August 28, 2012 Columns

ASHA Outcomes Measurement: A Model for Medicare

ASHA recently presented its National Outcomes Measurement System (NOMS) and the potential use of NOMS data to define episodes of care to a federal panel investigating payment reform for Medicare outpatient therapy services.

The Medicare Payment Advisory Commission (MedPAC)—an independent congressional agency that advises Congress on Medicare payment, access to care, quality of care, and other issues—invited ASHA to present the information. Congress mandated MedPAC to recommend a new Medicare payment system for outpatient therapy (speech-language treatment, physical therapy, and occupational therapy) that reflects individual acuity, condition, and therapy needs of the patient.

Need for Reform

The MedPAC report is part of a broader congressional effort to reform the current system, which caps the amount of services each Medicare beneficiary may receive in a year and forces Congress to legislate an exceptions process for beneficiaries who need services that exceed that amount. Congress also is responding to increased use of therapy services disproportionate to the number of beneficiaries, and to the perception of increased fraud and abuse.

The Middle Class Tax Relief and Job Creation Act passed in February mandates MedPAC to make recommendations for a payment system that reflects individual acuity, condition, and therapy needs of the patient. The Centers for Medicare and Medicaid Services included a system for reporting outcomes on claim forms in its proposed 2013 Medicare Physician Fee Schedule (see "Medicare Manual Review Rules to Affect Providers"); the data would be used to inform the creation of an alternative payment system.


As part of its research into alternative payment methods, MedPAC invited ASHA to present the NOMS system at an Aug. 13 meeting. ASHA submitted a model that uses NOMS data to stratify clients into clinical cohorts and calculates the amount of speech-language treatment needed for successful episodes of care.

NOMS data collected since 1998 have demonstrated that three factors—patient complexity, severity, and diagnosis—best explain variations in the amount of treatment needed to make meaningful clinical progress.

  • Diagnosis refers to the medical and speech-language conditions of the patient.
  • Patient complexity refers to the number of disorder-specific NOMS Functional Communication Measures (FCMs)—motor speech, spoken language expression, spoken language comprehension, reading, writing, voice, swallowing, memory, attention, problem solving, and pragmatics—involved in each client's treatment plan, and the extent to which those FCMs are spread across different domains of speech-language treatment (e.g., cognition, speech, language, swallowing).
  • Severity is measured by the client's score on the FCMs at the time of admission to speech-language care.

After a patient is stratified into cohorts based on these factors, NOMS data can be used to calculate the amount of treatment typically associated with similar clients' successful episodes of care (see sidebar on episode payment below). This amount would be used to set reimbursement rates based on this specific combination of clinical characteristics and treatment outcomes.

MedPAC's public meeting on outpatient therapy reform is scheduled for Sept. 6–7. The final MedPAC report, although due July 1, 2013, is expected to be released this fall to address the pressing need for congressional action on the therapy cap and exceptions process.

In addition to inviting ASHA to present NOMS information, MedPAC staff requested ASHA representation on a one-time, in-person panel meeting to discuss Medicare outpatient payment policy issues. Nancy Swigert, 1999 ASHA president and director of speech-language pathology and respiratory care at Central Baptist Hospital in Lexington, Kentucky, represented ASHA on the July 31 panel, which included representatives from physical and occupational therapy and researchers in functional outcome measures.

As payment reform and functional outcome measures continue to be the center of discussion, speech-language pathologists can prepare by becoming familiar with outcome measurement tools such as NOMS.

Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at

Rob Mullen, MPH, director of the National Center for Evidence-Based Practice in Communication Disorders, can be reached at

cite as: Satterfield, L.  & Mullen, R. (2012, August 28). ASHA Outcomes Measurement: A Model for Medicare. The ASHA Leader.


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