CMS Watching Home Health Providers Closely Amid Shifting Therapy Strategies

Home health providers aggressively changing how they’re delivering physical, occupational and speech therapy services need to remember one thing: The U.S. Centers for Medicare & Medicaid Services (CMS) is watching.

Since Jan. 1, several industry-leading providers that Home Health Care News has connected with in the aftermath of the Patient-Driven Groupings Model (PDGM) have reaffirmed their commitment to therapy in their service mix. Those providers include Birmingham, Alabama-based Encompass Health Corporation (NYSE: EHC) and Moorestown, New Jersey-based Bayada Home Health Care, just to name a few.

But while some providers take tempered, responsible approaches to therapy under PDGM, it’s becoming increasingly clear that many others are not. Stories of widespread layoffs of PTs, OTs and SLPs persist — and now new reports of agencies incorrectly telling their patients that Medicare no longer covers therapy under the home health benefit have surfaced.


That kind of misconception is dangerous for providers and Medicare beneficiaries alike.

“It’s something that we had never heard before,” Sharmila Sandhu, the vice president of regulatory affairs for the American Occupational Therapy Association (AOTA), recently told HHCN. “So, we are trying to understand where that is coming from.”

If home health providers needed a reminder of CMS’s oversight, they got one. On Monday, CMS released a special edition Medicare Learning Network (MLN) Matters article highlighting the role of therapy under PDGM. MLN is CMS’s educational arm tasked with informing the physician, provider and supplier communities about the latest Medicare changes.


In the article, MLN’s authors don’t mince words when answering the question: “Has home health eligibility and coverage changed under PDGM?”

Their answer: No.

“While there has been a change to the case-mix adjustment methodology and the unit of payment beginning in CY 2020, eligibility criteria and coverage for Medicare home health services remain unchanged,” the MLN team wrote. “That is, as long as the individual meets the criteria for home health services …, the individual can receive Medicare home health services, including therapy services.”

The case for therapy

By spending the time and energy to release a special edition of MLN Matters, CMS is politely telling the home health world to “knock it off” when it comes to drastically cutting back on therapy services. Some kind of warning was to be expected, especially after the agency likely caught wind of some providers ignoring or changing physician orders.

In addition to layoffs and visit reductions, AOTA uncovered that trend as part of an ongoing survey it’s conducting to explore PDGM’s impact on OTs.

“The majority of responses that we’re getting from occupational therapy practitioners is that their home health agencies are reducing the number of OT visits, and that those reductions appear to be mandated by the agencies,” Sandhu said. “Some of the responses are extremely concerning. For example, some have said their home health agency is not fulfilling physician orders for OT [services].”

Conditions of Participation (CoPs) say the provision of therapy services should be determined by the individual needs of patients, without restriction or limitation on the types of disciplines provided, the frequency of visits or how long visits last. And ultimately, the physician responsible for the written home health plan of care — in collaboration with home health clinicians — is tasked with determining patient need.

In other words, home health agencies can’t substantially change or entirely ignore physician orders just because therapy maybe isn’t as profitable as it was a couple months ago.

“All services must be furnished in accordance with physician orders and accepted standards of practice,” MLN authors stated in this week’s article. “Therefore, the visit patterns of therapists should not be altered without consultation and agreement from the physician responsible for the home health plan of care.”

Apart from the straight rules and regulations, home health providers looking to scale back also need to remember the value therapy services bring to the table, particularly in regard to patient outcomes and quality metrics.

Earlier this month, for example, a study published in the Journal of the American Geriatrics Society found that home health patients living with dementia who received physical therapy services had a 75% chance of seeing improvement in tackling activities of daily living (ADLs). Those who did not only had a 60% chance of ADL improvement.

Similarly, an April 2019 study published in the Journal of the American Medical Directors found that one to two weekly PT sessions can help lower home health patients’ chances of re-hospitalization by up to 82% in a 60-day period.

“When we think about rehab services and the impact on readmissions, I think we start with functional impairment,” Dr. Jason Falvey, a Yale University School of Medicine researcher and therapy expert, said during a presentation at the 2019 National Association for Home Care & Hospicee (NAHC) annual conference. “Functional impairment is a really strong predictor for hospital readmissions. When you look at potentially preventable readmissions, that relationship is even stronger.”

Meanwhile, PDGM doesn’t change the fact that quality scores and patient satisfaction results are still posted on Home Health Compare. Through the online tool, consumers have ample opportunity to see how well agencies have done at helping their patients get better at walking, getting out of bed or bathing — the wheelhouse of therapy staff.

“Therefore, high-quality therapy services with a focus on patient outcomes can help [home health agencies] achieve higher patient satisfaction and higher quality scores,” the MLN authors note.

Finding a middle ground

CMS shouldn’t fault home health providers too much for the shifting therapy strategies. After all, it’s what federal policymakers wanted.

The Medicare Payment Advisory Commission (MedPAC) has long been vocal about what it perceives to be an over-utilization of therapy services in the home health space under the Prospective Payment System (PPS). After PPS went live, therapy visits went from accounting for about 10% of all home health visits in 1997 to more than 39% in 2016, according to MedPAC data.

Along those lines, PTs, OTs, SLPs and other therapy professionals shouldn’t be shocked that agencies are, in some cases, converting positions to part-time status, lowering pay, reducing visits or adopting predictive analytics tools for the sake of efficiency. By eliminating volume thresholds, therapy is no longer a major reimbursement driver for providers, who, in 2020, are now tasked with doing more with less in nearly all facets of their businesses.

“What we see with PDGM is all this financial pressure is happening. You’re having your rates changed as an agency, you’re having margins compressed, so you’re having all of this institutional pressure financially,” Medalogix CEO Elliott Wood recently told HHCN. “And the question is, ‘How can you continue to do what’s best for the patient?’”

In order to keep the focus on patients, home health providers, CMS officials and therapy professionals are going to need to find middle ground, reaching some level of mutual understanding.

On their end, those providers who are aggressively cutting therapy need to consider whether they’re throwing the baby out with the bathwater and jeopardizing long-term success for the short-sighted gaming of today’s reimbursement system. 

If that doesn’t happen, the home health industry is going to lose some of the standing it has worked so hard to gain within the broader health care continuum.