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  • CMS Considers Upgraded Requirements for Orthotics and Prosthetics Providers

    A proposed new rule from the Centers for Medicare and Medicaid Services (CMS) would include qualified physical therapists (PTs) among the providers who could furnish and bill for custom orthotics and prosthetics; however, the CMS definition of "qualified" may have administrative and financial implications for PTs.

    The proposed rule, issued on January 11, aims to tighten up requirements around who CMS will work with when it comes to making and furnishing devices ranging from glass eyes to exoskeletal systems and finger orthotics. In addition to an estimated 900 PTs who could be affected by the proposed rule, the provisions would also have an impact on facilities including skilled nursing facilities (SNFs) and rehabilitation agencies.

    For PTs, the most notable parts of the proposed rule have to do with how a provider would become qualified to participate in the system. According to a fact sheet from CMS, while PTs are among the providers who could participate, they would need to be "licensed by the state [as a qualified provider of prosthetics and custom orthotics], or … certified by the American Board for Certification in Orthotics and Prosthetics … or by the Board for Orthotist/Prosthetist Certification." These requirements would need to be met within a year after CMS posts its final rule, or at the time of the provider's reaccreditation cycle, whichever is later.

    CMS is accepting comments on the proposed rule until March 13, 2017. APTA regulatory affairs staff is preparing comments to CMS and will post a fact sheet on the proposal in the coming weeks.

    Home Health Agencies Face New CMS Rules for Participation Starting July 13

    The Centers for Medicare and Medicaid Services (CMS) brought its home health participation rule out of the 1990s by issuing its first revision to the rule in more than 20 years. The new rule, set to go into effect July 13, 2017, establishes minimum standards for home health agencies (HHAs) that want to serve Medicare and Medicaid beneficiaries, and includes requirements that CMS hopes will strengthen patient rights, encourage more effective communication between patients and caregivers, and result in better outcomes reporting.

    APTA regulatory affairs staff are reviewing the 374-page rule now, and will publish a fact sheet in the coming weeks. In the meantime, here are a few basics on the new rule.

    • Physical therapists (PTs) as clinical managers. APTA was successful in its advocacy for PTs to be included in the list of providers qualified to serve as clinical managers for an HHA. Under the new rule, managers have oversight responsibilities related to patient and personnel assignments, care and referral coordination, needs assessments, and plans of care.
    • Communications standards and patient rights. The rule requires that the HHA have an integrated communication system for care coordination, with an active link between the HHA and the patient's physician. HHAs must also provide patients with a written notice of rights.
    • Patient information. Under the new rule, patients and caregivers must receive education and training "including written instructions outlining medication schedule/instructions, visit schedule, and any other pertinent instructions" related to patient care.
    • Patient assessment. HHAs must conduct a more comprehensive patient assessment to guide the development of a plan of care.
    • Quality reporting. The new rule "further refines current HHA quality efforts and brings HHA quality programs in line with their counterparts in a variety of other settings, such as hospitals and hospices," CMS states.

    Want to stay on top of all the Medicare changes affecting PTs in 2017? Check out APTA's "2017 Medicare Changes" webpage.

    2016's Top Stories From PT in Motion News

    From national recognition of the importance of physical therapy as a first-line approach to pain treatment, to state-level wins that could set the stage for even bigger changes to come, 2016 had no shortage of news that affected the physical therapy profession. Here's a rundown of the 5 most-viewed stories from PT in Motion News.

    (Editor's note: Be sure to take a minute or 2 to scroll through reader comments—often as interesting as the story itself.)

    1. A top SNF therapy provider reaches a $125 million settlement with DOJ after a PT whistleblower takes action.
    January: The US Department of Justice (DOJ) announced that the nation's largest nursing home therapy provider has agreed to pay $125 million to settle a DOJ lawsuit that alleged the company engaged in a "systematic and broad-ranging scheme" to increase Medicare reimbursements by submitting false claims for rehabilitation therapy.

    2. Oregon becomes the first state to adopt the physical therapy licensure compact.
    March: Oregon made physical therapy history by becoming the first state to join the Physical Therapy Licensure Compact, a system that aims to make it possible for physical therapists and physical therapist assistants to practice in multiple states through a single license and privilege.

    3. Wisconsin law says PTs are authorized to order x-rays.
    April: The new Wisconsin law is historic because it's the first time a state physical therapy practice act has specifically listed ordering x-rays as within a PT's scope of practice.

    4. CMS issues a final fee schedule that acknowledges levels of physical therapy evaluations—but doesn't assign different payment values.
    September: Though the lack of tiered payment values was disappointing, the new 3-level coding system opens up the possibility for physical therapists to help shape the future of payment.

    5. The CDC issues prescription guidelines that recommend physical therapy and other nonopioid approaches as the "preferred" approaches to treatment of chronic pain.
    March: The CDC delivered a clear message that PTs and PTAs have known for some time: there are better, safer ways to treat chronic pain than the use of opioids. The guidelines became a touchpoint for APTA's #ChoosePT antiopioid campaign.

    NYT: CMS Consideration of Outpatient TKA Sparks Debate

    The New York Times (NYT) is reporting "deep discord in the medical world" over the possibility that the US Centers for Medicare and Medicaid Services (CMS) could allow total knee arthroplasty (TKA) to be performed as an outpatient service for its beneficiaries. While a final decision may be a year or 2 away, the Times reports that "many orthopedic doctors and hospitals" are lining up against free-standing surgery centers and outpatient facilities over the issue.

    At the center of the debate is CMS' ongoing consideration of reimbursing for outpatient TKA, and its recent efforts to solicit comments on the change. According to NYT, CMS documents state that an "overwhelming majority" of commenters were in favor of the outpatient option. APTA is on record as a supporter of the move, though the association cautioned that the change would need to be accompanied by updated payment methodologies.

    The December 20 NYT article casts the debate as "as much about money as medicine," with reporter Christina Jewett writing that the allowance for outpatient TKA could create "a huge shift in money—out of hospitals and into surgery centers." On the medical side of the equation, the debate centers on whether the move would create more risk of complications postsurgery, or if "advances in surgical technique, anesthetics, and patient education"—accompanied by careful selection of outpatient candidates—would make the outpatient option a viable one.

    Trump Taps Price for HHS, Verma for CMS

    President-elect Donald Trump has announced his hoped-for changes to leadership of the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), with Georgia Rep Tom Price (R-6th) to be nominated for HHS secretary, and Seema Verma, CEO of the Strategic Health Policy Solutions (SVC) consulting group, tapped to serve as CMS director.

    Price joined Congress in 2004, where he now serves as chairman of the House Budget Committee, and is a member of the Health Subcommittee of the House Ways and Means Committee. Trained as an orthopedic surgeon, Price worked in private practice for nearly 20 years.

    In her work with SVC, Verma is credited with an instrumental role in crafting Healthy Indiana 2.0, Indiana's Medicaid program introduced by Gov Mike Pence, now the vice president-elect.

    “No matter what health care changes are ahead, APTA’s goals remain unchanged. APTA will continue to advocate for policies that benefit the health of all Americans by removing barriers to physical therapist treatment," said APTA President Sharon L. Dunn, PT, PhD. "And we will continue to be guided by our vision of transforming society by optimizing movement to improve the human experience.”

    Price's and Verma's nominations need to be confirmed by the Senate.

    The Good Stuff: Members and the Profession in Local News, November, 2016

    "The Good Stuff," is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    “It’s more than a miracle, I got my husband back, my kids got their dad back. These folks here are more than just miracle workers—they're now part of our family.” - Deanna Messinger, wife of Mark Messinger, on the physical therapy team that helped her husband recover from injuries sustained from a falling tree. (WIVB4 , Buffalo, New York)

    Laura Markey, PT, DPT, is using her experience with breast cancer to empower others to live boldly. (Prescott, Arizona, Daily Courier)

    A special physical therapy program is helping young cancer survivors get back in the game. (5News, Fort Smith, Arkansas)

    Andrea Zujko, PT, DPT, is helping to lead an innovative program that brings physical therapy sessions to dance students at Barnard College. (New York Columbia Spectator)

    Sara Garcia, PT, DPT, "uses her heart to help toddler's muscles grow." (KETV7, Omaha, Nebraska)

    Employers are finding value in "onsite" physical therapy. (PropertyCasualty360)

    Diane Page, PT, DPT, continues to inspire her students, even after losing her home to a fire. (WLOS News 13, Asheville, North Carolina)

    From the North American Cystic Fibrosis Conference: the role of physical therapists is "essential" in addressing secondary impairments associated with CF, including urinary incontinence. (Cystic Fibrosis News Today)

    Robert Cochrane, PT, DPT, discusses how physical therapy can help people who are suffering the aftereffects of concussion. (Bangor, Maine, Daily News)

    “I tell patients, 'The surgery restores your anatomy. The rehab restores your function.' You don’t get good, strong, powerful motion if you don’t rehab it – and that’s the ultimate result patients are looking for." – former physical therapist, now orthopedic surgeon Ryan Wilkins on the importance of physical therapy after surgery. (Buffalo, New York, News)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Draft Recommendation: Children With Obesity Require at Least 26 Hours of 'Intensive Behavioral Interventions'

    A federal task force thinks that health providers should routinely screen children 6 and older for excess weight, and recommend at least 26 hours of "comprehensive, intensive behavioral interventions" for those found to be obese. That recommendation, and the study supporting it, are now open for public comment.

    Developed by the US Preventive Services Task Force (USPSTF), the recommendation is based on an evidence review of studies on pediatric obesity screening as well as research on behavioral interventions for children who are obese. As it did in its 2010 recommendation, USPSTF urges clinicians to perform the screening and recommend the behavioral interventions—what's different about the latest draft recommendation is that it includes what the task force believes is the minimum amount of time needed for these interventions to have an effect.

    "Lifestyle-based weight management interventions with 26 or more hours of intervention contact generally increased weight reduction with no apparent harms, and some cardiometabolic measures were improved with 52 or more hours of contact," write authors of the USPSTF study. "Less intensive programs are unlikely to improve weight status, except perhaps for children who are overweight but do not yet have obesity."

    The study recommends interventions that address 4 areas: dietary modification, increasing energy expenditure, family involvement, and behavior change techniques such as goal setting, self-monitoring, reward systems, and stimulus control.

    "Most successful interventions included sessions that targeted both the parent and child (separately, together, or both); offered individual family sessions as well as group sessions; provided information about healthy lifestyle choices; encouraged the use of stimulus control (eg, limiting access to tempting foods, limiting screening time), goal-setting, self-monitoring, contingent rewards, and problem-solving; and included some supervised physical activity sessions," authors write. "Parents were frequently asked to modify their behavior and were sometimes actively engaged in weight loss interventions themselves."

    The task force doesn't know whether the recommendation, if followed, will help children maintain a healthy weight through adulthood. The public comment period on the recommendation and supporting study is open until November 28.

    APTA offers several resources on obesity, including continuing education on childhood obesity, and a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity. In addition, the March 2016 issue of Physical Therapy includes recent recommendations for physical therapists treating children with obesity.

    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.

    US News: Time for Chronic Pain Treatment Without Opioids – and Policies That Make it Possible

    Two researchers believe that when it comes to pain treatment, if the US truly wants to alter the future, it could do well to look to the preopioid past—and then make policy changes that would increase patient access to nondrug approaches to chronic pain.

    In a recent opinion piece published in US News and World Report, authors Jason Doctor, director of health informatics at the USC Leonard D. Schaeffer Center for Health Policy and Economics, and Joan Broderick, senior behavioral scientist at the University of Southern California Center for Economic and Social Research, write about the ways pain treatment should change in light of the Comprehensive Addiction and Recovery Act passed by Congress earlier this year. That act, aimed at battling the opioid abuse epidemic, includes the establishment of a Department of Health and Human Services task force that will review and modify best practices for pain management.

    Broderick and Doctor assert that simply reducing the amount of opioids prescribed won't by itself address the issue of what to do for the millions of Americans who will continue to suffer from chronic pain. That, they argue, will require the HHS task force to take a kind of back-to-the-future approach.

    "The task force needs to look back prior to the [opioid abuse] epidemic when the first-line treatment for chronic pain was not drugs," they write. "Teams of occupational and physical therapists, social workers, physicians, and psychologists—frequently operating in multidisciplinary centers—addressed the social, psychological, economic, and physical components of pain."

    When it comes to the treatments themselves, Broderick and Doctor don't mince words. "They worked," they write. "They made patients physically stronger and gave them the self-management skills that helped them lead more fulfilling and productive lives."

    The problem, they write, is that the current health care environment stacks the deck against nondrug approaches—something that must change.

    "That earlier era of chronic pain management can be revived with less expensive avenues of access, better incentives, and improved reimbursement," they write. "Medicare can lead the way in making pain coping skills widely available. Most important, it needs to create billing codes that make the services reimbursable." Broderick and Doctor also argue for quality performance standards "that would promote integrative solutions."

    The changes advocated by Broderick and Doctor echo the policy changes identified by APTA as crucial to improving patient access to PTs for treatment of pain. Those changes include the repeal of the Medicare therapy cap, more extensive direct access provisions, better private insurance coverage, and limits on physician self-referral.

    APTA's #ChoosePT campaign, which targets the opioid abuse epidemic, is at the center of the association's activities during National Physical Therapy Month. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT resources now include a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    DEA Reduces 2017 Opioid Production Quotas – Mostly by Eliminating 'Buffer'

    It's good news, just maybe not as good as it seems at first blush: yes, the US Drug Enforcement Administration (DEA) is reducing the amount of opioid controlled substances that can be manufactured in 2017, citing slowing sales and a drop in demand from physicians. But most of that reduction is related to the DEA's decision to eliminate a 25% "buffer" of excess production to offset potential shortages.

    Last week, the DEA announced that production quotas for "almost every" Schedule II opiate and opioid medication will be reduced by 25% for the coming year, with a few—including hydrocodone—being cut by a third. Details on quotas for individual drugs were released in a final order available for public inspection at the DEA website.

    According to a statement from the DEA, the reduction is intended to support the agency's responsibility to create quotas that "reduce or eliminate diversion from 'legitimate channels of trade.'" That non-legitimate use of opioids, often described as an epidemic, has received widespread media attention, and is the basis for APTA's #ChoosePT campaign to educate the public on physical therapy as a safe and effective alternative to opioids for the treatment of some types of pain.

    In its statement on the quotas, the DEA cites data from the National Survey on Drug Use and Health that the nonmedical use of controlled prescription medication was second only to marijuana in terms of the number of Americans 12 and older who reported drug use. At an estimated 6.5 million, that number is more than the number of cocaine, heroin, and hallucinogen users combined.

    In terms of the amount of opioids available for prescription, the reductions may not represent a big change. According to the DEA, "much of" the reduction is related to the elimination of an across-the-board 25% buffer to accommodate shortages that never occurred since the DEA started the buffer program in 2013. That year, the production of hydrocodone spiked at 150,000 kilograms, or about 163 tons; in 2017, that quota will drop to 108,000 kilograms.

    The #ChoosePT campaign targeted at the opioid abuse epidemic is also at the center of the APTA's activities during National Physical Therapy Month. Housed at MoveForwardPT.com/ChoosePT, resources now include a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    CDC: 2 in 10 Health Care Workers Didn't Get Flu Vaccines; 3 in 10 in Long-Term Care Settings

    About 20% of health care personnel didn't receive influenza vaccines during the 2015-2016 flu season, with employees in long-term care settings reporting an even higher—albeit improved—rate of non-vaccination, according to new data from the US Centers for Disease Control and Prevention (CDC).

    The report, based on an opt-in Internet panel survey of 2,258 health care personnel during March and April 2016, found that the overall rates didn't change much between the 2014-2015 and most recent flu season, with the most recent 79% rate more or less unchanged from the previous year's rate of 77.3%. Among settings, personnel working in hospital settings reported a higher rate of vaccination (91.2%) compared with those working in ambulatory care (79.8%) and long-term care (69.2%) settings.

    Not surprisingly, vaccination rates were highest among workers whose facility required vaccination (96.5%), but that rate fell to less than half (44.9%) for personnel whose employers didn't require, promote, or offer onsite vaccination programs. Coverage was highest among physicians (95.6%) and lowest among assistants and aides (64.1%). Physical therapists (PTs) and physical therapist assistants (PTAs) were not specifically listed in the data, but "other, clinical" was listed at a 94.4% overall rate.

    The only real gains from the 2014-2015 flu season and the most recent season were made in personnel working in long-term care settings, where vaccination rates rose from 63.9% to 69.2%. Authors of the CDC report described vaccinations in these settings as "especially important because influenza vaccination effectiveness is generally lowest in the elderly."

    CDC researchers link the lack of vaccination coverage to employers who don't require, promote, or offer onsite vaccination, writing that "health care personnel working in long-term care settings consistently are the least likely to report that their employer either required or promoted vaccination, or made vaccination available at no cost." In long-term care settings, 40.6% respondent reported that their employer offered no onsite vaccination or promotion.

    Infectious disease control should never be an afterthought. Check out APTA's resources at its Infectious Disease Control webpage.