Rural, For-Profit SNFs Experienced Greater Therapy Staff Declines Amid Pandemic, Medicare Reimbursement Reform

The dual impact of COVID-19 and Medicare payment policy reform on therapy staffing varied by skilled nursing facility (SNF) characteristics, with rural and for-profit SNFs experiencing the sharpest declines, according to findings published in the Journal of the American Geriatrics Society.

In October 2019, the Centers for Medicare & Medicaid Services implemented the Patient Driven Payment Model (PDPM), which changed the way SNFs were reimbursed for therapy provision. PDPM was associated with an increase in SNF payments in 2020 but a decrease in physical and occupational therapy staffing, researchers said. 

“The COVID‐19 pandemic complicates our understanding of PDPM's effect on staffing changes in SNFs,” investigators said. “This study aimed to characterize the dual impacts of PDPM and the COVID‐19 pandemic on therapy staffing in SNFs.”

Using Medicare administrative data from January 2019 to March 2022, researchers analyzed changes in staffing levels, type of staff, and organizational characteristics across a national cohort of SNFs.

PDPM implementation was associated with a 6.54% decrease in total therapy staffing levels, with the most significant declines impacting assistants and contractors, findings showed. 

The early phase of the pandemic was also associated with a 2.46% decrease in staff, but trends in per-patient staffing levels varied throughout the study period as the resident census changed, researchers said.

“Trend changes during early COVID‐19 were positive for all categories; the PDPM declines either slowed or reversed,” researchers said. “However, late‐COVID‐19 trends were negative through March 2022. Only in‐house staffing had returned to pre‐PDPM levels by the end of March 2022.”

The largest PDPM-related declines occurred in SNFs that were rural, for-profit, or chain-affiliated, as well as SNFs that provided more intensive therapy, employed more assistants, and admitted more Medicare beneficiaries prior to the reimbursement reform. 

Rurality was also associated with the largest COVID-19–related staffing declines, while there were smaller early declines in SNFs that were hospital-based, for-profit, or recipients of more relief funding.

“SNFs that historically engaged in profit-maximizing behaviors (eg, providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs,” investigators said. “Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.”

Reference:
Prusynski RA, Humbert A, Leland NE, Frogner BK, Saliba D, Mroz TM. Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities. J Am Geriatr Soc. Published online December 26, 2022. doi:10.1111/jgs.18208