Therapy, Outcomes and the New Patient Driven Payment Model

by Lisa Chambers, MS, CCC/SLP

The Patient Driven Payment Model drives a CARE model that uniquely identifies the patient’s needs based on their diagnosis and clinical category and not on the amount of therapy that is needed.  At first glance this may seem like therapy is no longer a key driver within the reimbursement system.

This could not be further from the truth!!

This care model is driven by three distinct parts to determine reimbursement:   the patient’s clinical category as it relates to the ICD-10 diagnosis + function score in Section GG + the Cognitive score on the BIMS = CARE = REIMBURSMENT level.

Therapy will still need to play a key role within the interdisciplinary team to identify skilled need, appropriate diagnosis and clinical category selection, the classification of the true function of the patient as well as determining the patient’s cognitive status.

The future of value-based reimbursement in the post-acute setting will be driven by the outcomes provided in these very important sections of the MDS. 

Another incredibly important detail is your patient and family satisfaction. This is driven, in large part, by the therapy provided. How much or how little truly impacts the family and patient experience.

CMS has circulated data points via PEPPER reports and other similar published reports that highlight the amount of therapy that was provided under the RUGS system. The expectation as stated by CMS would be that a similar delivery model continues to be provided to the patient receiving therapy services and that appropriate outcomes are delivered under PDPM.  Patients, families, payers and referral sources will have the same expectations.

Therapy is still a key driver of reimbursement in this model which is no longer based on the volume of minutes but based on the patient’s outcome and clinical needs.

We strongly believe that outcomes will be a critical driver in the near future. A value-based reimbursement model within the post-acute care setting is the goal and we believe Blue Sky Therapy is the best solution for providing innovative therapy tools, within the post- acute care setting today, tomorrow and beyond. 

Physical Therapy PDPM