A proposed change in how Medicare would reimburse for lower-limb prostheses is drawing mounting criticism from patients and stakeholder organizations—including APTA. According to the association, the proposals now being considered would negatively affect patients by "restrict[ing] the ability of a therapist to provide the appropriate medically necessary care if they are providing therapy to a patient who has received an ill-fitting, or non-customized prosthetic or component based on Medicare coverage policies."
In a letter submitted to the durable medical equipment administrative contractors (DME MACs), the association takes issue with a proposal developed by the DME MACS that would impose extensive restrictions on who could receive a lower-limb prosthesis, what kind (or kinds) of prosthesis they could get, and when and under which conditions Medicare would pay for the devices. Though the DME MACs contend that the changes are necessary to counteract steep rises in prosthetics expenditures among Medicare beneficiaries, critics including APTA believe the proposal ignores the realities of rehabilitation and shortchanges the importance of clinical judgment.
"APTA understands the difficult balance of providing quality care that is medically necessary while attempting to curtail costs," the association states in its letter. "However, this [local coverage determination] has the potential to result in lower quality of care while ultimately increasing costs. In the long run, costs could be higher to Medicare due to complications associated with prosthetics that were inappropriate for the patient due to restrictive requirements, provided untimely or not provided at all."
APTA's concerns about the proposal range from what it views as overly restrictive definitions of terms in some sections to a lack of clarity in others, and addresses provisions that the association feels would minimize the importance of the expert individualized determinations made by appropriate health care professionals.
Additional problematic areas of the proposal cited by APTA and other organizations include the potential for CMS to restrict patients to older-model artificial legs if the beneficiary has any form of mobility aid (such as a walker or cane) that they would use for limited purposes, and a requirement that the prosthesis must provide "the appearance of a natural gait." In its letter, APTA points out that "'Natural gait' is a subjective term—and potentially discriminatory, particularly when dealing with individuals with disabilities."
Last week, opponents of the proposal staged a protest at the headquarters of the US Department of Health and Human Services (HHS), an event that drew coverage by CNN and other news outlets. The protest effort received a boost from former Nebraska Senator Bob Kerrey, who himself has an amputation and was quoted in a press conference as saying that "this is as stupid a rule as I've ever seen," and that the rule "completely ignores what's going on with amputees."
The comment period on the proposed changes closed on August 31. CMS has not established a timeline on when any new rules would take effect, according to an article in Modern Healthcare.
A recent Wall Street Journal (WSJ) article on the potential overuse of ultrahigh therapy hours among nursing homes prompted a response from APTA that delivers the physical therapy profession's perspective.
"Patient care decisions should be made by clinicians in accordance with their clinical judgment and ultimate professional responsibility to their patients," President Sharon L. Dunn, PT, PhD, OCS, writes in a letter to the editor published on August 26 (registration/sign in maybe required to view WSJ version; access an online copy from APTA here). "Value … should be the primary indicator of performance."
The APTA letter was written after the WSJ published an article citing "copious" use of ultrahigh therapy hours billed to Medicare by skilled nursing facilities (SNFs). That report claims that between 2001 and 2013, the use of the ultrahigh category of rehabilitative therapy reimbursement—720 minutes or more a week per patient—has increased from 7% of patient days in 2002 to 54% of patient days in 2013.
"The challenges to ensuring delivery of appropriate patient care against systems that incentivize volume-based rehabilitation services are, unfortunately, well known to those in the rehabilitation profession," Dunn writes. "It isn't uncommon for rehabilitation professionals to find themselves in situations in which they are pressured to meet goals that have less to do with the patient's needs and more to do with the volume of services provided."
The letter also describes the collaborative efforts of APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA) to push for value-based care based on clinical judgment, not productivity goals. "We are deeply committed to ensuring that the correct incentives are invoked in care delivery in a manner that earns our patients' trust," Dunn writes.
More on the value-vs-volume debate, and APTA's efforts to support practice integrity: APTA, AOTA, ASHA Consensus Statement on Clinical Judgment in Health Care Settings (.pdf); APTA Center for Integrity in Practice website (includes a free course on compliance); "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.
Patient access to physical therapy, legal protection for the term "physical therapy," and the detrimental effects of high patient copays were all part of the discussions taking place at the APTA exhibit booth at the National Conference of State Legislatures (NCSL) Annual Conference held last week in Seattle. This year's conference attracted almost 5,000 state legislators, regulators, association representatives, corporations, and public policy experts from around the country.
APTA staff and volunteers from the Physical Therapy Association of Washington helped to get the policy messages across in conversations with visitors to the booth as well as through the "APTA PT Challenge," a quiz on term protection, copays, and patient access that visitors took to be eligible to enter a drawing for a Fitbit. In addition, the association participated in the annual NCSL "Walk for Wellness," with members of the Washington Chapter leading warm-up exercises.
Also on hand at the APTA booth: a representative from the Federation of State Boards of Physical Therapy, who provided information on the proposed Interstate Licensure Compact for Physical Therapy.
Check out the Storify below to see how the #PTTransforms message is being shared.
Data, data, data. The final rules for inpatient rehabilitation facilities (IRF) payment and the inpatient prospective payment system (IPPS) continue the Centers for Medicare and Medicaid Services' (CMS) effort to put teeth into its push for more quality reporting while offering a mix of payment increases and cuts.
In rules that aren't significantly different from what they were when proposed in April (IRF, IPPS), CMS is applying more pressure to make the shift to a system it describes as being "based on the quality, rather than the quantity of care [health care providers] give patients."
CMS issued fact sheets on both the IRF and IPPS final rules. Here's a quick rundown.
Inpatient Rehabilitation Facilities
Payment: CMS has updated payments in 2016 by 1.8%--about $135 million. No changes were made to facility-level adjustments, which remain frozen at 2014 levels.
The big takeaway: After several years of evaluation, CMS has finally created a standalone market basket for IRFs, which will in turn boost payments. The trade-off: substantially increased quality reporting requirements.
The exclusive IRF market basket will allow CMS to collect outcome measures required by the IMPACT Act, a law that seeks to standardize reporting across postacute care facilities. These measures, which initially will include data on pressure ulcer incidence, falls, and changes in patient function and cognitive function, will be expanded over time. CMS expects to publicly share IRF reporting data beginning in the fall of 2016.
Inpatient Prospective Payment System
Payment: Not surprisingly, it's complicated. Acute care hospitals that successfully participate in the quality reporting program and that are "meaningful" users of electronic health records would receive a .9% payment update. Hospitals that don't successfully participate in the quality reporting program face a one-fourth reduction in that update; facilities that are not meaningful users of EHRS would have their update reduced by one-half.
CMS is also continuing its penalties on high readmission rates. According to an article in Kaiser Health News, the majority of hospitals will face reductions based on 30-day readmission rates between 2011 and 2014. Other reductions include a potential 4.6% overall reduction for long-term care hospitals (LTCHs).
The big takeaway: Data and outcomes. CMS will update the hospital inpatient quality reporting program by adding 7 new measures in 2018 and 2019, and will increase the measures required in the value-based purchasing program. LTCHs will also be required to report the same postacute care measures that will be required of SNFs through the IMPACT Act.
APTA provided comments on both the IRF (.pdf) and IPPS (.pdf) proposed rules, and will develop summary highlights on the final rules in the coming weeks.
Skilled nursing facilities (SNFs) will see a Medicare rate increase next year, although it won't be quite as much as originally proposed by the Centers for Medicare and Medicaid Services (CMS). And while news about next year's payment adjustment almost always gets attention, some of the most notable parts of the new rule are more focused on the future beyond 2016, and what SNFs will be expected to do if they want to avoid penalties—or pursue incentives.
As for payments, the rule rolled out last week by CMS includes a rate increase of 1.2% for 2016, a bump that's down about $70 million from the 1.4% increase proposed earlier this year. Overall, CMS projects aggregate payments to increase by $430 million in 2016.
But the news isn't just about payments. Other parts of the rule are worth noting because of the ways they will change reporting requirements over the next few years. These changes apply to 3 main areas:
The reporting changes are designed to comply with specific mandates in the Affordable Care Act, the Protecting Access to Medicare Act, and the IMPACT Act, but CMS believes the combined effect of the new requirements will be to move the ball closer to the goal of value-based payments. "The final rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people," CMS states in a fact sheet on the changes as proposed in April.
APTA submitted comments on the proposed rule (.pdf), and will develop a summary and highlights guide during the coming weeks.
Internationally educated physical therapists (PTs) will soon be able to get up to speed on crucial areas of the US health care system, thanks to a collaborative effort to develop an online course that aims to smooth the transition into practice as a licensed PT in the US.
APTA, the Federation of State Boards of Physical Therapy (FSBPT), the Foreign Credentialing Commission on Physical Therapy (FCCPT), and APTA's Section on Health Policy and Administration (known as HPA: The Catalyst), recently announced that Duke University has been selected to develop, run, and administer an online course that covers the health care delivery system in the US. According to a news release from APTA and its project partners, the course is designed to help PTs educated and trained outside the US "overcome hurdles resulting from cultural differences and achieve a smoother and quicker transition" to stateside practice.
The joint effort to establish the course began over a year ago, led by a multi-organization project team with members from each of the participating entities.
Aspects of the American health care system that will be covered in the 10-module course will include the role of federal and state governments, Medicare and Medicaid basics, the private insurance system, proper use and supervision of support personnel, ethics and integrity in practice, cultural competence, billing, and direct access.
The course will be made available online through Duke University. Participants will receive college credit for completing all 10 modules.
Duke was selected from among 10 candidates that had submitted proposals.
"This is a fantastic example of what can be achieved when leading groups in health care collaborate to achieve a common goal," said APTA President Sharon L. Dunn, PT, PhD, OCS, in the statement. "We are excited to get the ball rolling."
When it arrived as signed legislation 50 years ago, Medicare and Medicaid was far from the system we know today—especially when it comes to physical therapy. APTA is marking the program's half-century birthday by highlighting how its evolution affected the profession, and vice-versa.
Just in time for the July 30 anniversary of Medicare and Medicaid, the association has released an infographic (.pdf) that lays out the timeline for physical therapy's involvement in a program that covers an estimated 124,000,000 people (55 million via Medicare and 69 million through Medicaid). The program, controversial at the time of its implementation, now is credited with increasing life expectancy and reducing poverty in the United States.
Today's Medicare and Medicaid are significantly different from their original forms. Medicaid, for example, was tied to welfare, and Medicare didn't cover prescription drugs. Initially, private insurance played a far less prominent role than it does today, and hospitals and nursing homes were racially segregated (something Medicare and Medicaid helped to eliminate).
The physical therapy profession became part of this evolution in 1968 and has remained integral to the program ever since. Like almost every other element connected to Medicare and Medicaid, however, the relationship between the programs and physical therapy has changed over time.
It's a relationship that, judging from the APTA timeline, has had its share of ups and downs. But it generally has trended toward increased patient access to physical therapist services. Among the notable developments listed in the infographic:
Many more details appear on the timeline, including more recent developments such as the repeal of the flawed sustainable growth rate formula and the signing into law of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.
"It's nearly impossible to underestimate the effects Medicare and Medicaid have had on the overall population health of the United States," said APTA President Sharon L. Dunn, PT, PhD, OCS. "The physical therapy profession has had a relationship with these programs for nearly as long as they've existed. We should take pride in the ways our commitment to patient health and transformation has, in turn, helped Medicare and Medicaid evolve."
Interested in more history and real-world accounts of the ways in which Medicare and Medicaid have made a difference in people's lives? Check out the CMS webpage devoted to the anniversary.
In addition to its annual payment update, the recently released Centers for Medicare and Medicaid Services (CMS) proposed rule for the 2016 Medicare home health prospective payment system (HH PPS) includes policy changes for home health agencies and a new value-based home health model to encourage quality.
Below are some key highlights of the rule that impact physical therapists and physical therapist assistants. The association will prepare a more-detailed summary in the coming days and post it to APTA's website.
Payment Policy. Taking into account all the policy changes, CMS estimates that overall Medicare payments to home health agencies will be reduced by $350 million or 1.8% in 2016 compared with 2015. This decrease reflects a 2.9% market-basket update and 0.6 percentage point cut for productivity, which is mandated by the Affordable Care Act. The rule also includes a 1.72% cut in each of 2016 and 2017 to account for estimated case mix growth 2012-2014, which the agency believes is unrelated to patient acuity, and a scheduled -2.5% rebasing adjustment, the third of a 4-year phase-in. In addition, the proposed 2016 national, standardized 60-day episode payment rate would be $2,938.37. If a home health agency (HHA) does not submit the required quality data, that rate would drop by 2% to $2,880.92.
Home Health Quality Reporting Program. CMS will add 1 standardized cross-setting measure to the Home Health Quality Reporting Program for 2015, as required by the IMPACT Act of 2014. The law requires HHAs, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals to submit standardized patient assessment data and standardized data on quality measures and recourse use. The proposed new measure, the National Quality Forum (NQF)-endorsed measure: Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), addresses changes in skin integrity. Also new for 2016, all HHAs will need to submit both admission and discharge OASIS assessments for at least 70% of all patients whose episodes of care occurred during the reporting period starting July 1, 2015. The threshold will increase by 10% in each of 2016 and 2017 to reach 90%.
Home Health Value-Based Payment Model. HHAs in 9 states will participate in a new value-based payment model beginning January 1, 2016. These HHAs will receive a payment increase or reduction in a future year based on quality performance in the designated earlier year, and CMS projects an estimated $380 million in total savings 2018-2022 from reductions in unnecessary hospitalizations and skilled nursing facility usage. The states, chosen randomly from within designated geographic groupings, are Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington. Among the details of the program:
In the first physician fee schedule rule to come out since the repeal of the sustainable growth rate formula, the Centers for Medicare and Medicaid Services (CMS) proposes revisions to payment policies, establishes 2016 payment rates for Medicare-billed services, and updates quality provisions. The rule also begins implementation of the new merit-based incentive payment system, applicable for now to physicians and other designated providers (not physical therapists) only.
How will the rule impact physical therapists (PTs) and physical therapist assistants (PTAs)? Below are some key highlights from APTA's initial look at the proposed rule. The association will prepare a more detailed summary in the coming days and post to APTA's website.
2016 Payment Rates. The payment rate for physical therapy services is estimated to increase approximately 0.5%. This is based on:
Misvalued Codes. Ten CPT codes that PTs typically report were identified by CMS for review to determine if they are "misvalued" and need to be updated based on possible changes in physician work and direct practice expense inputs, as these codes haven't been reviewed since 2009 or earlier. The codes are 97032 (electrical stimulation), 97035 (ultrasound therapy), 97110 (therapeutic exercises), 97112 (neuromuscular reeducation), 97113 (aquatic therapy), 97116 (gait training), 97140 (manual therapy), 97530 (therapeutic activities), 97535 (self-care management training), G0283 (electrical stimulation other than wound). They are among 118 total "high expenditure" codes (with Medicare allowed charges of $10 million or more) that CMS identified for review, with a target of a 1% reduction in expenditures for misvalued codes in 2016.
Quality Provisions. Reporting requirements and the measures that PTs report in 2016 under the PQRS program will be largely unchanged from 2015. PTs who don't successfully participate in PQRS in 2016 will face a 2.0% reduction in payment in 2018. In other quality reporting provisions:
Physician Self-Referral. CMS proposes some major provisions related to the physician self-referral law (ie, Stark Law) and its exceptions. CMS states the purpose of these proposals is "to accommodate delivery and payment system reform, to reduce burden, and to facilitate compliance," and "to expand access to needed health care services."
APTA will submit comments on the proposal, which are due September 8.
Did you know that Medicare payments will be increased by 0.5% effective July 1? Stay on top of the new rates with APTA's MPPR calculator—an outpatient therapy claim pricer that can help you determine your payment for services.
Tip: Be sure to click on the calculator that corresponds to the date service was provided.
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