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  • A Stark Reality: APTA Continues Efforts to Shore Up Self-Referral Law

    As the US Centers for Medicare and Medicaid Services (CMS), lawmakers, and others continue to press for more value-based approaches to care, attention has turned to a law that bars physicians from referring Medicare patients to services in which the physician has a financial interest, aka "self-referral." CMS has hinted that the prohibition, known as the Stark law, may interfere with the adoption of new, more integrated models of care, and a US House of Representatives subcommittee held a hearing on "modernizing" the law, perhaps through loosening up restrictions. APTA argues that at least part of the reform efforts should be aimed at eliminating exceptions as a way to increase value-based care opportunities.

    Recently, APTA staff were on Capitol Hill to encourage legislators and their staff to take a careful approach to decisions about the Stark law, which was the subject of a July 17 House Ways and Means Health Subcommittee hearing. During that hearing, legislators were weighing the law's effect on the ability to create alternative payment models (APMs)—systems that often seek to streamline and coordinate entire episodes of care. The hearing echoed a recent CMS request for information from the public on the Stark law, and discussed whether there is a need for "revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law."

    In comments provided to the House subcommittee, the association argues that a reformed Stark law with fewer loopholes could actually promote the growth of value-based care by leveling the playing field for physical therapists (PTs).

    As APTA explains in its comments, the current version of the Stark law includes an exception that allows physicians to self-refer for so-called "in-office ancillary services" (IOAS) that include physical therapy. That exception winds up hurting the development of APMs because it "fail[s] to promote collaboration with small- and medium-sized physical therapy and nonphysician practices," APTA writes.

    "Until [the US Department of Health and Human Services] creates a more level playing field between these different types of providers, physical therapists will be unable to meaningfully participate in Medicare and Medicaid APMs, despite their desire to do so, potentially impeding patient freedom of choice and access to the highest-quality care," the comment letter states.

    The association isn't alone in its commitment to eliminating Stark law loopholes. In 2017, APTA joined with the Alliance for Integrity in Medicare to support a bill in the House of Representatives that seeks to eliminate the IOAS exemptions. That bill, also supported by AARP, has not been scheduled for House committee review

    "We see the recent subcommittee meeting as a chance to highlight the need for more opportunities for physical therapist to participate in alternative payment models, all while protecting patient choice, increasing transparency, and strengthening access," said Justin Elliott, APTA's vice president of government affairs. "Effective value-based care is important. Eliminating conflicts of interest in health care is important. There's no reason why the two can't coexist."

    APTA will share that sentiment with CMS when it delivers the association's response to the CMS request for information (RFI) on the Stark law. The CMS call for feedback is largely focused on how the Stark law could be weakened through the creation of more exceptions or other tweaks, all in the name of promoting more coordinated care models. APTA is coordinating with the APTA Private Practice Section to draft comments by the August 24 deadline.

    The association also has developed a template letter that allows individuals to create a customized-but-consistent response to the CMS request (scroll down the webpage to the second bullet point under "APTA's Current Regulatory Advocacy Efforts).

    APTA is a strong supporter of easing unnecessary regulatory burdens on providers, but CMS and Congress must proceed with caution," said Kara Gainer, APTA's director of regulatory affairs. "We are urging CMS to think very carefully about the unintended consequences of making any changes that increase self-referral. A weaker Stark law could actually impede the transition to value-based care and worsen the patient experience in the process."


    • What about: States where the is currently direct access laws and has a very large health care system that requires physician referral for PT. This is referral for profit for the health care organization. They are the largest employer of MD's in the state. This leads to increased consumer costs as well as bigger health system profit. Referral for profit.

      Posted by concerned PT on 8/8/2018 9:36 AM

    • the IOAS loophole has basically neutered the Stark Law as it was intended. Large POPS have severely hindered the growth of PP PT's.

      Posted by Dean Erie on 8/8/2018 4:42 PM

    • While physician self-referral remains a problem, in my opinion, physicians referring to hospital based practices appears to be more rampant and more damaging. As hospitals either establish or purchase physical therapy practices in the community, it becomes increasingly difficult to compete as physicians are instructed to refer to hospital practices. This is not permitted with medication prescriptions, and should not be permitted for physical therapy orders (or any other physician orders, for that matter). It appears the APTA is either unaware of this problem, or is not willing to take action. Fighting POPTS is important, but in my area, referrals directed to hospital facilities is a much greater problem.

      Posted by John Hilson on 8/8/2018 6:04 PM

    • Three quick counter points: You want to level the playing field? Then fight for legislation to allow physical therapists to own physician practices. Many physician practices are selling out to hospitals where self referral is required by some contracts. I have seen no evidence that CMS wants to improve value. Their actions demonstrate they only want to cut cost and increase administrative burden.

      Posted by James Barsky, PT, DPT on 8/9/2018 5:55 AM

    • APTA and my state chapter have essentially jumped in bed with hospital systems here in SC. As someone mentioned above, hospital owned PT practices are becoming more prevalent. Since they also own the physician practices, they are de facto POPTs practices. The hospital system lobbies are incredibly powerful...will be interesting to see if any headway is made closing the Stark loopholes. Doubt it in this age of corporate-ness.

      Posted by Derek Sessions on 8/9/2018 8:59 AM

    • Instead of worrying over who physicians are referring to perhaps we should add mandatory patient education regarding their choice to go to whatever physical therapy practice they would like to go through to receive their care. There are good PTs at private practice, hospital based, and physician owned practices. I work in a hospital based outpatient therapy practice. The CEO of my hospital is a SLP, the rehab director is a PT. We get referrals from all over. We are 13 clinicians that are paid well with good benefits. We are held to 95% productivity- or 12 patients a day. We get to spend the time with the patients that need it. The problem here is that patients go to wherever their doctor tells them to unless they know that they don't have to. I've had multiple returning patients tell me that their doctor insisted they stay within their PT practice next door. The law will always come with loopholes, but making a person aware of their treatment options does not have loopholes.

      Posted by Natalee Cifuentes -> BLX^DL on 8/11/2018 8:43 PM

    • I agree that Hospital systems own most of the MD practices and are now also hiring surgeons who are told to refer only to the hospital based PT practice. I actually work for one and love my job, and we do give excellent one on one Care, but it definitely has become difficult for private practices to compete. APTA seems to turn a blind eye to it.

      Posted by Barbara Haughey on 8/12/2018 5:55 PM

    • This referral for profit (from physicians and hospitals alike) will stifle PT innovation and will limit patient care! Private practice allow for PT Innovation that will improve delivery of care by developing alternative models, techniques and approaches that larger organizations have too much bureaucracy and a lack of desire to even try. Small practices can pivot on a dime, move quickly with ideas and concepts, adapt and change in short minute. At our clinic we use music and dance with our patients and we offer a blend of group wellness programs that we transition patients into (without billing Medicare or charging the patient) even before they are discharged from individual PT. They can try our group program in addition to their individual treatment. We treat pain and mobility limitations with large movements, music and dance- along with traditional treatment. This could not happen in the big hospital system where PT’s are often juggling 2 patients through the day. Private practice PT provides healthy competition and new ideas. In our community, hospital system referrals go directly to the hospital owned clinics. Our referrals come directly from patients-but even when patients ask for our clinic they still get a call from the hospital PT clinic! Physicians have told me they cannot refer directly to our clinic. They tell their patient to stop by and talk to us and then the patient initiates the referral- extra burden on the patient, and I am sure some will not do it. I will gladly submit that template letter to CSM. Thank you for your advocacy. Patrice Hazan, GroupHab Physical Therapy, SC

      Posted by Patrice Hazan on 8/17/2018 9:31 PM

    • All of you that work for these hospital owned / POPT practices as PT's are absolute sell outs! If you wanted to do something about the APTA turning a blind eye to the issue of hospital owned PT practices, which is a bigger problem than POPTs, then STOP WORKING FOR THE HOSPITAL OWNED & POPTS!! I'm in the trenches fighting for the scraps of patients. Get in the trenches with your fellow PT's and stop selling out! I don't think that the ATPA is going to make the necessary changes in legislation. Guess, I'll have to be the change that I want to see. I'll be reaching out to private practice owners on L.I soon!!!

      Posted by Parsa K, PT on 11/28/2019 11:17 AM

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