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So here we are…October 23rd, 3 weeks into PDPM and we are surviving. I’ve spent the last 2 weeks at conferences, hearing from colleagues and the “experts” and I have been reading the articles, with many thoughts and opinions and I’ve landed on some conclusions: 

We know ultimately CMS wants us to provide care more effectively and less costly.  Their message in preparation for PDPM was “but not yet, because nothing should really change!” “If they needed 720 minutes in September, they should need 720 minutes in October”, “if you are doing less than 1% of group under RUGs we shouldn’t see 25% group in PDPM”, “we will be watching”, “therapy is still valued and necessary but it won’t drive revenue”, “this will be budget neutral”, etc. 

CMS has the ability to assess changed behavior and imply that it means previous behavior was wrong, inappropriate, unnecessary and could claw back. They also have the ability to adjust on the go forward based on the changed behavior…remember, SNF PPS didn’t have expected behavior modifications baked into it like PDGM, at least not officially. 

The industry is saying…..there is less money, and specifically there is less therapy money. CMS expects therapy utilization to go down…they designed PDPM accordingly. We need to lower our pricing and since you will gain efficiencies from group and concurrent, that is reasonable, as long as our OUTCOMES don’t change!   OUTCOMES is a BIG BUCKET….it has a lot of different meanings, none of which is a great indicator of effective therapy!

CMS says they will be watching “everything”. 

So WHO do we listen to??? WHAT do we do??? HOW do we move forward without fear of repercussions? Do we have the solution 1 day, 1 week, 3 weeks into this new payment model to do it more efficiently when we didn’t have that last month? Does it really matter?

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Observations 5 days into PDPM….
 
·       The RUG system had flaws, therapy minute thresholds being the biggest.  CMS designed the thresholds as minimums and the industry adopted them as maximums.
·       In 1998 several thousand therapists were laid off while the industry “figured it out” and then eventually hired them back, and more.
·       PDPM was designed to be budget neutral based on the data used.  There are inherent flaws in this assumption when using old data, however from a strictly dollar perspective….the money is all there, it is just in different buckets and requires more effort to access.  Rehab RUGs provided large dollars, the majority of which were used to pay for more than just therapy.  PDPM requires data to be collected in order to support the CMGs/CMIs and subsequent dollars.
·       We, both providers and contract therapy have been defending therapy utilization and minutes for 20 years as reasonable and necessary.
·       The industry accepted the narrative that under PDPM there would be less money to pay for therapy, that it was somehow less valued and this has resulted in lower pricing.  Some of this was based on the new opportunity to use group/concurrent without it being perceived as “punitive” operationally, but not all of it.
·       Regardless of the all the analyses performed in the past 2 years, we have NO CLUE how this will really shake out.
 
On Day 1 of PDPM headlines surfaced with stories about therapists being laid off, having their status’ changed to PRN, taking pay cuts, being told that group/concurrent are mandatory and not optional and that less therapy will have to be the result of PDPM. 

I have been in this industry for over 26 years…there are opportunities for efficiency and effectiveness within healthcare, no one can argue this.  But DAY 1, really?  Why do we do this to ourselves?  We have touted the necessity of 144 minutes of therapy a day for 20 years…okay, not quite, but close and now all of a sudden we want our clinicians to determine appropriate levels of therapy delivery as long as it is less and includes group/concurrent?

We cannot have our cake and eat it too….yes, PDPM will change many aspects of SNF care.  I guess I had hoped we would have spent a little more time transitioning in an effort to ensure we don’t knee jerk and make a difficult change just a little bit worse.