AOTA Works To Lessen Impact of Changes in Skilled Nursing Facilities on OT
By Stephanie Yamkovenko
When the Centers for Medicare & Medicaid Services (CMS) proposed the new rule for skilled nursing facilities (SNFs) in May 2011, the American Occupational Therapy Association (AOTA) immediately got involved. AOTA analyzed the proposed rule, met with SNF experts, asked for AOTA member feedback, communicated with CMS, and developed comments based on this information.
“Policy staff have to really understand what the proposal means and what the implications are for practice, along with the economic effects,” says Christina Metzler, AOTA’s chief public affairs officer. “It is a big job that requires a lot of outreach, staff interaction, and careful thought and analysis.”
In the comments, AOTA advocated for a more prominent role for occupational therapy practitioners in clinical decision making than the proposed rule suggested. AOTA argued that CMS should gather more data and complete a more thorough analysis before implementing the suggested drastic payment cuts to SNFs. AOTA strongly opposed the new definition of group therapy and the proposal to reconfigure group therapy minutes allocation. AOTA urged CMS to ensure that assessment and documentation requirements are not overly burdensome. AOTA did support the proposed removal of the line-of-sight supervision requirement for therapy students and recommended that CMS adopt and publicize specific guidance for student supervision. (Read the full comment letter here).
CMS issued its final rule for SNFs on July 29, and it contained very few changes to the proposed rule. “We were disappointed that no changes were made but we were not alone,” says Jennifer Bogenrief, AOTA’s senior regulatory analyst. “The industry and other professional organizations were somewhat surprised that there seemed to be no revisions in response to comments.” The final rule adopted an 11.1% payment cut to SNFs and retained proposed changes to group therapy, assessments, and new student supervision rules. News of the drastic cuts to SNF payments caused SNF stocks to tumble.1
To try to understand the concerns and rationale of CMS, AOTA had an opportunity to participate in a briefing with CMS officials on the day the final rule was posted. CMS provided an overview of the lengthy rule—analyzing the rule is a long process—and explained their reasoning for adopting the rule with very few changes. CMS explained that many of the changes in the final rule were in response to analyzing utilization data, MedPAC recommendations on group therapy, and an Office of the Inspector General report, which found that questionable billing practices have resulted in SNF payments that have been too high.
“We feel there is recognition of the importance of unfettered clinical judgment by therapists,” says Metzler. “However the changes in SNFs may affect the day-to-day work of occupational therapy practitioners and administrative requirements. The underlying theme, though, is that CMS wants the therapy decisions to be made by therapists,” says Metzler.
A positive development with the final rule is that CMS removed the line-of-sight student supervision requirement in SNFs. “We think CMS listened to us and the other therapy groups about appropriate supervision” says Bogenrief. “CMS posted our therapy student guidelines on their Web site, which is a positive step.”
In other inpatient settings CMS does not specify student supervision requirements and expects facilities to determine supervision based on a student’s needs and state and local laws. CMS specifically mentioned that associations, including AOTA, play an important role in defining applicable standards of practice for student supervision and posted those guidelines on their Web site. Bogenrief notes that while eliminating the line-of-sight requirement is good, the supervising therapist still cannot be treating another patient at the same time; more specific information is expected as CMS develops changes to the Resident Assessment Instrument (RAI) Manual prior to October 1. (Find information on student supervision requirements in all settings here).
AOTA was also able to arrange a special briefing with CMS specifically for the national therapy professional associations. “The meeting with the other therapy groups was an important briefing, and we heard a lot from CMS about how they understand the position of therapists in many facilities,” says Bogenrief. “We were able to turn this understanding into a commitment from CMS to work with us to develop specific educational materials for therapists.” Bogenrief believes that this commitment will provide some important reference material for therapists to defend their clinical judgment and decisions about frequency, duration, and other aspects of therapy provision.
AOTA will provide feedback to CMS about what types of information CMS should develop to educate therapists about their role with assessments. AOTA will also provide input to CMS about developing changes to the manual that will help therapists clearly understand the new requirements.
“AOTA will continue to work with CMS and our internal experts as the October 1 implementation day gets closer,” says Metzler. AOTA is creating a podcast on how to comply with the new regulation; look for it on the Web site and in a future 1-Minute Update. AOTA provided a detailed analysis of the SNF final rule, and will continue to update members as staff gather more information.
· CMS Adopts Major Changes for SNFs in Final Rule
· 2011 SNF Final Rule (on CMS Web site)
· AOTA’s Analysis of Final Rule
· AOTA Comments on 2011 SNF Proposed Rule
· 2011 SNF Proposed Rule (on CMS Web site)
· AOTA’s Analysis of Proposed Rule
Stephanie Yamkovenko is AOTA’s staff writer.
1. Jain, S. (2011, August 1). Skilled nursing stocks in sick bay on big Medicare cuts. Retrieved August 18, 2011, from http://www.reuters.com/article/2011/08/01/us-skillednursing-shares-idUSTRE7704BO20110801