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  • New Tool for Managing Arthritis Focuses on Prevention and Management in Primary Care

    Nearly 1 in 4 adults in the United States has arthritis—some 54 million people, according to the US Centers for Disease Control and Prevention. Chances are more than good that many of your patients and clients are among them. A new tool developed by the Osteoarthritis (OA) Action Alliance, the US Bone and Joint Initiative, and numerous experts in the field—including a representative from APTA—can expand your knowledge of OA. In addition to provider-facing information, the Osteoarthritis Prevention and Management in Primary Care Toolkit also includes patient handouts and resources that you can use to empower your patients and clients to engage in self-management strategies that complement your clinical care.


    October 12 is World Arthritis Day—spend some of it educating yourself on OA by visiting APTA's arthritis webpage, which links to the OA toolkit and other resources such as community-based programs that can extend the benefits of your treatment and help patients and clients maintain their movement and independence.

    APTA: New SNF Payment System Should Drive Quality Patient Care, Not Staff Layoffs

    Fewer than 48 hours after the launch of a new Medicare payment system for skilled nursing facilities (SNFs), APTA began receiving word from physical therapists (PTs) and physical therapist assistants (PTAs) that a number of providers were announcing layoffs or shifts to PRN roles with reduced hours and fewer or no benefits. Many were told by their employers that the new system, known as the Patient-Driven Payment Model, or PDPM, was the reason for reduced staffing levels and less therapy.

    There's one problem with that explanation: it isn't true.

    That's the message APTA is delivering to SNFs, association members, and the media as it works to debunk myths surrounding a system that was designed to support clinician decision-making and push SNFs toward a more patient-focused payment model.

    "Yes, this is a new payment system, but it doesn’t change the reality that staffing and service delivery must continue to be grounded in quality patient care," said Kara Gainer, APTA's director of regulatory affairs.

    What PDPM changes—and what it doesn't
    The US Center for Medicare and Medicaid Services (CMS) describes the PDPM as an attempt at "better aligning payment rates…with the costs of providing care and increasing transparency so that patients are able to make informed choices." In that sense, PDPM is another step in the overall evolution of health care toward a more outcome-based, patient-focused system. And it didn’t arrive out of nowhere: CMS has been floating proposals for revamping SNF payment since at least 2017.

    Still, the new system, with its basis on classifying SNF residents among 5 components (including physical therapy) that are case-mix adjusted and employing a per diem system that can be adjusted during a patient's stay, marks a big change for SNFs. For SNFs that embraced volume-based approaches to care, the shift is even more significant.

    That may be true, Gainer said, but some of the most important elements of PDPM are the things that haven't changed under the new system.

    "Absolutely nothing changed between September 30 and October 1 [the startup date of PDPM] about patient needs in SNFs, or the value of physical therapy in meeting those needs," Gainer said. "PDPM is predicated on the idea that rehabilitation professionals will exercise clinical judgment and furnish reasonable and necessary services to patients."

    APTA created a 1-page handout that summarizes what's different about the PDPM—more patient focus, reduced administrative burden, a new definition of group therapy and a 25% combined limit on group and concurrent therapy, and a new way to determine function scores—but the resource also points out what remains unchanged: medically necessary care as a baseline standard, the criteria for skilled therapy coverage, and the centrality of clinical judgment, among other elements. Additionally, the need for daily skilled nursing services or rehabilitation services has not changed.

    The bottom line, according to Gainer, is that decisions that override clinical judgment and reduce or compromise patient care shouldn't be attributed to any requirements contained in PDPM.

    "Assertions that the PDPM mandates cuts in care are untrue, as are claims that PDPM requires the maximum use of group or concurrent therapy, sets out productivity requirements, and dictates how many minutes of care therapists can provide based on payment categories," Gainer said. "Whether deliberate or simply a misinterpretation of the rule, these myths need to be put to rest."

    A big incentive for SNFs to get past the myths: CMS is paying attention
    As APTA members began sharing their stories of layoffs and status shifts attributed to PDPM, APTA President Sharon Dunn, PT, PhD, took to Twitter with a simple message:

    "PDPM changed Medicare payment methodology for SNFs on Oct 1. It did not change the value of physical therapy services or patient needs. Reducing PT and PTA staff 46 hours into this model reflects poorly on the commitment to patient access and quality of care. And CMS is watching."

    SNFs should pay particular attention to the last sentence of Dunn's tweet, Gainer said.

    "Anyone who's followed CMS rulemaking over the past few years knows that patient outcomes data and their link to plans of care are becoming extremely important in how CMS shapes payment and other rules—and rightly so," Gainer said. "CMS has already indicated to us that they are closely monitoring the actions of health care facilities post-PDPM to determine if patient needs are driving decision-making, and may propose changes to counter any trends that impede the overall goals of the system."

    In an interview for an article on PDPM published in Skilled Nursing News, Robert Lane, a consulting director for health care consulting firm BKD, called the SNF layoffs and adjustments "premature," and stated his surprise that the SNFs didn't "pump the brakes a little for 90 days to see where we're at after the first quarter, couple of billing cycles."

    And like Gainer, Lane told Skilled Nursing News that it's certain the sudden drastic changes will "draw attention from CMS."

    APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have issued a joint statement noting that they have shared reports of layoffs directly with CMS and will continue to keep the agency abreast of reductions that put patients at risk.

    APTA's continued work
    The first versions of what evolved into PDPM emerged in spring of 2017, and APTA immediately began advocating to CMS on behalf of patients and the physical therapy profession. The association's efforts, fueled by member engagement, led to some significant changes to the final rule—including CMS' decision to implement a combined limit of 25% of group and concurrent therapy.

    But now, with PDPM in place, APTA's efforts need to shift to careful monitoring of how the rule is being interpreted and implemented, and its impacts on patient care and the PTs and PTAs providing that care. The reason is simple, according to Gainer: rules can be changed.

    "Another myth that's being circulated is that the PDPM is now written in stone and that no adjustments can be made," Gainer said. "That has never been the case with rules from CMS, and certainly isn't the case with this system—especially given the amount of attention CMS will be paying to how SNFs interpret and implement PDPM, and the degree to which those changes impact patient access to medically necessary care."

    Get the facts on PDPM and stay up-to-date on news about the new system: visit APTA's Skilled Nursing Facility and Home Health Payment Models webpage. Do you have your own story about how the PDPM has affected your work? Contact advocacy@apta.org.

    Biased? Me? PT in Motion Magazine Takes a Look at Unconscious Cultural Attitudes

    Want to get an up-close glimpse at a person with cultural biases? Follow these instructions:

    1. Grab a mirror.
    2. Look into it.

      That's one way to summarize the starting point for "Battling Bias's Distorted Images," the cover story for the October issue of PT in Motion magazine. The article makes the case that while unconscious bias—also known as implicit bias—is very much a part of the human condition, it's something that can be acknowledged and managed in ways that minimize its impact on relationships. For health care providers including physical therapists (PTs) and physical therapist assistants (PTAs), that's an important step to take in effective patient care.

      Through interviews with PTs in a variety of settings, author and Associate Editor Eric Ries explores how implicit bias—and these PTs' recognition of it in themselves—has impacted and changed their lives, particularly at the professional level. Several describe the journey as a path that's not always easy, but absolutely crucial to providing the best possible person-centered care.

      The article also delves into how you can uncover implicit biases through self-tests such as the Implicit Association Test series, and what to do after they're identified. PTs interviewed for the article provide insight on how physical therapy education programs can respond to the challenges of implicit bias, and provide practical tips on making behavior changes that may in turn lessen, if not eliminate, a particular bias.

      According to Hadiya Green Guerrero, PT, DPT, interviewed for the story, efforts to counter implicit bias are necessary for PTs and PTAs because the stakes are high.

      "Do your best to think about your biases and check them at the door," Green Guerrero says in the article. "Seek to learn and understand each patient or client to the clinic, what constitutes his or her biggest health concerns, and what barriers that person faces to optimal well-being and needed interaction with the health care system."

      "Battling Bias's Distorted Images" is featured in the October issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA.

      Where Things Stand, What APTA's Doing: Fee Schedule, SNF, and HH Rules From CMS

      The Centers for Medicare and Medicaid Services (CMS) spends much of its spring and summer churning out regulatory rules for the coming fiscal and calendar years. That means it's an equally busy time for APTA, its members, and other stakeholders to stay on top of the proposals, respond to whatever challenges emerge, and advocate for change when needed.

      This year's standout challenge: advocacy efforts around the CMS proposed physician fee schedule (PFS). The rule as proposed includes at least 2 troubling provisions that demanded a strong response—1 around how CMS would go about determining whether therapy services were delivered "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), and another that proposes an estimated 8% cut to reimbursement for physical therapists (PTs) and several other professions.

      APTA has been aggressively fighting these changes through comments, creating a platform to facilitate a flood of individual member letters to CMS, multiprovider organization sign-on letters, meetings with CMS representatives, and the latest: a bipartisan letter signed by 55 members of Congress urging CMS to rethink the cuts.

      So where do things stand with CMS rulemaking, and what is APTA doing around the PFS and other developments? Here's a guide to 3 of the biggest rules issued to date in 2019, along with information on our advocacy efforts.

      Medicare Physician Fee Schedule
      Status: Proposed (comment period closed); final rule expected in early November

      Quick take
      A misguided attempt by CMS to define (and pay less) when services are delivered "in part" by a PTA or OTA, and an arbitrary 8% cut in 2021 to PT and OT services as well as similar cuts to services furnished by clinical social workers, clinical psychologists, audiologists, and other providers could have major impacts on patient access to care. The rule also includes changes to the Merit-based Incentive Payment System (MIPs) and other areas.

      Our advocacy

      Resources: CMS fact sheet; PT in Motion News stories on PTA modifier and proposed cut; recorded webinar (from August 15); upcoming "Insider Intel" phone-in session (November 27)

      Skilled Nursing Facilities (SNFs) Prospective Payment System
      Status: Final, effective October 1, 2019

      Quick take
      CMS followed through with plans to dramatically change the payment system for SNFs by adopting the Patient-Driven Payment Model (PDPM), a system based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employing a per diem system that adjusts payment rates over the course of the stay. In a win for APTA and its members around group therapy, CMS moved away from a rigid 4-person definition and adopted the association's recommendation that the definition of group therapy as 2 to 6 patients doing the same or similar activities—the same definition used in inpatient rehabilitation settings.

      Our advocacy

      • APTA comment letter
      • In-person meeting with CMS representatives
      • Multiprofession coalition sign-on letter
      • Templated comment letters for individual clinicians

      Resources: CMS fact sheet; APTA fact sheet; PT in Motion News stories on proposed and final rule; APTA SNF PDPM webpage; recorded webinar series; recorded Insider Intel session (May 22)

      Home Health Prospective Payment System
      Status: Proposed for 2020 (comment period closed), final rule expected in early November

      Quick take
      Similar to its efforts around SNFs, CMS wants to transition to a new payment system for home health agencies (HHAs), known as the Patient Driven Groupings Model (PDGM). That system moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The proposed rule would also allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist and would end the HHA split payment approach in favor of a more efficient notice-of-admission approach.

      Our advocacy

      Resources: CMS fact sheet; PT in Motion News story on proposed rule; APTA webpage on PDGM; recorded webinar (August 5)

      Other advocacy efforts
      APTA has also provided comment letters on CMS rules on outpatient payment, Medicaid access, inpatient rehabilitation facilities, and hospital payment; and signed on to multiprofession coalition letters to CMS on outpatient payment and rules around durable medical equipment, prosthetics, orthotics, and supplies.

      Stay tuned
      As APTA continues to advocate for the profession, the association also provides its members with plenty of opportunities to get up-to-speed with both proposed and final rules. Keep the following upcoming events on your radar for more insight on payment and regulation:

      CMS Hospital Discharge Rule Puts the Focus on Patient Choice, Goals in Postacute Care

      In this review: Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies, and Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care (final rule)
      Effective date: November 30, 2019
      CMS Press Release

      The big picture: A better patient discharge process that falls short in some areas
      The US Centers for Medicare and Medicaid Services (CMS) has released a final rule intended to support patient preferences around discharge planning for a move from a hospital or critical-access hospital (CAH) to a home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long-term care hospital (LTCH).

      While the new requirements include APTA-supported changes that help put patients at the center of discharge to postacute care (PAC) providers, the rule lacks provisions that would strengthen patient choice by including physical therapists (PTs) on the discharge planning team.

      The rule goes into effect on November 30, 2019.

      Notable in the final rule

      • Patients will receive a list of potential PAC facilities for discharge. Under the new rule, the hospital's discharge plan must include a list of the HHAs, SNFs, IRFs, or LTCHs that participate in Medicare and that serve a particular geographic area—in the case of HHAs, that would be the area as defined by the HHA; in the case of SNFs, IRFs, and LTCHs, it would be the geographic areas requested by the patient. The discharge planning team would also share key performance data related to the PAC providers under consideration.
      • The process for providing the PAC provider list is designed to keep the playing field level. In response to commenters who asked how hospitals and ACHs can avoid steering patients toward 1 PAC provider over another, CMS states that facilities are required to present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences for all available PAC providers. Providers will also have to document all interactions around PAC care in the patient's medical record.
      • Patient goals must be the focus of the discharge plan. In an effort to create a more patient-centered process for discharge, CMS makes it clear that the plan must focus on the patient's goals and treatment preferences, and must include that patient and/or her or his active partners in the planning process.
      • Patients will be entitled to access their medical records. The final rule establishes that patients have the right to access their medical records in whatever format they prefer, providing that format is able to be produced.
      • HHA discharge planning time estimates will get an additional 5 minutes. CMS upped its estimates for the time it should take HHA PTs or nurses to complete information for discharge from the HHA from 5 minutes to 10 minutes. Some commenters advocated for as much as a 15-minute estimate, but CMS believes that most discharges will be uncomplicated and that the 10-minute estimate will be closer to an overall average.
      • The HHA discharge process will supply more information to patients. HHAs will be required to provide more information to patients who are discharged or transferred to another postacute care provider to help them select a provider that meets the patient’s needs and goals.

      What the rule doesn't do

      • PTs (and other relevant providers) aren't part of the discharge team requirements. Despite APTA and other commenters advocating that providers such as PTs, nutritionists, mental health professionals, and others be required to be included in the discharge team, CMS didn't make any changes, citing potential increases to the cost and complexity of the discharge process
      • Rehab nurses and respiratory therapists won't be required, either. CMS refused to follow the recommendations of some commenters that rehabilitation nurses and respiratory therapists be involved in the discharge needs evaluation and creation of the final plan.
      • Discharge instruction requirements aren't as detailed as in the proposed rule. Commenters expressed concerns with the proposed rules’ overly prescriptive discharge instructions for hospitals. CMS acknowledged these concerns and didn't finalize the requirements; however, under the new rule, hospitals can develop discharge instructions or share discharge information in accordance with applicable law earlier than the time of discharge.

      APTA will provide information on how to comply with the new requirements as it becomes available.

      APTA Helps You Spread the ChoosePT Message During National Physical Therapy Month

      It's October, which means one thing: you’re itching to get out into the community and promote your profession during National Physical Therapy Month (NPTM). But where to begin?

      As shared in an earlier PT in Motion News story, there are multiple ways to participate in this year's NPTM and deliver the message that physical therapy is effective for a wide range of conditions including pain. But you can't be everywhere at once—that's why it's a good idea to load up on handouts and share graphics that help spread the word.

      APTA has you covered. Just stop by our ChoosePT Toolkit webpage to browse a collection of free downloadable resources that help you get out the NPTM message. Here are a few examples:

      Handouts. Boot up your printer and create your own supply of flyers that make the case for physical therapy. Handout topics include an explanation of PTs and the benefits of physical therapy, how physical therapy is a safe alternative to opioids for pain management, questions to ask your health care provider about pain management, the APTA pain profile, and a handout on what PTs and PTA s need to know about the opioid epidemic.

      Postcards and signs. It's easy to produce professional-looking NPTM postcards and signs. Just take 1 of the files on the toolkit webpage to your local professional print/copy store, and they'll take it from there. Options include 11x17-inch posters and 5x7-inch postcards, such as this one available in available in English and Spanish.

      Social media graphics. APTA offers 5 different easy-to-download graphics that you can use on Facebook, Twitter, and anywhere else you make your social media mark. Some of the messages are focused on pain treatment and opioids, while others promote physical therapy as a wise overall health choice.

      Just in time for NPTM: APTA has refreshed the ChoosePT brand and consumer website in ways that promote physical therapy as an effective option for much more than pain management. We've also launched an improved Find a PT database that helps patients connect with local PTs. Be sure to update your Find a PT profile and help consumers choose physical therapy—and you.

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      2019 APTA Honors and Awards Nominations Now Open

      Members of the physical therapy profession do amazing things for people every day, and not just inside the walls of a clinic. And with National Physical Therapy Month upon us, now's the perfect time to honor those contributions by nominating an APTA member for national recognition through the APTA Honors & Awards program.

      The APTA Honors & Awards program is now accepting nominations for the 2020 awards cycle, an annual effort aimed at celebrating members' outstanding achievements in the areas of education, practice and service, publications, research, and academic excellence. In 2017 the awards program was expanded to include humanitarian work and societal impact, and this year's awards program features 2 new opportunities: outstanding physical therapist fellow and outstanding physical therapist resident.

      The program also includes the Catherine Worthingham Fellows of APTA, the Mary McMillan Lecture Award, and the John H.P. Maley Lecture Award.

      Detailed award descriptions, eligibility information, and nomination instructions for these and the many other awards and honors in the program are available on the APTA Honors & Awards webpage. Deadline for nominations is December 1.

      Award winners will be recognized at the 2020 NEXT Conference and Exhibition, set for June 3-6 in Phoenix. For more information, email Alissa Patanarut.

      CMS Releases a Burden Reduction Rule That Affects a Wide Range of Facilities, Settings

      In this review: Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care (final rule)
      Effective date: November 29, 2019, for most provisions; March 30, 2020, for implementation of hospital and critical-access hospital (CAH) antibiotic programs; March 30, 2021, for changes to Quality Assessment and Performance Improvement Programs in critical access hospitals
      CMS Press Release
      CMS Fact Sheet

      The big picture: An omnibus rule that could ease some regulatory burdens
      The US Centers for Medicare and Medicaid Services (CMS) has released a final rule aimed at reducing Medicare- and Medicaid-related regulatory burdens in a range of settings, from hospitals to home health care. And for the most part, the rule hits its target.

      The final rule includes provisions related to outpatient rehabilitation facilities, home health agencies, ambulatory surgical centers, hospitals, CAHs, psychiatric hospitals, transplant centers, X-rays, community mental health clinics, hospice care, and more. For the most part, the changes either lift or relax requirements, giving facilities more leeway in meeting reporting and other duties. CMS estimates the changes will save providers 4.4 million hours of paperwork time and result in $800 million in savings annually.

      Most provisions in the rule go into effect November 29, 2019.

      Notable in the final rule

      • Relaxed emergency preparedness requirements for most settings—except long-term care facilities (LTCs). The new rule changes a mandate for an annual self-review of a provider's or supplier's emergency program to every other year, except for LTCs, which will still have to submit reviews every year. The move to biennial requirements is also applied to training and testing around emergency preparedness (again, with the exception of LTCs), and allows providers to choose the type of test they administer—either a community-based full-scale test, or a facility-based exercise.

      CMS will also lift a requirement that Medicare and Medicaid providers and suppliers must document efforts to contact local, tribal, regional, state, and federal emergency preparedness officials, as well as document participation in "collaborative and cooperative planning efforts."

      • Less burdensome evaluation rules for home health aides, and more limited requirements around notifying home health patients of their rights. The final rule also gives home health agencies (HHAs) more latitude in how they assess the competencies of aides to allow for a "simulation" on a patient or "pseudo patient." In addition, aides who are found to be deficient in certain skills will need to undergo retraining and revaluation only on those particular skills, and be subject to a comprehensive process.

      HHAs will also be operating under less rigid rules about notification of patient rights: instead of requiring verbal notification of all patient rights, providers will be required to provide notification only of rights related to Medicare, Medicaid, or other federal programs, as well as potential patient liabilities as described in the Social Security Act.

      Comprehensive outpatient rehab facilities get a break on utilization review plans. The new rule reduces the frequency of utilization reviews from quarterly to annually.

      • More flexible requirements for hospitals around the use of comprehensive medical histories and physical examinations (H&P) presurgery/preprocedure. Instead of requiring H&P, hospitals will be permitted to use a presurgery/preprocedure assessment if, in the hospital's opinion, that's the appropriate way to go. The assessment option must be well-documented, and hospitals must consider the patient's age, diagnoses, type and number of procedures to be performed, standards of practice related to specific patients and procedures, and all relevant state and local laws.
      • Fewer requirements for hospitals and CAHs that provide swing beds, and easier reporting requirements for CAHs. The new rule changes requirements for swing bed providers—hospitals and CAHs that designate some of their beds for skilled nursing facility care—in a few ways: CMS is removing requirements that the facilities offer patients opportunities to "perform services for the facilities" if they choose, as well as requirements mandating ongoing activity programs, a full-time social worker for facilities with more than 120 beds, and the provision of 24-hour emergency dental care.

      CAHs will see some lessened reporting burdens as well—they will no longer be required to disclose the names of people with a financial interest in a CAH, and a current annual requirement to conduct a policy and procedures review will be changed to every other year.

      APTA's efforts, and the possibility of more to come
      The new rule is part of CMS' broad "patients over paperwork" initiative that continues to explore ways to decrease the regulatory burden on facilities and individual providers, and APTA has seized every opportunity to provide input to CMS on the topic. The latest rule reflects only some of the areas addressed by the association, according to Kara Gainer, APTA's director of regulatory affairs.

      "As we've done in nearly every call for comment on administrative burden, APTA and individual PTs have highlighted multiple areas that we think are in need of change," Gainer said. "This rule is a step in the right direction, but there are many more steps that should be taken if CMS truly wants to fulfill its commitment to putting patients over paperwork."

      APTA will provide information on how to comply with the new requirements as it becomes available.

      Want to find out more about the new rule? CMS is holding a national stakeholder call on the burden reduction rule on Thursday, October 3, 2019, from 1:00 pm-2:00pm ET. To join in, call 1-888-455-1397 and use conference ID 4114189. TTY Communications Relay Services are available for the hearing or speech- impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

      APTA to CMS: Proposed 8% Cut is 'Arbitrary' and Puts Patients at Risk

      The big picture: APTA is fighting a "nonsensical" and "arbitrary" plan to cut physical therapy reimbursement by 8% in 2021.
      The US Centers for Medicare and Medicaid Services' (CMS) proposed physician fee schedule (PFS) rule for 2020 is, as always, a wide-ranging plan that affects multiple types of providers. But this year, physical therapists (PTs), physical therapist assistants (PTAs), and the patients they serve are facing a particularly pointed threat: a cut to the reimbursement codes most often used in physical therapy. Combined, these reductions would reduce reimbursement by an estimated 8% in 2021. APTA's comment letter to CMS lays out how the cut could dramatically reduce patient access to effective care, forcing many PTs and other rehabilitation providers to leave Medicare or shutter their doors entirely.

      The comment letter also addressed numerous other provisions in the proposed rule, including changes to the Merit-based Incentive Payment System (MIPS), remote physiologic monitoring, digital evaluation, dry needling codes, and telehealth. Additionally, APTA reiterated many of its concerns regarding CMS’ proposal for determining when therapy services are delivered "in whole or in part" by a PTA or occupational therapy assistant. Those concerns were communicated to CMS in detail in August in a comment letter that described the plan as "fundamentally flawed." APTA and 2 of its members, along with 3 other associations, met in-person with the CMS Administrator earlier this month, echoing the same concerns.

      The proposed cut, and why it's a bad idea
      The cuts are associated with a CMS plan to adopt the American Medical Association-recommended increases in values for office/outpatient evaluation and management (E/M) codes, an increase that APTA sees as generally positive. The problem is in CMS' approach to paying for the increase.

      In order to adopt those increases and maintain budget neutrality, CMS proposes cuts to other codes to make up the difference. We believe there are other, more valid ways to respond: seeking additional funding for the increase; applying negative adjustments uniformly across all services; not excluding any specialties, procedures, or service codes; increasing the conversion factor; and phasing in any proposed reductions would be "appropriate and necessary" actions to take, as stated in our letter. Instead, CMS attempts to keep the E/M increase budget neutral through a seemingly haphazard approach that lowers reimbursement for non-E/M codes, resulting in the most drastic cuts to reimbursement for providers who don't bill E/M. That list of providers isn't limited to PTs and occupational therapists—it also includes audiologists, clinical social workers, clinical psychologists, ophthalmologists, optometrists, chiropractors, and more.

      In our comment letter to CMS, we point to 5 major areas of concern:

      1. The plan is an arbitrary, across-the-board cut that doesn't account for reimbursement decreases in other areas.
      We argue that PTs have been the target for cuts through other policies such as the multiple procedure payment reduction (MPPR), sequestration, Correct Coding Initiative edits, and by way of a 2018 revaluation of current procedural terminology (CPT) codes, particularly to the practice expense (PE) of certain codes. When those reductions are combined with the proposed 8% cut, on top of the pending 15% reduction in payment for services furnished by PTAs and OTAs in 2022, the reductions for many PTs could be closer to 23% in 2022. We call that an "unrealistic" plan that will lead to a "significant decline in beneficiary access" to physical therapy.

      2. The cut runs counter to CMS' efforts to provide patient access to better care.
      Both the US Congress and the Department of Health and Human Services emphasize the importance of a Medicare system that supports integrated team-based care, chronic disease management, and reducing hospital admission and readmission rates—concepts that are central to PT practice. Given this emphasis, we write, it's "nonsensical" to cut reimbursement to the very professionals who play key roles in achieving these aims by decreasing functional limitations and increasing strength and flexibility deficits.

      3. In the midst of an opioid crisis and a national conversation on pain management, CMS should be promoting physical therapy, not decreasing patient access to it.
      Research makes the case over and over again: physical therapy lowers overall costs of care, and is an effective pathway for management of many types of chronic pain. We ask CMS to explain how the proposed 8% cut supports those ideas, and argue that if Medicare beneficiaries are in need of access to effective nonpharmacological pain management treatments, "there must be adequate payment and coverage."

      4. There was little transparency and a seeming lack of responsible analysis in the development of this proposal.
      The Regulatory Flexibility Act requires CMS to conduct a regulatory analysis of changes, such as the 8% cut, including the ways it would affect small businesses and possible options for achieving its goals that reduce economic impact. If such an analysis was conducted, it doesn't seem to be reflected in the plan, which clearly puts PTs and many other providers at risk. We write that CMS' nontransparent approach and lack of dialogue with providers may have led to "many flawed assumptions regarding practice."

      5. The cut includes unfair reductions to practice expense (PE).
      PTs have seen reimbursement for PE—costs incurred in renting office space, purchasing supplies and equipment, hiring nonphysician and administrative staff, and more—decreasing since 2011, when CMS started introducing cuts through MPPR. APTA has always held that applying MPPR to PTs was inappropriate in the first place, and often results in underpayments. The proposed cut includes a PE reimbursement decrease of at least 3%. We write that it's a plan that puts "expediency ahead of quality." Instead, we argue for the removal of the proposed cuts to the PE values of codes used by physical therapists and that CMS recoup that money by looking to those codes used by providers "who do not have as demonstrable costs for equipment and supplies as physical therapy providers."

      What's next?
      The comments are one part of a multifaceted approach to advocacy against the proposed cuts. APTA members, patients, and other stakeholders have joined a grassroots effort opposing the plan, and the association has joined with the American Chiropractic Association, the American Psychological Association, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and 5 other professional associations in a letter opposing the cuts and requesting additional dialogue. APTA will continue to work with CMS to educate them on the negative consequences on patient health if this reduction is implemented. APTA and our members will also have a second formal opportunity to fight any proposed cut in the 2021 proposed fee schedule rule that will be released in July 2020.

      After the deadline for comments closes at 11:59 pm on September 27, CMS will begin its review process. The final rule is expected to be released in early November.

      Reading this before 11:59 pm on September 27? There's still time to add your voice to the effort. Visit APTA's "Regulatory Take Action" webpage to access a customizable template letters on both the proposed 8% cut and the PTA/OTA modifier proposal. It's easy—and crucial.

      APTA Co-Sponsored Study: Seeing a PT First for LBP Lowers Odds of Early and Long-Term Opioid Use

      In this review: Observational retrospective study of the association of initial health care provider for new-onset low back pain with early and long-term opioid use
      (BMJ Open, September, 2019)

      The message
      An analysis of more than 200,000 commercial and Medicare Advantage insurance beneficiaries has revealed what researchers describe as a "significant" pattern: among patients seeking treatment for low back pain (LBP), those whose initial visit was with a physical therapist (PT), chiropractor, or acupuncturist decreased their odds of early opioid use by between 85% and 91%, and lowered their odds of long-term opioid use by 73% to 78% compared with those whose index visit was with a primary care physician (PCP).

      The study
      Researchers reviewed insurance claims from 216,504 adults with new-onset LBP between 2008 and 2013 to explore the relationship between the type of provider seen at the initial (index) visit and subsequent opioid use. The study looked at opioid use in terms of both "early" use, defined as a filled opioid prescription within 30 days of the index visit, and "long-term" use—a filled opioid prescription within 60 days of the index visit and either an opioid supply of 120 days or more over 12 months or a supply of 90 days and 10 or more opioid prescriptions over 12 months. The analysis included claims for patient visits, inpatient and outpatient treatment with initial providers, and pharmacy services.

      Authors of the study were also interested in gauging the impact of varying levels of direct access to PT visits as allowed in state laws, and evaluated rates of initial physical therapy use in states with access laws they defined as "limited," "provisional," and "unrestricted."

      The de-identified data, provided by OptumLabs®, included both commercial insurance and Medicare Advantage claims, and are described by authors as "representing a diverse mix of ages, ethnicities, and geographical regions across the USA." The study itself was sponsored by the American Physical Therapy Association (APTA) and UnitedHealthcare®, and included APTA members Christine McDonough, PT, PhD, and Julie Fritz, PT, PhD, FAPTA, among the authors.

      Findings

      • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, and insurance enrollment for at least 12 months before and after the index date), 53% initially met with a PCP. Among what authors call "conservative providers"—PTs, chiropractors, and acupuncturists—chiropractors were the most frequently seen, drawing 23.1% of patients, followed by PTs (1.6%), and acupuncturists (0.8%).
      • About 18% of patients filled an opioid prescription within 3 days of the index visit, and 22% received a fill within the first 30 days. Only 1.2% of patients met the researchers' criteria for long-term use.
      • In terms of early opioid use, patients who saw a PT first had 85% decreased odds of receiving an opioid fill within the first 30 days after the index visit compared with patients who saw a PCP first. Patients whose index visit was with an acupuncturist were associated with 91% decreased odds compared with PCPs, and those who saw a chiropractor first were correlated with 90% decreased odds.
      • The decreased odds of opioid use with conservative treatment also carried over to long-term use, with 73% decreased odds associated with a PT index visit, 74% decreased odds for acupuncturists, and 78% decreased odds for chiropractors compared with patients whose index visit was with a PCP.
      • Compared with states in which direct access to PTs is limited, patients in states with provisional access to PTs—for example, states that impose time or visit limits—had 21% increased odds of seeing a PT at index. Those odds increased to 67% in states with unrestricted direct access.
      • Compared with patients whose index visit was with a PCP, patients who saw other types of physicians, such as orthopedic surgeons and neurosurgeons, tended to have lower odds of early opioid use—but those lower odds disappeared when it came to long-term use.

      Why it matters
      This large-scale retrospective study—authors believe it's one of a very few to look at opioid use patterns across multiple providers—adds to the evidence that conservative approaches to LBP can significantly lower the odds of opioid use, an important consideration as the country continues to struggle with its opioid crisis.

      The bottom line, according to authors is that "early engagement of conservative therapists may decrease initial opioid prescriptions in association with MD visits by providing the opportunity to incorporate evidence-based nonpharmacological approaches."

      More from the study
      Authors believe several factors might be at work when it comes to lower opioid use among patients whose index visit was with a conservative care provider:

      • These providers can't prescribe opioids, which may lower short-term use rates.
      • Patients who seek out conservative care providers may be doing so because they don't want to take opioids.
      • Conservative therapies tend to decrease LBP, lowering the need to seek other treatment.

      Related APTA resources
      The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

      Keep in mind…
      Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients, a factor that could influence the decision about which type of provider to see first. Researchers were also unable to dive more deeply into patient preferences and behavioral factors that might influence index visits and opioid use.

      Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

      [Editor's note: McDonough and Fritz are also the recipients of grants from the Foundation for Physical Therapy Research: McDonough received a Magistro Family Foundation Research Grant in 2015 as well as a New Investigator Fellowship Training Initiative in Health Services Research grant in 2009; Fritz was awarded an Orthopaedic Research Grant in 2002.]