that they need more therapy versus speech or like the nursing might be bigger on another so it's really supposed to kind of adjust based on those patient needs so again this is just a reminder that these are the section GG items that are utilized for that case mix index those three eating items and those seven um Mobility items so the same as the quality measures again another element in pdpm which I think pdpm is one of the more complicated payment models because it has so many different elements um there is a 25 limit on concurrent and group therapy per discipline now technically there is not a formalized penalty in place for violating it but CMS is keeping track of facilities that do violate the group and concurrent therapy requirement especially routinely so even though there's not currently a penalty it doesn't mean there won't be one in the future so there's a 20 25 limit and this is per discipline so you can't have 30 big group and concurrent for PT and have it balance out with only 20 for OT it's per discipline CMS defines a group as two to six patients doing the same or similar activities concurrent being as two patients doing different activities and it's always important to remember that it is not required under pdpm there is nothing in the regulation that says that all patients must receive group and concurrent therapy in fact it is the opposite CMS still indicates that individual therapy should be the primary mode of therapy and that is up to the therapist discretion to determine when and if group and concurrent interventions are appropriate so the big question how has pdpm impacted therapy and outcomes well there was a study that was completed after the implementation of pdpm and this is the association between patient-driven payment model and therapy utilization and outcomes in U.S skilled nursing facilities this actually mirrors a very similar um study that was done before pdpm that looked at Medicare and Medicare Advantage patients and they found very similar outcomes so this is a cross-sectional study that looked at over 200 000 patients that had a hip fracture so it's important to kind of know with this study that it is a patient you know the hip fracture population is generally going to be a population that needs less therapy than someone who's had a stroke or other more complex conditions but what they found is that patients that were admitted post pdpm received about 13 fewer therapy minutes on average than those before pdpm so it did show a behavior change as a result of reimbursement in terms of decreased therapy which I think if you talk to any therapist that's been working in a sniff anecdotally they would tell you that this is accurate that there's definitely been a decline in therapy use however with that decline in therapy utilization the likelihood of re-hospitalization and functional scores did not change so basically what this is saying is that even though therapy went down the quality of care did not decrease the outcome terms of care did not decrease so this is what what is indicating through this research is that there was an overabundance or over provision of therapy that did not also then increase the quality of care now obviously this information is only as accurate as the data that is submitted so if people are not scoring those functional scores correctly um that can definitely influence the study but overall it confirmed what we already knew is that there was an over provision of care um pre-pdpm now in home health we have another fun complex payment model we have the home health prospective payment system which is again more commonly called the patient-driven groupings model pdgm versus pdpm so pdgm was implemented January 1st of 2020 so just before everything shut down so made it a really difficult time for home health agencies under Home Health we have the outcomes and assessment information set for the Oasis which is similar right to the MDS and the Earth pi um the pdgm did eliminate therapy thresholds so kind of like the rugs there was therapy thresholds where if you provided up to six visits you made a certain amount if you provided like I want to say it was like 6 and 14 you got x amount of dollars and then six to or 14 to 20 you got that much but then Medicare didn't pay for anything over 20 visits in an episode so they eliminated therapy thresholds because I felt that that was too volume based and they implemented what they call Home Health Resource groups or herds and there are over 400 options so 400 combinations of reimbursement I believe the exact number is like 432 but there are four main uh categories that go into considering the herg which is the admission source and Mission timing so they look at Community versus institution and early versus late the clinical category so their primary diagnosis why are they receiving Home Health Services the functional level something that therapy can heavily influence right in terms of accurate scoring and comorbidities now the functional level is different from other settings where an ltat or an earth pi and sniff right it's based on Section GG in home health it's based off of the M 1800 numbers and same thing for their quality measures in ltech Earth and sniff their quality measures are based on Section GG and Home Health they're based on the m1800 numbers or some of the Oasis items and they do not utilize section GG for payment or quality in home health so the functional level is determined by the m1800 items which if you're not familiar with the Oasis those are the ADL items as well as the hospital readmission risk and so there are three categories there's low medium and high and patients with a low functional impairment receive less funding funding versus if they have a high functional impairment you get more funding to accommodate needing more care so that's why accurate scoring especially on admission is absolutely critical now some updates to home health is that OT continues to not be a qualifying discipline for the initial order but we are a qualifying discipline for recertification what this means is that if a patient wants Home Health Services Under part A they do have to have another discipline on there so either PT speech or nursing but aota is just about to introduce new legislation called The Home Health accessibility act uh we already have sponsors lined up and so we're just waiting for it to be introduced and that legislation would add occupational therapy as a qualifying discipline so make sure to contact your legislators and ask them to pass that bill we do now have the ability to complete the start of care Oasis and therapy only cases this is permanent so under the public health emergency we were able to initiate the start of care in any case even when nursing was available but that has expired again when the public health emergency expired on May 11th but it is permanently into the regulation that we are able to do it in therapy only cases making us equal with PT and speech therapy so we had to get that step done first before we could ask for the qualifying discipline so it's exciting now to see that advocacy ongoing so how does pdpm implement or impacted therapy or pdgm so there has been a decline in therapy visits I started in calendar year 2019 when therapy threshold removal was finalized so in 2019 CMS announced that they would be moving to pdgm and so then home health agencies were starting to prepare for pdgm to be fully implemented in 2020. so what this table is that is actually from the home health proposed rule of 2023 so they actually went through the data and they looked at they did a look back of how many visits on average patients are receiving now remember what I said is that previously if you looked back right there receiving an average of like 73 visits over the full episode if you look here they're obviously receiving significantly less now these are 30 days so right because under pdgm it switched to the 30-day payment instead of 60 which is why these are simulated they probably just took like how many they received in 60 days and approximately divided them in half but if you look at therapy definitely decrease so OT went from on average 1.2 visits 1.02 visits in 2018 down to 0.77 visits in 2021 um now again there's lots of patients that don't receive therapy so on average patients do receive more than just one visit of OT but this is kind of out of all the cases but you can see overall that the number of visits also declined from 9.86 to 8.22 and the reason CMS pulled out this table was to show that not only did um they were trying to show that the reduce reduction in therapy visits and the reduction in Services was not a result only of the pandemic so because we start to see this Behavior change in 2019 that it's showing that Home Health agencies were starting to prepare for the implementation of pdgm and started reducing care already so this was so CMS felt comfortable concluding that the behavior change in CMS or in home health was as a result of pdgm and not necessarily a result of pandemic obviously it had an impact but they felt that it was pretty clear the correlation so some food for thought right how does what does this mean for therapy well we used to be a revenue producer now we are considered a direct cost so we used to be firmly in the green right especially under rug levels under feet for service with therapy thresholds more therapy meant more money so they wanted more therapists to be there now we are seeing a direct cost so instead of seeing adding to income we're seeing as being taken away as a line item so facilities are really questioning why should they pay an OT or PT to do something that they think an aid can do or an activity director could do right why should I pay an occupational therapist 50 40 50 an hour when I could pay a tech 15 an hour if the patient is going to get showered either way what is it that OT is doing that makes them two three four times as expensive as an aid when at the end of the day the patient still receives a shower the patient still gets dressed the patient's happy are they the same quality we know they're different but how do we explain that to someone else so really making sure and questioning ourselves you know is what I'm doing high value is it worth what I'm getting paid and also really questioning and thinking about were we truly providing value-based care before payment changed the data would say no right if we look at some of PD some of that changed with pdpm and showing that even though there's a 13 decrease in therapy we still didn't see a change in functional outcomes and that has been seen in other alternative payment models that they've been looking at that there has been a decrease in post-acute care utilization but we're not seeing changes in mortality we're not seeing changes in patient satisfaction so what does that mean for therapy are we actually providing value and what can we do to make sure that we are providing value and again kind of thinking about you know what role did we play in driving up care costs and so we have to take some of that historical responsibility as well in if we weren't making sure that we were providing high value care and we were just providing more and more therapy what role did we play in kind of putting in our own um our own parameters because obviously they felt that spending was out of control and felt the need to put in those caps so on that note what is the future of value-based care what's coming up so for the future of value-based care we're going to see the continued expansion of value-based care models Right value-based Care is not going away it is only going to continue to grow personally I think this is a great opportunity for occupational therapy especially because we're so focused on value on function on mobility and really improving their overall health then I think value-based care overall can be really positive for us especially because of our scope of practice is so broad that we can be really flexible and Innovative as these payment models continue to get broader which allows for more innovation we're also going to see the development of unified Post Acute Care payment system and I have some more slides on that it's a really interesting the way that they're thinking about the unified pack payment that's part of the impact act that's requiring unified Post Acute Care we're going to again continue to see reduction in fee for service so this is time to start thinking about what will this look like for Medicare Part B right what would it look like for outpatient would it be bundled payments based on the evaluation code that we pick you know what exactly would CMS try to consider when looking at a bundled payment for Part B or is it going to be more episodic like we see with the comprehensive drawing replacement program so things to kind of think about and prepare for especially as we&am