Before We Point Fingers….

I have met many therapists currently working in home health that used to work in skilled nursing facilities (SNFs). Many times there is a visible grimace about the counting of minutes of therapy and the pressure felt to maximize that number. Earlier this month, CMS released a new report on SNF utilization looking at 2013 data with results confirming concerns about the utilization of therapy.

  • Medicare spending for approximately 2.5 million stays in just over 15 thousand facilities exceeded $27 billion dollars.
    • Use of “ultra-high” therapy represented $16.6 billion (61%)
    • Use of “very-high” therapy represented $5.5 billion (20%)
  • The average standardized payment per stay for all SNFs was $10,919.
  • More than 1 in 5 SNFs reported 75% or more of the time they were in one of these two categories, the total minutes were just above the minimum threshold by 10 minutes or less.
Also released in early March was a similar report for Home Health agencies.
  • Medicare spending for 6 million episodes of care for just over 11 thousand home health agencies exceeded $18 billion.
  • The average standardized payment per episode for all HHAs was $3,037
  • In 2013, the total number of early episodes at 0 – 13 therapy visits, 14 – 19 therapy visits and early/late episodes with 20 or more visits was 3,948,351
    • 0 – 13 therapy visits = 3,060,630 claims (78%)
    • 14 – 19 therapy visits = 531,631 claims (13%)
    • 20 or more therapy visits = 356,090 claims (9%)
      • Inclusion of late episodes drops this to 6% of the total

Home health providers have felt the pressure on defending the use of therapies as seen in the number of audits and subsequent denials. At times, these denials do not even have a clearly supported denial reason  (like citing the absence of short and long term goals – something that is not in the actual regulations AND lacks a standardized definition of what constitutes either one). 
Looking at the SNF data, it is tempting to point the finger at that setting as a bigger and more expensive provider of questionable amounts of therapy services. The larger issue is when we step back and realize how much of our future will be shaped not by individual setting but as the “post acute continuum”. This is not an issue of determining who is the perceived bigger problem BUT how do we work together to ensure services are being provided based on the needs of the patient and not manipulation of the payment methodology of the specific setting. All providers of post acute care have skin in this game and are already seeing initiatives that cut across settings. But what is the specific role and responsibility of the therapist working in either one of these settings? Stay tuned…….
Cindy Krafft, March 28, 2016

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