The Medicare Patient-Driven Payment Model (PDPM) in Skilled Nursing Facilities

ASHA, APTA, AOTA, and CMS held a free webinar "Therapy Services After Payment Changes in SNFs: How to Show Your Value Within PDPM" to help you prepare for the transition.

The Medicare Patient-Driven Payment Model (PDPM) is a major overhaul to the current skilled nursing facility (SNF) prospective payment system (PPS). It is designed to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives. This revised payment methodology is driven by the patient's clinical characteristics rather than the number of therapy minutes provided. Other significant elements of the PDPM include the use of Section O of the Minimum Data Set (MDS) to track the delivery of therapy services and a limitation on the use of group and concurrent therapy [PDF] combined at 25% of all therapy provided to the patient, per discipline. PDPM will be implemented on October 1, 2019.

ASHA actively engaged in the development of the PDPM through formal written comments, meetings with CMS staff, and speech-language pathology member representation on technical expert panels to ensure a move to such a payment model represents appropriate clinical practice.

See: CMS Finalizes Dramatic Overhaul of SNF PPS Effective October 1, 2019

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Speech-Language Pathology Case-Mix Factors

Under the PDPM, payment for patients with speech-language pathology needs will be determined by the presence of the following five case-mix factors:

  1. the patient's primary diagnosis,
  2. the presence of one or more of twelve comorbidities (aphasia; CVA, TIA, or stroke; hemiplegia or hemiparesis; TBI; tracheostomy care while a resident; ventilator or respirator while a resident; laryngeal cancer; apraxia; dysphagia; ALS; oral cancers; speech and language deficits)
  3. a mechanically altered diet,
  4. a swallowing disorder, and/or
  5. a cognitive impairment.

For example, a SNF resident who meets the criteria for all five factors would get a higher speech-language pathology payment than a resident with only one or two of these case-mix factors. 

See: CMS Fact Sheet on PDPM Patient Classification [PDF]

Speech-Language Pathology Diagnosis Codes

The list of diagnosis codes (International Classification of Diseases or ICD) that trigger a speech-language pathology payment and the speech-language pathology comorbidity payment (when an applicable comorbidity is present) is available on the CMS website (see "PDPM ICD-10 Mappings"). The current list of ICD-10 codes relevant to speech-language pathology services is limited because the historical claims data CMS used to develop PDPM did not include enough information associated with cognitive, communication, and swallowing disorders. However, the list will be modified over time, as CMS refines the payment system. Moving forward, it is important for SLPs and SNFs to accurately and comprehensively include the specific treating diagnosis codes (in addition to the medical diagnoses) that describe cognitive, communication, and swallowing disorders on claims. This will help ASHA to advocate for future changes to PDPM.

Payment for Speech-Language Pathology Services is Unique

It is also important to note that payment for speech-language pathology services is different from payment for occupational and physical therapy (OT and PT). For example, ASHA successfully advocated for the inclusion of comorbidities in the speech-language pathology portion of the SNF payment. PT and OT are not reimbursed for comorbidities. Another key distinction is that PT and OT payments decrease as the episode goes on (known as a variable per diem payment) while speech-language pathology payment is consistent across the episode. 

Practical Tips for Succeeding Under PDPM

Although PDPM is meant to alleviate pressures to provide as much therapy as possible, it does not address industry-developed pressures such as productivity requirements. It also creates potential new challenges for SLPs. For example, the additional payment for patients on mechanically altered diets may create unintended payment incentives to place patients on mechanically altered diets unnecessarily or keep patients on them longer than clinically warranted.

ASHA's free webinars on PDPM and other resources developed to help you know the facts and know your value should help dispel the myths surrounding PDPM and empower you to take charge of describing the value SLPs bring to patient care in SNFs.

Remember, it is critical for services to be driven by patient need, not administrative or payer mandates. ASHA, the American Occupational Therapy Association, and the American Physical Therapy Association have developed a consensus statement [PDF] on the importance of clinical judgment in care decisions. Additionally, if you feel you are being asked to do things that violate ASHA's ethical standards, payer requirements, or are contrary to patient needs, there is a mechanism available to report these concerns [PDF].

Quality Improvement

SNFs assess its quality on a variety of externally (e.g., payer-developed) and internally developed measures. A recent analysis of publicly reported Medicare quality reporting program (QRP) data [PDF] provides an interesting snapshot of areas where SNFs have the opportunity to achieve additional gains. Such opportunities include avoiding the payment penalties associated with the QRP, improving patient quality and experience of care, and potentially achieving efficiency and reduced costs. SLPs stand ready to assist in achieving these shared goals.  

Measure  # of SNFs (sample)  # with "problematic" score  % Impact 
Falls  15,507  4,875  31% 
MSPB  15,495  6,848  44% 
Discharge home/community  12,539  8,007  64% 
Functional goals  15,505  3,584  23% 

SLPs' Role in Fall Prevention

Factors such as depression, hearing loss, medication management, cognitive impairments, and poor sleep all impact a patient's risk for falls as well as their ability to report them in a timely fashion. Good clinical practice dictates determining whether these risk factors play a role in the care of the patients in SNFs. Approximately 60% of older adults with cognitive impairment fall annually, almost two times more than their peers without a cognitive impairment (Eriksson, et al., 1993). Among individuals with dementia, fall frequency can even reach as high as 80% (Shaw et al., 2003). The high prevalence of falls among patients with dementia, despite relatively intact motor function, highlights the idea that falls are often not just a motor problem (Van Iersel, et al., 2006). Risk of persistently high expenditures for fall-related injuries among older Medicare community-dwelling fee-for-service beneficiaries, is significantly higher for individuals with cognitive impairments, which leads to hospital/facility readmissions (Hoffman, et al., 2017).  

SLPs can help detect cognitive impairment to identify older adults who are at higher risk for falling. Cognitive impairment can be a risk factor for falls and a barrier to safe/independent discharge to prior living environments consequent to the fall. SLPs have a critical role in assessing cognitive-communication and cognitive deficits in patients of all ages including patients who have had a stroke, traumatic brain injury, or suffer from a neurodegenerative condition such as Parkinson's Disease, and all forms of dementia. Appropriate referrals can help SLPs design interventions so the patient can reduce their fall risk (e.g., designing memory aids and cues to help the individual follow safety precautions and self-regulate impulsive behaviors). Emerging evidence indicates that cognitive interventions have effects that carry over from the cognitive to the physical domain to enhance gait, and may reduce fall frequency (Segev-Jacubovski, et al, 2011). 

SLPs' Role in Discharge to Home/Community

SLPs can help increase the rate of discharge back to the community and decrease avoidable re-hospitalizations. Specifically, SLPs can positively influence the following factors that contribute to discharge back into community: 

Communication: A primary purpose for addressing communication and related disorders is to affect positive measurable and functional change(s) in a person's communication status so that they may participate in all aspects of life—social, educational, and vocational. Key considerations for treatment include maximizing improvement and/or maintenance of functional communication, evaluation of communication outcomes, and enhancement of quality of life. SLPs recognize that communication is always an interactive process and that the focus of intervention may include training of communication partners (e.g., caregivers, family members, peers, educators) and modification of communication in schools, workplaces, and other settings (ASHA, 2003). Communication is central to discharge back into the community, especially in individuals with speech/language impairments or cognitive deficits associated with a variety of diagnoses. Several studies have indicated that communicative competence predicts individuals' safe discharge back to the community. For example, a 2013 study found that deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a health care facility (e.g., SNF), rather than to a community-based environment, after adjustment for physical therapy and occupational therapy recommendations (González-Fernández, et al., 2013). Functional dependence and comorbidities, such as chronic aphasia, have been found to be a significant predictor of a non-home-based discharge setting in post-stroke individuals (Mees, et al., 2016). The SLP's scope of practice and unique training specifically equips them to prepare individuals to return home with appropriate communication facilitators, as needed, ensuring maximum safety. 

Cognition: Cognition is an important predictor of safety and functional independence in determining discharge to home, even in individuals undergoing purely orthopedic related rehabilitation (Ruchinskas, et al., 2000). Several studies emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients (MacNeill, et al., 1997). The Scope of Practice in Speech-Language Pathology (ASHA, 2016), as it relates to cognitive-communication impairments, indicates that the practice of speech-language pathology includes providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up for disorders of cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions). CMS has reinforced the role of SLPs in providing cognitive treatment as outlined in a response to ASHA seeking clarification of billing for cognitive treatment. 

Swallowing: SLPs with appropriate training and competence diagnose and manage oral and pharyngeal dysphagia. SLPs also recognize causes, signs, and symptoms of esophageal dysphagia, and make appropriate referrals for diagnosis and management. The SLP's specific role and level of involvement may vary for each clinician and across patients, work settings, and institutions. Presence of dysphagia represents a significant barrier to returning home, specifically in neurogenic diagnoses. Those individuals with dysphagia, post-stroke, are more likely to be discharged to institutional settings, such as SNFs, after inpatient stroke rehabilitation, and experience longer stays at these facilities (Nguyen, et al., 2015). Aside from the significant costs resulting from chronic dysphagia and associated care, these conditions have a negative impact on an individual's quality of life.   

Health Literacy: More than just a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual knowledge. According to the IOM report (2004), health literacy is "the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health." Inadequate health care literacy affects all population segments but is predictably more common in certain demographic groups such as the elderly, those with limited education, members of minority groups, and recent immigrants to the United States. Patients with aphasia or other neurological disorders affecting speech, language, or cognition, or those with severe hearing loss, are at risk when presented with vitally important written or verbal medical information. In addition, patients who face the stress of a medical crisis, possibly without an advocate or significant other being present, or while in a state of pain, confusion, or depression, may have difficulty understanding written or verbal medical information. SLPs have a vital role in effective patient-provider communication. As federal laws, regulations, guidelines, and accreditation standards mandate improved patient provider communication, it is vital to maximize the SLP's contributions to this significant area of practice that impacts patients' safe discharge back to the community. Nearly half of all adult Americans—90 million people—have difficulty understanding and using health information. Further, the rate of hospitalization and use of emergency services is higher among patients with limited health literacy (Kindig, et al., 2004). Limited health literacy may lead to billions of dollars in avoidable health care costs and, more importantly, impact thousands of lives. Inadequate health literacy directly affects the physical aspects of patient safety and negatively affects the fiscal aspects of health care delivery. The costs of poor health care literacy are staggering due to longer and more frequent hospital stays, ineffective use of prescriptions, and misunderstanding treatment plans. SLPs can assist with discharge planning while considering an individual's health literacy to minimize these costs (Rasu, et al., 2015).  

SLPs' Role in Functional Goals

Functional person-centered goals in rehabilitation directly impact an individual's return to home and participation in activities of daily living (ADLs) with maximum independence. SLP intervention in the domains of communication, swallowing, and cognition help address the following four questions in relation to rehabilitating, maintaining, or compensating for an individual's functional abilities: 

  1. Can the patient communicate effectively (ranging from his/her basic wants and needs to complex and abstract concepts such as emotions, social communication, and health care needs)?  
  2. Can the patient take nutrition, hydration, and medication safely and in adequate amounts? 
  3. Is the patient safe in his/her living environment and what cognitive supports can be in place to ensure effective return to least restrictive living environment?  
  4. What education/training is needed for patient, family, and/or caregiver to ensure safe discharge to prior level of function? 

ASHA Resources

Free ASHA Webinars and Podcast

This two-part series about PDPM dispels the myths surrounding the transition, discusses your role in patient care, and demonstrates the value of speech-language pathology in skilled nursing facilities. 

Questions? Contact ASHA's health care policy team at reimbursement@asha.org.

ASHA Website Resources

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