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Toni Talks about PT Today

My Fear of Maintenance Therapy

Published June 4, 2013 2:26 PM by Toni Patt

Last week in his post, fellow ADVANCE blogger Dean Metz shared some good news. CMS has ruled the need for skilled intervention, not functional improvement, makes therapy reimbursable. This means, as he pointed out, patients with chronic conditions can receive treatment without first experiencing an exacerbation. This will undoubtedly result in an improvement in quality of life while decreasing the cost of caring for them.

Taken in that context, it's a very good thing. Many neuromuscular diseases are chronic and progressive. It will also benefit chronic spinal cord injury patients, stroke survivors and residents of long-term care facilities. Those residents are at high risk to deteriorate functionally. Many of them have chronic conditions such as contractures. Others are frequent fallers. Sooner or later, they'll all receive therapy and be discharged with a restorative nursing program.

Many nursing homes are struggling to survive. Last week, the director of my facility attended our staff meeting to share the financials. Since the sequester kicked in, there has been an additional 2% cut in Medicare reimbursement, or roughly $9/day per patient. While this doesn't seem like much at first, it adds up to thousands and thousands of dollars over the course of the year. This translates into additional budget cuts and efforts to generate revenue.

Therefore all of our part A patients are now at the highest RUG level. Everyone is being seen for at least 50 minutes, often more, with the expectation they remain on caseload the full 100 days. And we're not alone. I just returned from another three-city teaching trip. Attendees in each city told me their facilities are doing something similar, although mine is the only one where absolutely everyone gets the maximal minutes.

Now add in reimbursement for skilled care unrelated to function. It probably won't make much difference to those who are under part A. But depending on how skilled service is defined, just about everyone in the facility could conceivably be appropriate for therapy under part B. Residents currently on restorative programs could be readmitted to therapy. Residents not receiving any intervention could also be admitted if a skilled need is identified.

Defining a skilled need is challenging enough right now. Linking it to function gave us a yardstick. Taking function out of the equation introduces new variables. For example, we occasionally get referrals for therapy because the family wants the patient to have it. Without function as a determinant, one could argue those residents deserve a therapy trial because while function might not improve, it could deteriorate without therapy.

I don't expect CMS to step in and clarify the ruling. Nor do I see them monitoring how SNFs respond. There are measures in place such as therapy spending caps to limit the cost. It would only take a few maintenance patients each month to boost the bottom line. All that would be required is a need for some kind of skilled care.

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Dr Patt, I share your concerns completely. I also share the view that the ruling is good news. I am alarmed that a facility has ALL part A patients at the highest RUG level. Nobody may notice that for a while, but eventually that will raise a red flag somewhere. To be fair, as you stated, with the sequestration administrators have a thankless job of trying to keep facilities operational on less money while maintaining compliance. I wouldn't want to be in their shoes.

What I might suggest is instead of waiting to see how many appropriate vs inappropriate referrals for maintenance therapy start coming in to our departments, we might be proactive and educate the administrators and managers on what constitutes an appropriate referral for maintenance treatment. Lets not leave it up to bureaucrats or nurses in admin to decide. I don't know of many PTs or PTAs who work in SNFs with lots of spare time, but it may be worth the sacrifice in the long run.

Glad you're continuing the dialogue!

Dean Metz June 4, 2013 3:41 PM

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