Six Years Under PDPM and PDGM: What SLPs Need to Know About These Payment Systems and How to Improve Them

The Centers for Medicare & Medicaid Services (CMS) implemented the Patient Driven Payment Model (PDPM) in 2019 and the Patient Driven Groupings Model (PDGM) in 2020. These models dramatically changed Medicare payment for therapy services provided in skilled nursing facilities (SNFs) and home health settings, transitioning from systems paying for the volume of services provided to patient clinical characteristics. Then the COVID-19 pandemic triggered a second fundamental shift in the way care is delivered to some of the most vulnerable patients.

CMS, clinicians, and payers needed time to understand how these new models and the pandemic impacted payment systems and changes in patient demographics. Six years post implementation, ASHA has overhauled the member education resources we developed in 2019. Our goal is to help SLPs working in these settings understand what these systems are, how to ensure their personal compliance, and how they can support their employers and patients in ways that reinforce their own value as clinicians.

ASHA also believes in advocating for improvements to PDPM and PDGM—and SLPs are uniquely qualified for this task. Misinformation and misunderstandings about how these payment systems work, as well as administrative mandates designed to maximize profit and minimize risk, can make this kind of advocacy difficult. But SLPs and their employers can convince CMS to update these systems by engaging in compliance, quality improvement, and accurate, comprehensive coding on the Outcome and Assessment Information Set (OASIS) and the Minimum Data Set (MDS) and on claims.

Patient Driven Payment Model

PDPM transitioned payment from a focus on the minutes of therapy delivered to patient characteristics that typically align with therapy provision, including speech-language pathology services. An ASHA member served on a technical expert panel to help drive the development of PDPM in ways that reflected the clinical realities on the ground for SLPs in SNFs. Changes achieved in the early development of PDPM included exemption of speech-language pathology services from the variable per diem payment reduction applied to physical and occupational therapy services and payment for comorbidities, which are not applied to other therapy services.

Before PDPM was implemented, ASHA recognized that one of the primary challenges our members working in SNFs would face would be layoffs and shifts in how their employers expected them to deliver services. Such a fundamental shift in the payment system also created a lot of confusion and uncertainty. So we developed (and recently revamped) several resources:

• A webpage that explains what PDPM is, how it was developed, and how service delivery might change (for better or worse) with the new payment system
• Joint resources developed with the American Physical Therapy Association and the American Occupational Therapy Association that explain the importance of upholding clinical judgment [PDF] regardless of how services are paid and reporting violations [PDF] of federal laws and regulations when appropriate
• Resources designed to bust the myths of the new payment systems and arm SLPs with the information necessary to reinforce their value in skilled nursing.

We’re currently monitoring our members’ experiences in SNFs since PDPM’s implementation and trends identified through the CMS Research Data Assistance Center to ensure our resources continue to meet our members’ needs and drive improvements to the payment systems themselves.

ASHA has also developed several new resources—including a patient fact sheet [PDF] SLPs can share with their patients to help them understand how PDPM works and how to advocate for themselves as well as a resource that demonstrates the role of SLPs in ensuring compliance with the survey and certification process. We are also working on creative ways to share this information with members, including social media campaigns and a presentation at this year’s ASHA Convention.

ASHA also recently held a day-long meeting with SNF industry stakeholders, including professional and trade organizations and leadership of several large SNF and contract therapy companies. We shared our resources to reinforce the broad value SLPs provide in SNFs and identified areas of improvement that we plan to jointly advocate on with CMS. Moving forward, the meeting participants agreed to meet quarterly to advance the work identified at the meeting.

Patient Driven Groupings Model

PDGM was implemented on January 1, 2020. The federal public health emergency for COVID-19 was declared about a month later. Because PDGM didn’t really get off the ground before the world shut down, it’s challenging to determine how well it’s been working. While ASHA served on a panel in the development of PDGM, many of the changes we advocated for were not adopted.
PDGM is similar to PDPM in many ways. It’s also based on patient characteristics and not the number of therapy visits delivered. Many of the challenges SLPs faced in skilled nursing, such as layoffs and changes in service delivery patterns, were also seen in home health—meaning many of the resources developed for PDGM were similar to those developed for PDPM.

Knowing the facts of the home health payment system and the value SLPs can bring to this setting and their patients is an important way to ensure SLPs remain members of interdisciplinary care teams and maintain access to care for patients. SLPs serve as both clinicians and advocates for clinical judgment [PDF] over administrative mandates, report violations [PDF] of federal laws and regulations, and partner with their patients in advocacy [PDF].

Give ASHA Your Feedback

ASHA is determining how best to engage the home health industry directly to support our members working in this setting. If you work in home health, please feel free to share your experiences with us via this confidential feedback form.