Therapy Survival Tips for PDGM

With the Patient-Driven Groupings Model (PDGM) set to move home health payment away from existing therapy thresholds and toward patient characteristics in 2020, providers will need to break down silos within their own operations if they want to be successful.

Generally, many providers have often relied on a therapy-driven model, which has been a big reimbursement boon for the industry since the current Prospective Payment System (PPS) was put in place about two decades ago. But due to that trend and perceived overutilization, the Medicare Payment Advisory Commission (MedPAC) has long been a proponent of striking therapy-visit volume as a determining factor in calculating reimbursements.

While experts have called PDGM’s therapy changes an “over-correction,” some agencies have felt “hostage” to therapy in the past, according to J’non Griffin, president of Home Health Solutions LLC, a Carbon Hill, Alabama-based consulting company.


“You had to have a therapist to be sure to have enough revenue coming through your door, so then therapists were able to dictate to agencies, ‘I will do this, I won’t do this,’” Griffin said, speaking on a Wednesday panel at the 2019 HHCN Summit in Chicago. “I think those days may be coming to an end.”

To be successful under PDGM, therapists will have to be better case managers and be willing to do everything they are authorized to do in terms of meeting patients’ needs.

In other words, home health agencies will need to make sure therapists are “practicing at the top of [their] license” in preparation for the upcoming payment overhaul, according to Bud Langham, chief clinical officer of the home health and hospice segment of Encompass Health Corporation (NYSE: EHC)


“What is the value the therapist at your office is bringing you?” Langham asked Summit attendees. “If it’s just visits and reimbursement, then you have a problem. Practicing at the top of your license means you’re going to case manage, you’re going to work with therapy assistants, you’re going to oversee them so we can expand your reach.”

Just one specific example of better case management: Having therapists take vital signs when they enter the home, which has historically been something therapists have been somewhat averse to doing.

“There is a long history of, ‘I’m just here to do exercises, I’m just here to ambulate somebody,’” Langham said. “There is this siloed methodology where no one tells them what to do. There is a long history of it, and it’s going to be Job 1 if you haven’t already started tackling it.”

Other examples of better case management include auscultation and case conferencing, according to Langham.

Because of PDGM’s proposed therapy changes, many agencies have expressed plans to scale back on delivering those services and sending therapists into the home come 2020. In most cases, that would likely be a mistake, according to Griffin and Langham.

Apart from sending a red flag to the Centers for Medicare & Medicaid Services (CMS), slashing therapy would put patient health outcomes in jeopardy. Previous research has found, for instance, that one to two weekly therapy sessions can help lower re-hospitalization risk among older adults by up to 82% in a 60-day period.

“I’ve heard agencies say, ‘We are just going to cut the visits,’” Griffin said. “CMS has said they will come after you if they just see a total cut in visits all of a sudden. You need to have a clear business plan going into PDGM.”

About 25% of providers that participated in a recent National Association for Home Care & Hospice (NAHC) survey said they plan to reduce therapy utilization by more than 10% in 2020. In contrast, only 2% said they plan on increasing therapy utilization.

One way to approach therapy differently could likewise be through telehealth.

Broadly, telehealth could provide a cost-effective alternative to in-person visits, with the idea being that providers replace therapy services with digital check-ins and telemonitoring when appropriate.

Some of the major roadblocks to providers implementing telehealth have been the potential workflow disruption and inadequate IT infrastructure.

“If we have been waiting to implement some kind of tele-intervention, PDGM is definitely going to be the nudge to do that,” Langham said. “Being able to make sure that you are only making visits to the home when they are actually necessary, and using technology whenever you don’t have to be there, will be critical.”

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