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.