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The Patient-Driven Payment Model and Patient-Driven Grouping Model

Posted on: March 10, 2020

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The Centers for Medicare and Medicaid Services (CMS), has created the Patient-Driven Payment Model (PDPM) and the Home Health Patient-Driven Groupings Model (PDGM) as a means to replace fee for service to a system that holds providers accountable for costs and patient outcomes. The SNF PDPM began October 1, 2019 corresponding to the 2020 fiscal year and the PDGM went into effect on January 1, 2020. There has been miss-information about how the PDPM and PDGM will affect patient care.

According to the APTA (American Physical Therapy Association):

“PDPM was implemented to improve payment accuracy by addressing each patient's circumstances independently and classifying patients into payment groups based on specific, data-driven patient characteristics. PDPM redefines the relationship between payment and quality measures, realigning payment incentives and quality incentives. Claims that the PDPM itself mandates reductions in care simply aren't true. Similarly, assertions that the new system requires maximum use of group therapy, sets out productivity requirements, limits medically necessary therapy service, and dictates which therapy disciplines provide care based on payment categories are not accurate.”

“The PDGM is a patient-centered payment system that places home health periods of care into more meaningful payment categories while eliminating the use of therapy service thresholds for adjusting payment for home health episodes. The system also moves payment from a single 60-day episode to 30- day periods of care, still retaining the 60-day certification and plan of care requirements. There are several myths about the PDGM. Claims that the need for therapy will be diminished, that only patients discharged from an institutional setting will receive therapy, that the PDGM doesn’t support maintenance therapy, and that services cannot be delivered after the first 30 days are false. Similarly, rumors that therapy will be covered only when a patient is assigned a clinical grouping of musculoskeletal rehabilitation or neurological/stroke rehabilitation, that Medicare will dictate which providers are qualified to provide certain types of therapy, and that home health visits will be dictated by the Low Utilization Payment Adjustment (LUPA) claims system are all untrue.”

The PDPM and PDGM eliminate the connection between volume (time spent and number of visits) with reimbursement, and instead, they connect payment with patient characteristics, conditions, and needs.  Because of this, now, more than ever, the physical therapist must demonstrate the value and cost-effectiveness of services within SNFs and home healthcare.

The APTA asserts that “at the same time, what doesn't change is the coverage criteria or documentation requirements associated with the skilled therapy service coverage under PDPM and PDGM. More important, there is no change to the care needs of SNF and home health patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies. That some providers may choose to reduce PT and PTA staff reflects poorly on the industry's commitment to patient accessibility and availability, safety, and quality of care.”

With the newly CMS implemented the PDPM and PDGM physical therapists need to understand the implications on their practice and how to demonstrate their value to their facility and, more importantly, to the patient. To do this make decisions based on evidence, use appropriate tests and measures for each patient, select relevant ICD 10 codes, follow Best Practice guidelines, and utilize Outcome Tools and or participate in the Physical Therapy Outcomes Registry.

For in-depth recommendations, visit the APTA's Best Practices page of the association's Center for Integrity in Practice; read the “Choosing Wisely” initiative, and the crucial role of the practitioner's clinical judgment, using evidence-based practice. Finally participate in the Physical Therapy Outcomes Registry.

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Allison Stringer, MS, PT, FAAOMPT, CHA
About Allison Stringer, MS, PT, FAAOMPT, CHA

Allison Stringer, Physical Therapist, is the Clinic Director for Professional Physical Therapy in Salem, MA. Allison received her Master’s Degree in Physical Therapy from Simmons College in 1993. In 2000, she achieved the status of a Fellow of the American Academy of Orthopedic Manual Physical Therapists after completed the Institute of Orthopedic Manual Physical Therapy. Allison continues to treat patients and specializes in manual Physical Therapy for patients with orthopedic injuries to the spine and extremities, sports medicine, and wide range of Women’s Health issues including incontinence.