Therapy layoffs, conversions to part-time status and general service reductions are beginning to ramp up in the home health space, multiple professional association groups told Home Health Care News. So much so, in fact, the U.S. Centers for Medicare & Medicaid Services (CMS) may be preparing to speak up.

The current shift in how and when home health agencies deliver physical, occupational and speech therapy services begins and ends with the Patient-Driven Groupings Model (PDGM). Effective on Jan. 1, PDGM largely bases therapy reimbursement on patients’ characteristics, as opposed to the sheer amount of services delivered.

Minimizing therapy volume’s role in the reimbursement equation is an intentional effort by CMS to fix what it and others have historically seen as over-utilization. Contrary to some misconceptions, PDGM does not stop reimbursing for therapy services entirely, nor does it mean home health agencies can decline to deliver therapy service when a patient’s plan of care explicitly calls for it.

The American Physical Therapy Association (APTA) recently launched a survey of its members to better understand PDGM’s impact on therapy. Meanwhile, the American Occupational Therapy Association (AOTA) has been gathering feedback in a survey of its own since the end of December.

As of Monday, AOTA’s survey included responses from at least 526 individuals, Sharmila Sandhu, the organization’s vice president of regulatory affairs, told HHCN. The survey has gradually grown by about 100 responses per week, a stat that reflects the profound reaction PDGM is having on therapy professionals nationwide.

“The majority of responses that we’re getting from occupational therapy practitioners is that their home health agencies are reducing the number of OT visits, and that those reductions appear to be mandated by the agencies,” Sandhu said. “Some of the responses are extremely concerning. For example, some have said their home health agency is not fulfilling physician orders to OT [services].”

About one-third of the respondents in the AOTA survey reported that they’ve been laid off or had their hours reduced in some capacity.

“In other cases, the OT visit is being shifted to another therapy colleague, such as a physical therapist,” Sandhu said. “We’re also hearing that agencies are telling actual patients or clients they don’t need occupational therapy and home health anymore, that they should wait until the patient gets outpatient therapy.”

Ignoring physician orders

Working alongside APTA and the American Speech-Language-Hearing Association (ASHA), AOTA has repeatedly met with CMS to identify red flags with PDGM and the overhaul’s impact on therapy services across the home health landscape.

While layoff reports are concerning, survey responses describing how some agencies are ignoring physician orders altogether are “terrifying” and “startling,” Sandhu said.

“It’s something that we had never heard before,” she added. “So, we are trying to understand where that is coming from.”’

APTA Director of Regulatory Affairs Kara Gainer said her organization has likewise received firsthand reports about PTs being laid off or seeing their salaries cut.

Another concern that has surfaced: Some therapists have been asked to do things they believe to be outside their scope of practice or not allowed under state laws. For example, some speech and language pathologists (SLPs) have been asked to do wound care when inappropriate, Gainer told HHCN.

“The impact of the new payment models on the physical therapy profession and the patients they treat has been significant,” she said. “However, PDGM changes nothing in terms of CMS’s requirements that [home health agencies] provide high-quality reasonable and necessary rehabilitation services — and that clinicians use clinical judgment in determining appropriate frequency, duration and modality of services.”

On Monday Kaiser Health News reported that Kindred at Home is one of the specific providers that has slashed therapy. In the report, an occupational therapist who allegedly used to work out of a Kindred at Home location in Omaha, Nebraska, noted that her agency laid off at least four OTs and three PTs last year in preparations for PDGM.

A Kindred at Home spokesperson told Kaiser Health News that the company does not discuss staffing decisions.

For the past three months, HHCN has steadily received emails and social media messages from therapy professionals regarding PDGM and changes at their respective agencies.

“The home health agency I worked for full time changed my status from full time to PRN and then promptly stopped giving me any more work by the second full week in January,” one Albuquerque, New Mexico-based SLP wrote. “This was due to my coworker, who is also a speech therapist, being the SLP with seniority.”

“PRN” is a term to describe as-needed or hourly workers.

“As a COTA, I was cut over $8 per visit in the home health setting,” a certified occupational therapy assistant told HHCN. “Census started falling in mid December with promises it would come back up. It did not. Our PRN assistant was being given visits over myself, being a full time employee.”

‘CMS is watching’

Many therapy experts predicted a correction to the Prospective Payment System (PPS) and its policies would be coming for years. From 2000 and 2016, utilization of Medicare home health therapy services increased 112%, according to Medicare Payment Advisory Commission (MedPAC) data.

With that in mind, it isn’t too surprising PDGM has triggered changes, Cindy Krafft, president of consulting firm Kornetti & Krafft Health Care Solutions, reminded HHCN.

“We all know that there was going to be some right-sizing in the initial phase here,” Krafft said. “There were providers providing too much therapy, so having their therapy downsized in the first quarter is not really a shock.”

But there’s a big difference between appropriately adjusting therapy volume to better match patients’ needs and indiscriminately cutting it to meet bottom-line goals, she added. That’s especially true when so many studies tout the overall benefit PT, OT and speech therapy services have when it comes to avoiding preventable hospital admissions and trips to the emergency room.

“We all know CMS is watching. They’re not happy with these kinds of stories,” Krafft warned. “And there’s discussion about issuing formal information to the industry from CMS to basically politely say, ‘Knock it off.’”

Timing-wise, PDGM’s impact to therapy has only been exacerbated by the Patient-Driven Payment Model (PDPM), a Medicare payment overhaul directed at skilled nursing facility (SNF) operators. In a December survey conducted by HHCN sister site Skilled Nursing News, 43% of respondents said that their firms laid off therapists in the immediate wake of PDPM.

It’s still early in PDGM’s history, but PDPM seems to be the greater trigger of therapy changes.

“Although the impact of PDGM has not been as big in terms of layoffs and cutting of hours [or] salary as PDPM, we still have heard of limitations being imposed on therapists and assistants in terms of the number of therapy visits they are able to provide,” Gainer said. “We also have heard of layoffs and cutting of hours or salary. So while less severe, it’s still impactful to the individuals who are losing their jobs — and their patients.”

Technology concerns

Some home health providers have turned to predictive-analytics tools to adjust their therapy utilization while transitioning to PDGM. They include Encompass Health Corporation (NYSE: EHC), which leverages a tool built by Medalogix that uses data and clinical insights to recommend an optimal number of visits a patient needs to achieve a positive outcome.

But home health providers need to use predictive analytics carefully, Gainer cautioner.

“We’re really trying to get our arms around and understand the newer … algorithms and predictive tools,” Sandhu said. “That is a great concern. The clinical judgment of the therapist could be overwritten. What if they believe that the patient could benefit from one or two more visits a week and that is not being permitted?”

Krafft agreed.

“There’s nothing wrong with predictive-analytics tools in terms of giving me some idea of — based on characteristics of the patient, based on expected revenue — where I’m going to land as a factor in decision making,” she said. “The problem I’m having is that the tools I’m hearing about and seeing right now are not based on evidence-based practices. They’re based on utilization to the bottom line.”

One of the therapy professionals who emailed HHCN said she experienced that scenario directly.

“Our therapists are going into the home to see patients without being able to use their own clinical judgement, all because our company is saying with this tool that a patient can or cannot have therapy,” the emailer wrote. “I feel this is unethical because our company is no longer letting our therapists use clinical judgement because they will ‘lose too much money.’” I have had several patients tell me they feel as if their care doesn’t matter anymore.”

Over time, at least some home health agencies will likely have to walk back potential over-corrections to therapy utilization, according to Krafft. But that course-correction process may take anywhere from six to nine months, she predicted.

It may be the chance of a CMS audit that prompts that correction. Ultimately, though, it may only come if Medicare beneficiary outcomes begin to noticeably decline.

“We’re talking about real humans. We don’t make widgets,” Kraffit said. “Where is the advocacy to say, ‘Listen. This is what my patient needs. Are we going to stand for what [patients] really need with evidence, or we are just going to roll over and do only six visits because the Magic 8-Ball told me that.”