Therapy providers in the skilled nursing space have been forced to adapt.
The sector has already seen a hindrance in access to care following cuts made earlier this year to the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS).
Specifically, Medicare Part B physical and occupational therapy rates took a 15% hit in reimbursement for services provided “in whole or in part” by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs).
And the recent reductions in reimbursement become more challenging when factoring in the latest CMS proposed rule for skilled nursing facilities — which includes a 4.6% cut related to the Patient-Driven Payment Model (PDPM).
Despite the current storms being weathered by therapy providers, and future troubles expected as Covid-19 federal funding and public health emergency-related waivers are phased out, there are some levers a provider could pull — but they can come at a cost.
That’s according to Mark Besch, senior specialist for government affairs and analytics at Aegis Therapies, and Bot Zantua, director of rehabilitation operations at Westminster Communities of Florida.
He and Zantua spoke about how therapy providers can find the right balance between access to care, balancing the budget and keeping staff happy during the current labor crunch.
And that balance cannot be struck without making significant investments into the staff, Zantua added.
“We have to invest in our people. Our people are our lifeline, it will make or break you,” she said during Skilled Nursing News’ recent Clinical Executive Conference in Chicago. “It is very critical that if you have excellent people, if you develop them with compliance, education, you will have the results you’re looking for. Clinical excellence drives operation and it cannot be the other way around.”
Cutting services not an option
Even with federal reimbursement rates for therapy services having been reduced by almost 30% overall, cuts to service are not an option for Zantua.
Instead, it’s about planning ahead and strategically analyzing data to make the best informed decisions for patients. Westminster has actually grown and enhanced its therapy services during this time period, according to Zantua.
Westminster is a life plan community that offers independent living, assisted living, nursing care and rehabilitation and therapy services. Its therapy service offerings include physical therapy, occupational therapy and speech therapy.
The “devil is in the details” when it comes to the potential impact of the cuts — including where that provider is located on the map, Besch said.
“If you’re a provider that largely relies on assistants, which frankly many smaller rural providers do, then your impact is going to be greater. If you’re a larger provider and you can have a mix of therapists, then there may be some options,” he said, referring specifically to the 15% cut to therapy assistants.
There are some strategies that may lessen the impact of the cuts for providers, but there will be costs and benefits associated with doing so.
A provider could try to avoid being financially impacted by the therapy assistant cut all together and deliver all physical and occupational therapy by a registered therapist.
But that task is easier said than done given the current industry-wide staffing crisis, and the increased cost associated with paying registered therapists to provide the care if they are available for hire, Besch said.
The scheduling of therapists and therapy staff can also become more purposeful, albeit more complex, to help avoid having assistants treating patients from payers who are going to pay less for that service, he added.
Ultimately, Besch believes now is not the time to be making cuts to an industry that continues to recover from the Covid-19 pandemic.
“There’s still a lot of recovery that has to occur. Staffing shortages are today as bad as they’ve ever been in my experience. I’m not sure if 2023 will be a whole lot better. So I think advocacy is critical,” he said during the panel discussion.
Therapy as a ‘cost center’ and the future of PDPM
PDPM was specifically designed to reimburse skilled nursing facilities based on the acuity of the patients they treat, rather than by how much time the patients spend in therapy.
As a result, therapy services are seen by some in the sector as a “cost center.”
No one can deny that therapy is a cost, Zantua said, but she pushed back on the idea that the service does not provide revenue.
“We are a cost I get it — that’s the reality of it. But we’re also bringing revenues. That’s the bottom line … There’s a lot of ways to enhance revenue. But again, it has to be clinically driven. When you do it the other way around, you’re gonna fail,” she said.
Besch, who echoed Zantua’s thoughts, also said the service remains “as critical today as it’s ever been.”
“Yes it is a cost center and no revenue is not directly related to therapy like it was under RUGS. But have the expectations of your patients changed? I would suggest not. Is all this therapy really worth it? We have the data that says absolutely it is,” he added.
As PDPM approaches its three year anniversary in October, Besch believes the relatively new payment system’s days could be numbered.
When asked by SNN whether PDPM would be around in the next decade, Besch said, “10 years might be a little long,” as he believes there is “building momentum” for a unified post-acute payment system.
He said that he would like to see a reimbursement vehicle designed around quality and outcomes.
“I think that it’s our obligation to deliver the absolute best, most effective services and interventions that we can and those who do should be rewarded,” Besch added.
