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  • New MACRA Systems Could Affect PTs by 2019: Here Are 5 Things You Need to Know Now

    Physical therapists (PTs) may not be immediately affected, but make no mistake: the future of payment has arrived. And it's time to start preparing.

    Last week, the Centers for Medicare and Medicaid Services (CMS) released proposed new rules for the Medicare and CHIP Reauthorization Act (MACRA). As promised, the new rules feature some game-changers for health care providers around the CMS Quality Payment Program, specifically through the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).

    Although PTs will not be included when the new systems begin in 2017, APTA Director of Regulatory Affairs Roshunda Drummond–Dye says that members of the profession can be assured that it's only a matter of time. "It's clear that CMS hasn't forgotten physical therapy," she said. "MACRA is the first tangible step toward mandating a payment system that bases reimbursement on quality of care and outcomes and begins the phase-out of fee-for-service, and PTs need to familiarize themselves so they're not taken by surprise when the change reaches them, possibly as early as 2019."

    The proposed MIPS rule for next year affects physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include those providers. Among other things, the new system consolidates the Physician Quality Reporting Program (PQRS), the Value-Based Modifier Program (VBM), and the "meaningful use" of electronic health records (EHR) program into a single system that will rate providers according to 4 "performance categories": quality of care, advancing care information, clinical practice improvement activities, and cost/resource use.

    At the same time, CMS will get much more specific about requirements for approved APMs, and create a roadmap that will guide providers on forming or participating in models such as accountable care organizations and patient-centered medical homes. (For a useful overview of the MACRA changes, check out this recent article in Health Affairs. CMS has also provided an overview of MACRA and the proposed changes.)

    So what are the big takeaways for PTs right now? Here are 5 things you need to understand.

    1. Data collection systems such as the Physical Therapy Outcomes Registry will play a huge role.
      Although claims-based reporting is initially allowed under MIPS, the rule creates an infrastructure that will make participation in registries essential over the coming years, and by the time PTs enter MIPS, participation in a registry will mostly likely be mandated. "We've been saying for some time now that the collection and assessment of outcomes data is critical for PTs," Drummond-Dye said. "MACRA will only increase the importance."
    2. You need to get up to speed with EHRs.
      The "advancing care information" performance category is the rating category that contains evaluations of meaningful use of EHRs. So far, the meaningful use program hasn't directly affected PTs, but this too will change. The proposed rule under MIPS also factors in the use of a certified EHR, and that's not going away. "PTs will need to get serious about using an EHR if they haven't already done so," Drummond-Dye said.
    3. You can take MIPS for a test drive.
      While PTs aren't included in the list of providers who will be required to participate in MIPS beginning in 2017, it's possible to sign up for voluntary reporting to get a feel for the system before it becomes mandatory. Voluntary reporting is a good idea, not just for the individual PT, but as a way to assess MACRA's fit for the profession, and to guide advocacy around making the policy changes necessary to ensure that PTs can be successful in MIPS when it becomes a requirement.
    4. MIPS may be getting the most attention, but the APM changes are a big deal too—and the profession needs to be proactive about helping to shape future models.
      The ability to become a key player in an APM will be essential in future payment policy. The current scope of APMs in the rule is relatively narrow, but that scope will grow over time, and physical therapy will need to be at the table as the rule is widened. "It's APTA’s hope that there will be the opportunity to work with the federal government to create new APMs that will bolster participation," Drummond-Dye said. "The bottom line is, APTA and the profession have a lot of work to do in this area."
    5. We're not just talking Medicare.
      The policies contained in the MACRA proposed rule will not only affect Medicare payment but also sets forth payment polices that will extend to commercial payers. In other words: once MACRA starts affecting PTs, those effects will be felt nearly everywhere.

    APTA is developing a series of fact sheets on MACRA and will offer a comprehensive plan to help PTs participate in the voluntary report program in MIPS. In the meantime, programs such as APTA's Innovation 2.0 initiative are helping to better acquaint the profession with alternative payment models that include significant involvement from PTs.


    • PT, much like Psychology, best fits into a fee for service model. Currently, we have no ability to predict outcomes and we have limited information on defining the relationship between a " good outcome" and either the number of PT visits or the type of treatment delivered. In other words, we have limited standards of care with broad interpretations about delivery of care. Unlike a decision to perform a surgical procedure, such as a TKA which has specific inclusion and exclusion criteria with broadly accepted standards about the role the Orthopedic Surgeon plays in the patient's surgery, PT has almost no parallel standards. As in clinical Psych., we can't accurately project an outcome, or how long it will take to achieve the desired goal. For PT, we can't even say with any degree of certainty that we agree what the outcome should be. So, why aren't we arguing that these rules should not apply? If you tell me that the defined benefit is 25 visits per year, I can tell a patient that is all CMS allows. With the proposed paradigm, none of us will ever know how much service will be allowed. CMS will game that system even more than they are gaming the current system. Let's hear from PT's and the APTA that at the very least we understand what is being proposed is objectionable. Let us at least acknowledge that EHR has NOT brought about any change in sharing information about patient care among clinicians treating that patient but rather it has drained out bank accounts, increased our documentation time, reduced useful information reporting to the lowest common denominator and again forces us to spend more time on documentation of an encounter than on the quality of the encounter! Why aren't we screaming that the " emperor has no clothes "?

      Posted by Brian P. D'Orazio DPT, MS, OCS on 5/27/2016 5:31 PM

    • I just read your post and hear your arguments as sound and true. I've been in physical therapy for 33 years. I've only been in private practice for about 8. I'm literally thinking about leaving the profession and giving up on it. It's so hard all ready to make a living, and not actually a very comfortable one as a solo practitioner trying to do one to one care and give really good treatments to patients. I have found the EMR has definitely not helped and in fact has slowed my documentation down, as well as paired it down to sound bites that are less than useful. I'm tired and discouraged and and may leave the profession early despite the fact that I have a lot of years of experience that definitely helps my patient outcomes it's too hard to prove it.

      Posted by Teresa J Anderson on 7/24/2018 9:27 PM

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