RA-CMS-1-NEW How CMS' Proposed Changes to the SNF PPS Could Hinder Access to OT Services

Centers for Medicare and Medicaid Services (CMS)’ proposal earlier this year pushing for a new skilled nursing facility (SNF) payment model could prevent patients from receiving the amount of occupational therapy (OT) services they need and affect whether they’re able to access these services at all.

This post is the first in a two-part series that reviews the proposed changes to the current SNF payment model in depth and the implications for those practicing in SNF occupational therapy positions. Keep on reading to learn how the approval for and access to occupational therapy services would change under the proposed revisions. 

RCS-I to replace RUGs

The Medicare Part A SNF Prospective Payment System (PPS) known very well by clinicians in SNF could see a complete revamping come 2019. The Resident Classification System, Version I (RCS-I) could replace the current Resource Utilization Groups, Version 4 (RUG-IV) for SNF PPS.

CMS’ May 2017 publication of the advanced notice for the potential change proposes a shift in the traditional PPS payment system that currently bases therapy related SNF payments on the number of minutes of therapy provided to being one based on a patient’s clinical classification.

Under the current PPS, therapists’ clinical assessments help determine placement into a Resource Utilization Group (RUG) category characterized in part by a range of total therapy minutes a patient would receive across all rehab disciplines. When selecting the appropriate RUG category for a rehab patient, the decision should reflect which therapeutic needs a patient has and how much therapy would be required to meet those needs. In this case, the SNF reimbursement for rehab services is primarily driven by therapists as payment is determined based on a patient’s RUG classification (which is, again, determined by therapists’ clinical judgment).

Alternatively, the adoption of the RCS-I over the RUG system would see patients placed into a particular classification (based on patient clinical characteristics) which would ultimately determine the SNF payment. Each resident classification consists of the same payment determinant components to be used for all patients when assigning the appropriate classification; the payment determinant components are further broken down into predetermined categories. Essentially, the classification process yields a patient clinical profile and reimbursement is determined by using the cost of care for patients with a similar profile as a reference upon which the final payment amount will be based.

[Read alsoThe Distinction Between Reimbursement Sources in SNF vs Homecare Settings – Part 2 of 4 (Reimbursement Sources)]

With the RCS-I, by estimating SNF payment for a current patient by looking at past costs for a similar patient, SNF reimbursement is essentially predetermined: a set of payment amounts preexist for different patient profiles and with the way rehab therapists would be required to classify patients, SNF payments will ultimately match one of these pre-existing payment amounts. In this case, SNF payment is payer driven as reimbursement is controlled with the payer’s required use of resident classifications.

Payment Methodology and Provision of Care

While the differences between both systems highlight who becomes the primary driver of payment (an issue that certainly merits due attention for much-needed cost containment in our healthcare system), a major significance of this fundamental difference is the ultimate effect either methodology has on the provision of care.

With the PPS, therapists are able to fully exercise their professional, clinical judgment in evaluating and treating SNF patients, having the latitude to determine how much (or how little) therapy an individual needs. This can certainly lead to an overprescription of therapy and, consequently, unjustified spending. However, rehab therapy under the current PPS does allow the greatest opportunity for therapists to provide care according to patient need which is the ideal way to practice.

Clinical practice for rehab therapists under the RCS-I would find a greater challenge in justly providing patients complete and thorough care. Being required to fit their patients into preset clinical categories can limit the type and amount of care therapists provide if they are unable to accommodate the wide variances in patients’ clinical presentations when classifying patients per the RCS-I categories. Essentially, regardless of the care, a therapist deems necessary for a patient based on clinical expertise, it is possible some of these needs may not be addressed adequately, or at all if that patient’s presenting characteristics do not fit neatly into RCS-I clinical categories.

While the intent of the RCS-I to curb healthcare costs is a reasonable one and the idea of organizing a standardized payment methodology has promise, the potential detriment to patients justly receiving the care they need is the largest point of contention and concern within the rehab community that has arisen with this new proposal.

[Read alsoThe Shift Toward CMS Values-Based Care and Outcomes]

In order for CMS and the OT community to move toward a viable and fair reconciliation of this concern, it’s necessary to take a closer look at the implications on clinical practice this change in SNF payment and reimbursement could have for occupational therapists (OTs). 

Be sure to follow our blog to catch the next post that discusses how the future of occupational therapy services in the skilled nursing setting will be forever changed under these SNF PPS revisions.