Reductions in Therapy Provision in Skilled Nursing Facilities After Medicare Payment Reform and During the COVID-19 Pandemic: An Interrupted Time Series Analysis.

OBJECTIVE

To examine how rehabilitation service provisions (ie, physical therapy [PT], occupational therapy [OT], speech language pathology [SLP]) changed in skilled nursing facilities (SNFs) after Medicare implemented the Patient-Driven Payment Model (PDPM) and the COVID-19 pandemic began, while comprehensively accounting for changes in patient clinical characteristics.

DESIGN

Secondary interrupted time series analysis of 100% Medicare data from January 2018 to September 2021 with interruptions for PDPM implementation (October 2019) and COVID-19 (March 2020).

SETTING

United States SNFs.

PARTICIPANTS

All SNF stays for fee-for-service Medicare beneficiaries admitted to SNF within 3 days of hospitalization with complete data from SNF assessments and hospital claims. Stratified analyses included stays with facility data on ownership status and rural versus urban location.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Average total minutes of therapy per day (MTD) provided by assistants or therapists and MTD by discipline (ie, PT, OT, SLP).

RESULTS

For 3,917,261 SNF stays, PDPM implementation was associated with a decline of 28.9 total MTD, representing a relative reduction of 23.7%, compared to pre-PDPM averages. PT declined by 12.8 MTD (-23.5%), OT by 12.9 MTD (-24.3%), and SLP by 3.1 MTD (-21.7%). PDPM-associated declines were larger in for-profit SNFs versus not-for-profit and government-owned SNFs and in rural versus urban SNFs. Compared to what would have occurred if post-PDPM negative trends continued, COVID-19 was associated with a 15.3 minute (15.9%) increase in total MTD, a 5.4 minute (12.8%) increase for PT, a 5.1 minute (12.3%) rebound for OT, and a 4.5 minute (38.9%) increase for SLP, with greater relative increases in urban and for-profit SNFs.

CONCLUSIONS

Even when accounting for changing patient characteristics over time, PDPM implementation was associated with substantial declines in therapy provision, particularly in for-profit and rural SNFs. After COVID-19, these steep declines stabilized, with a slight recovery for SLP, but lower levels of PT and OT MTD persisted well into the pandemic.