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  • JAMA: Americans Aren't Any More Physically Active Than in 2007—And They're Increasingly Sedentary

    Here's some news you shouldn't take sitting down: since the release of national physical activity (PA) guidelines in 2008, Americans haven't really made a dent in improving PA rates, while "significantly" increasing the amount of time spent on sedentary behavior. Those findings were the major revelations from a first-of-its-kind study that factored work, leisure-time, and transportation-related PA (most PA studies have focused on leisure-time activity only).

    The study, published in JAMA Network Open, analyzed results from 27,343 adults who participated in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016. Researchers wanted to find out what percentage of Americans met the US Department of Health and Human Services' activity guidelines, and how that rate may have changed since the release of the guidelines in 2008. Those guidelines, updated in 2018, recommend at least 150 minutes per week of moderate-intensity PA or 75 minutes of vigorous PA (or an equivalent combination of both).

    What they found wasn't encouraging. Over the 10-year study period, the percentage of Americans who reported meeting the PA guidelines remained nearly flat—from 63.2% in 2007-2008 to 65.2% in 2015-2016.

    Even worse, researchers noted a significant increase in sedentary behavior over the same time period, from 5.7 hours per day in 2007-2008 to 6.4 hours per day in 2015-2016. The increase was recorded in nearly every demographic subgroup in the study, and was highest among individuals with college-or-higher educations and individuals who are obese.

    There were a few bright spots in the findings. The guideline-adherence rates for non-Hispanic black individuals rose by nearly 10 percentage points, from 52.7% to 62.6%. Other groups that recorded notable improvements included Americans 65 and older (44.3% to 49.1%), women (55.3% to 59%), current smokers (63.9% to 68.4%), and individuals with obesity (55.4% to 61.5%).

    Generally, however, there was more bad news than good. Not only did PA guideline adherence remain static overall, it actually declined, albeit slightly, for some groups including individuals 50-64 (61.3% to 60.4%) and those who are overweight (66.8% to 65.4%). The decline was most steep among individuals with less than a high school education, whose rates dropped from 53.3% in 2007-2008 to 49.4% in 2016-2017.

    Making matters worse, of course, was the rise in sedentary behavior, which was particularly notable among individuals 40-49 (from 5.4 hours to 6.2 hours), non-Hispanic whites (5.9 to 6.6), Americans with a college degree or above (5.8 to 6.5), people with obesity (5.8 to 6.4), and individuals with family income less than 1.31 times the poverty level (5.3 to 6).

    "Both insufficient [PA] and prolonged sedentary time are associated with a high risk of adverse health outcomes, including chronic diseases and mortality," authors write. "Our findings highlight a critical need for future public health efforts to aim for not only an increase in [PA] but also a reduction in sedentary time."

    APTA is a strong supporter of the HHS guidelines and the importance of PA. The association's prevention and wellness webpage provides resources on how physical therapists and physical therapist assistants can help individuals become more physically active. Additionally, the association's Council on Prevention, Health Promotion, and Wellness connects members interested in physical therapy's role in improving health. APTA is also an organizational partner in the National Physical Activity Plan Alliance and has a seat on its board of directors; the association also has a representative on the board of the National Coalition for the Promotion of Physical Activity.

    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.

    IRFs Receive 2.5% Increase From CMS in FY 2020; Additional Reporting Requirements in FY 2022

    In a final rule from the US Centers for Medicare and Medicaid (CMS), inpatient rehabilitation facilities (IRFs) will see a 2.5% payment increase in the 2020 fiscal year (FY), which begins October 1, 2019—an approximate boost of $210 million. But they'll also need to prepare for some expanded reporting measures in the years to come—including a requirement to report data on social determinants of health.

    Reporting requirements won’t change much in FY 2020. However, beginning with the FY 2022 IRF Quality Reporting Program (QRP), IRFs will be required to provide certain standardized patient assessment data (SPADE) to CMS. The additional SPADE requirements are aimed at bringing IRFs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care (PAC) settings. In a fact sheet on the final rule, CMS writes that the addition of these SPADES "will improve coordination of care and enable communication."

    Specifically, CMS will adopt the SPADES on pain interference on sleep, therapy, and day-to-day activities, provisions being added in light of the opioid crisis. CMS is considering adding future SPADEs including dementia, bladder and bowel continence, care preferences, advance care directives and goals of care, caregiver status, veteran status, health disparities and risk factors, and sexual orientation. Also on CMS' radar: assessments related to opioid use, and frequency, exchange of electronic health data, and interoperability.

    Beginning in FY 2022, IRFs will be required to report patient data on admissions and discharges dating back to October 1, 2020, in the following areas: cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidity; impairment; and a new category—social determinants of health (SDOH). IRFs have been reporting on some components of these areas since 2018, mostly related to function, pressure wounds, and skin integrity.

    To gather cognitive function and mental status data, IRFs will be now required to use the standardized items of Brief Interview for Mental Status (BIMS) and Confusion Assessment Method (CAM). APTA supported these in its comments but advised caution, expressing concerns that the assessments aren't sensitive enough to pick up mild-to-moderate cognitive impairments. The new SDOH would gather data on race, ethnicity, preferred language, interpreter services, health literacy, transportation, and social isolation—factors that CMS writes "[have] been shown to impact care use, cost, and outcomes for Medicare beneficiaries."

    CMS also finalized 2 new process measures; one having to do with whether a provider receives a current reconciled medication list at discharge or transfer, and another relating to whether the patient, family, or caregiver receives a similar list upon discharge from a PAC setting.

    Among other elements of the final rule:

    CMS backs away from weighted motor score. While CMS had proposed to use a weighted motor score to assign patients to case mix groups, it finalized the use of an unweighted motor score starting in FY 2020 “to ease providers’ transition to the use of the quality indicator data items for payment purposes beginning on October 1, 2019.” APTA had expressed in its comments concern about moving to a weighted motor score, specifically about the de-emphasis on patient mobility and that the proposed motor score weight index may compromise access to physical therapy in the IRF setting.

    The compliant IRF list is gone. CMS will stop publishing a list of IRFs that successfully met reporting requirements on its Inpatient Rehabilitation Facility Quality Reporting Program website.

    Reporting for some baseline nursing facility residents will decrease. Specifications of the discharge-to-community PAC measure would be altered to exclude baseline nursing facility residents.

    IRFs will make the call on who's considered a "rehabilitation physician." The final rule will loosen the definition of "rehabilitation physician," allowing individual IRFs to establish their own definitions.

    Final SNF Rule Sets New Payment System Into Motion October 1

    It's final: the US Centers for Medicare and Medicaid Services (CMS) is moving ahead with a rule governing skilled nursing facilities (SNFs) that's almost identical to what it proposed in April, including a change advocated for by APTA—a revised definition of what constitutes "group therapy" in SNFs. Aside from that alteration, it's a rule that hews to CMS' original plans to dramatically change the payment system for SNFs.

    As anticipated, the final rule proceeds with implementation of the Patient-Driven Payment Model (PDPM). The model is based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employs a per diem system that adjusts payment rates over the course of the stay. APTA has developed a number of resources on PDPM.

    Other notable elements of the final rule:

    • In a win for APTA and its members, 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.
    • The final rule adopts a "subregulatory" process to keep up with nonsubstantive updates to the ICD-10 codes used in PDPM, while substantive changes will be made through the traditional notice-and-comment rulemaking process.
    • CMS will implement 2 new quality measures—transfer of health information to the provider-post-acute-care, and transfer of health information to the patient-post-acute-care—to be provided by the SNF at the time of transfer or discharge.
    • The rule also adopts a number of standardized patient assessment data elements that assess cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidities; impairments; and social determinants of health.
    • CMS projects aggregate payments to SNFs will increase by $851 million, or 2.4%.

    PT in Motion News covered the PDPM in detail when the rule was proposed. Since that time, APTA has launched an education campaign on the new system that includes a webpage on PDPM as well as a prerecorded webinar and Q and A session. A live webinar with CMS on SNF PDPM and demonstrating value is scheduled for September 4.

    Proposed Outpatient Payment Rule From CMS Continues Previous Trends

    The US Centers for Medicare and Medicaid Services (CMS) is pushing for an outpatient environment in which payments vary less according to who owns a facility, hospitals get a supervision break, and patients have access to clear information on how much they're being charged for items and services. All 3 concepts figure heavily into the proposed 2020 outpatient payment system (OPPS) rule.

    The proposed rule, released July 29, would complete a 2-year CMS effort to move toward a "site neutral" payment model in its reimbursements for physician services, doing away with a system that pays so-called "off campus" hospital-owned facilities more than it does their independent equivalents. Payment for physical therapy services in outpatient settings are paid under the CMS physician fee schedule and so are not impacted by the OPPS site-neutral policies.

    Other trends continue as well, including an APTA-supported move toward easing supervision burdens placed on hospitals. The proposed rule would change supervision requirements for outpatient therapeutic services in all hospitals from "direct" to "general," meaning that while a given procedure would be furnished under a physician's overall direction and control, the physician's physical presence no longer will be required during the performance of the procedure. The change is viewed as a particularly positive one for critical-access hospitals and other facilities in underserved areas.

    A shift toward greater transparency also is reflected in the proposed rule, with CMS aiming to require hospitals to make their standard charges public for all items and services. These standard charge lists—a facility's gross and payer-negotiated charges for supplies, procedures, beds and food, practitioner services, and a host of other items—would also be required for a limited set of so-called "shoppable services" that can be scheduled by a consumer in advance. CMS puts teeth into the requirement through monetary penalties and publication of violations for facilities that don't comply.

    Another trend APTA is watching: prior authorization, which in the proposed rule would be required for several cosmetic procedures including rhinoplasty. While this doesn't directly affect services associated with physical therapy, APTA advocates in general against prior authorization requirements that slow the delivery of care and limit patient access to appropriate interventions.

    Also included in the proposed OPPS:

    • Payment rates for outpatient hospitals and ambulatory surgical centers (ASCs) would increase by 2.7%.
    • CMS is soliciting comments on adding 4 safety measures to the Outpatient Quality Reporting Program that have already been required of ASCs: patient falls, patient burns, wrong site/side/procedure/implant, and all-cause hospital transfers/admissions.

    A CMS fact sheet on the proposed rule is available online. APTA is analyzing the proposed rule and will provide comments to CMS by the September 27 deadline.

    Proposed DMEPOS Rule From CMS Aimed at Predictability, Clarity

    In its proposed 2020 rule for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), the US Centers for Medicare and Medicaid Services (CMS) aims to make payments for devices a little more predictable in light of the ever-increasing—and ever-advancing—range of options available to providers and patients. The agency's solution? A "comparable item analysis" system that CMS thinks will help make it easier to nail down exactly what Medicare will pay for those devices.

    In what a CMS fact sheet describes as an attempt to "improve the transparency and predictability of establishing fees for new DMEPOS items," the proposed rule establishes 5 major categories under which providers can compare older DMEPOS with new ones: physical components, mechanical components, electrical components (when applicable), function and intended use, and "additional attributes and features."

    The idea, according to the proposed rule, is that when the old and new items are comparable, CMS will use the fee schedule amounts for the existing older item in determining payment amounts for the new one. If there are no comparable older items, CMS says it will base payment on commercial pricing data such as internet pricing and supplier invoices. Those prices for the noncomparable items won't necessarily stay fixed: if commercial pricing drops, so will CMS rates.

    In addition to the comparison system, CMS is also proposing to revamp requirements around face-to-face meetings between providers and patients in need of DMEPOS that "may have created unintended confusion for stakeholders." The current requirements—essentially a collection of ad-hoc provisions that have accrued over the past 13 years—would be replaced with what CMS describes as a "single list of DMEPOS items potentially subject to a face-to-face encounter and written orders prior to delivery, and/or prior authorization requirements."

    APTA is analyzing the proposed rule and will provide comments to CMS by the September 27 deadline.

    Proposed Fee Schedule Rule Wrestles With PTA, OTA Services Delivered 'In Part'; Includes Changes to MIPS

    Despite serious questions and criticisms from APTA, the American Occupational Therapy Association (AOTA), and other stakeholders, the US Centers for Medicare and Medicaid Services (CMS) intends to move ahead with its plans to require providers to navigate a complex system intended to identify when therapy services are furnished by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). The approach, which in 2022 would trigger a payment differential depending on how many minutes of services are provided by a PTA or OTA, is included in the proposed 2020 physician fee schedule rule released by CMS on July 29.

    As always, the physician fee schedule (PFS) rule is an extensive document that covers a wide range of providers and settings, with an emphasis on individual provider payment rates. But for the physical therapy profession, the big story for the 2020 proposed rule is related to how CMS plans to require providers to comply with a law requiring identification of services furnished "in whole or in part" by a PTA or OTA. The approach being contemplated by CMS—to set a "de minimis" 10% bar—has been criticized by APTA as one that has "serious implications for beneficiary access to care," particularly in rural and underserved areas.

    The proposed 2020 rule would require the new PTA and OTA modifiers (CQ and CO, respectively) to be included in claims beginning January 1, 2020, with a payment differential implemented in 2022. CMS also proposes to add a requirement that the treatment notes explain, by way of a short phrase or statement, why the modifier was or wasn't used for each service furnished that day. In short, the system is rooted in minutes of service, and would require the use of the applicable modifier that would indicate when a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service.

    And yet, as most physical therapists (PTs) and occupational therapists (OTs) well understand, the provision of therapy services isn't quite that simple. Questions start to pile up fairly quickly: what if the PTA or OTA services are provided concurrently with the PT or OT? What if the PTA or OTA services are administrative or nontherapeutic? What about group therapy? How is time designated when delivering supervised modalities?

    CMS attempts to anticipate these and other potential complications by making a few definitive decisions—for instance, administrative or nontherapeutic services provided by a PTA or OTA that could be provided by others without PTA or OTA education and training don't count—and providing examples of how the time allotments would be calculated in various scenarios.

    Despite the extensive requirements and explanations (and accompanying charts), a CMS fact sheet on the proposed fee schedule states that the system imposes "the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute."

    APTA disagrees with that assertion, and has voiced additional concerns about how the system would impact patient access to care. While acknowledging that CMS is bound by law to create a PTA modifier, the association takes issue with CMS’ interpretation of “in part,” and asserts that the agency's attempt to quantify what "in part" means is excessively complex, discounts the role of the therapist, and exceeds the intent of the law. That mischaracterization of the law, APTA argues, will quickly lead to confusion and loss of access to care, particularly among beneficiaries in and underserved rural areas.

    APTA plans on continuing its advocacy for a less complex, more patient-friendly system, including lobbying federal legislators to take a closer look at the plan and seeking meetings with CMS. APTA also will provide comments on the PTA/OTA modifier plan and other elements of the proposed fee schedule by the September 27, 2019, deadline, and will create a customizable template letter, available on APTA's Regulatory Action webpage, for individual provider comment.

    Here are other highlights of the proposed rule:

    Payment would increase slightly
    CMS estimates that the 2020 conversion factor would be $36.0896, just about a nickel more than 2019's $36.04.

    MIPS measures and performance thresholds for PTs and OTs would change—and CMS is looking at ways to make things less complex
    The proposed rule would add measures for diabetes mellitus neurological evaluation, diabetes mellitus evaluation of footwear, screening for depression and follow-up plan, falls risk assessment, falls plan of care, elder maltreatment screen and follow-up plan, tobacco use screening and cessation intervention, dementia cognitive assessment, falls screening for future falls risk, and functional status change for patients with neck impairments. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.

    Additionally, CMS has proposed that MIPS-eligible clinicians with a final score of 45 would receive a neutral payment adjustment, a change that CMS believes will lead to more clinicians receiving positive adjustments than negative ones. The current neutral payment adjustment score is set at 30.

    CMS is also proposing the concept of shifting to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond. According to CMS, the MVP system would help providers align activities across the 4 existing MIPS categories by specialties or conditions. MVPs would focus on population health priorities and reduce reporting burden by limiting the number of required specialty- or condition-specific measures so that all clinicians or groups reporting on a clinical area would report the same set or sets of measures. The change would also provide more data and feedback to clinicians, which in turn "helps clinicians quickly identify strengths in performance as well as opportunities for continuous improvement," according to a CMS press release on the proposed rule.

    It's not a "limitation," it's a "threshold amount"
    In a change that adds semantic reinforcement to the end of a hard cap on therapy services established in 2018, the proposed rule clarifies that the dollar amounts assigned to therapy services aren't limitations per se, but "threshold amounts" that, when exceeded, require the KX modifier. In turn, the KX modifier would be regarded as confirmation that the additional services are medically necessary. CMS also says it will clarify regulations on the medical review threshold and the applicable years for the targeted medical review process

    New dry needling codes, and changes to codes and RVUs for biofeedback
    The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel approved 2 new CPT codes to report dry needling of musculature trigger points in 2020. These codes, with proposed relative value unites (RVUs) of .32 (205X1, needle insertion without injection, 1 or 2 muscles) and .48 (205X2, needle insertion without injection, 3 or more muscles), were surveyed and reviewed by the Health Care Professions Advisory Committee, a group of non-MD/DO health professionals, including a PT representative. Those new codes are included in the proposed PFS.

    Also, in September 2018, the AMA CPT Editorial Panel replaced CPT code 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) with 2 new codes to describe biofeedback training initial 15 minutes of 1-on-1 patient contact and each additional 15 minutes of biofeedback training.

    As a follow-up to another CPT editorial panel decision in 2018 that replaced a single CPT biofeedback code with 2 separate codes, CMS is also proposing an RVU of 0.90 for CPT code 908XX (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; initial 15 minutes of one-on-one patient contact) and 0.50 for code 909XX (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; each additional 15 minutes of one-on-one patient contact). The proposed rule also designates the 2 codes as “sometimes therapy” procedures, meaning that an appropriate therapy modifier is always required when this service is furnished.

    Intensive cardiac rehab (ICR) would be expanded
    CMS is proposing that coverage for ICR, which tends to be more structured, rigorous, and integrative in its emphasis on diet and cognitive-behavioral factors, be expanded to beneficiaries with stable chronic heart failure. It's also looking to expand coverage for both ICR and cardiac rehabilitation to other cardiac conditions as identified through a national coverage determination—providing that determination finds clinical support for an expansion.

    CMS is looking for comments on bundled payments
    Can concepts and principles associated with bundled payment models—particularly the idea of per-beneficiary payments for multiple services or condition-specific episodes of care—be applied to the PFS? CMS believes it has the flexibility to implement bundling concepts in future rules, and is looking for public comment on the idea.

    Want to hear more about the proposed fee schedule directly from the APTA experts? Be on the lookout for an upcoming special "Insider Intel" phone-in session exclusively devoted to the PFS in the coming weeks. We'll announce the date and time via PT in Motion News and social media.

    Proposed Home Health Rule Moves Ahead With New Payment System, Allows Therapist Assistants to Furnish Maintenance Therapy

    The US Centers for Medicare and Medicaid Services (CMS) intends to go full steam ahead with its plans to shift to a new payment system for home health beginning in 2020. The plans are accompanied by other changes that include allowing maintenance therapy to be furnished by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), providing a payment "add on" for rural home health care, and adopting an APTA-supported "notice of admission" requirement to avoid duplicate billing. The new provisions, which include a 1.3% payment increase, are included in CMS’ proposed rule released on July 11.

    The biggest shift has been more than a year in the making: a transition to a new payment system known as the Patient-Driven Groupings Model (PDGM). The PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. Instead, the system classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. APTA offers extensive information on the new system and will participate in a live August 5 webinar on the model jointly hosted by APTA, CMS, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. APTA members can participate in this webinar (free to APTA members, login required APTA members can participate in this webinar).

    But that's not all in the proposed rule (.pdf). CMS also plans to allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the therapist assistant, the qualified therapist still would be responsible for the initial assessment; plan of care; maintenance program development and modifications; and reassessment every 30 days. CMS believes the change would bring home health in line with other care settings and give home health agencies (HHAs) more latitude in how they allocate resources.

    The rule also would phase out the split payment approach that requires HHAs to submit a Request for Anticipated Payment (RAP) at the beginning of the initial episode for 60% of the anticipated final claim payment amount. A final bill for the remaining 40% is submitted at the end of the 60-day episode. RAP submissions are operationally significant, as they establish the beneficiary’s primary HHA by alerting the claims processing system that the beneficiary is under a home health plan of care and home health services are subject to consolidated billing, meaning Medicare makes payment for all home health items and services to the single HHA overseeing the plan of care.

    Instead, CMS proposes requiring HHAs to submit a notice of admission to alert the claims processing arm of CMS that a beneficiary is under a home health episode of care. The new system is a direct result of APTA advocacy, which was fueled by members in private practice settings who shared data with the association to help APTA make its case. The change will be phased in next year and fully implemented in 2021.

    APTA and its members successfully argued that the split percentage approach is fraught with logistical inefficiencies that often result in confusion for CMS and therapy providers in outpatient settings. The proposal to replace the RAP with the notice of admission, to be submitted within 5 days of the start of care, would be needed to establish the primary HHA so the claims processing system would be alerted to a home health period of care, helping to eliminate the possibility of any lag time between a beneficiary's admission in home health and the HHA's notice of the admission to CMS. This too-common delay trips up outpatient providers who begin treatment (and billing) before CMS knows that the beneficiary has transitioned to home health. CMS describes the change as "an important step in paying responsibly and appropriately for home health services," according to an agency fact sheet on the proposed rule.

    As for payment, home health would see an overall 1.3% boost—about $250 million. The increase, initially targeted at 1.5% to comply with the Bipartisan Budget Act of 2018, was decreased by .2% to accommodate a rural add-on policy.

    Among other elements of the proposed rule:

    SPADE requirements are expanding. CMS is continuing its efforts to increase the range of standardized patient assessment data (SPADE) reported by HHAs. The use of SPADE in home health was instituted to bring HHAs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care settings. The proposed rule would follow through with the expansions, but it also includes requirements for reporting on cognitive function and mental status, comorbidities, and social determinants of health, among other categories. HHAs would be required to report these additional elements beginning in 2022 for admissions and discharges that occur between January 1 and June 30, 2021.

    A pain measure would be discontinued. Partially in response to concerns about the potential for overprescription of opioids, CMS is proposing to remove the Improvement in Pain Interfering with Activity Measure (NQF #0177) from the Home Health Quality Reporting Program (HH QRP) beginning in 2022. Under this proposal, HHAs would no longer be required to submit OASIS Item M1242, "Frequency of Pain Interfering with Patient’s Activity or Movement" for quality reporting purposes beginning in 2021.

    A pain-related question would be deleted from patient surveys. CMS proposes to remove a patient survey question that asks whether the patient and provider talked about pain in the past 2 months. The question, currently in the "Special Care Issues" composite measure, would be dropped beginning July 1, 2020. Similar to the pain measure being proposed for deletion, the survey question is being eliminated due to concerns about the ways it might influence unnecessary drug prescriptions. The changes are consistent with an earlier CMS decision to eliminate pain-related items from hospital patient surveys.

    APTA continues to review the proposed rule and will provide comments to CMS by the September 9 deadline. In the coming weeks, APTA also will post a unique template letter on its Regulatory Take Action webpage for individuals to use to submit their own comments on the proposed rule.

    From PT in Motion Magazine: Social Determinants of Health

    Health care is one thing. But the context of that care, the constellation of factors that can affect health for individuals and entire communities? That's something else entirely—and physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy education programs are engaged.

    Now available in the July issue of PT in Motion magazine: "Addressing Social Determinants of Health," an exploration of the ways the physical therapy profession is responding to the concept that improving the health of society demands providers, researchers, educators, and policymakers get involved with the economic, environmental, and behavioral factors that can shape health. These factors, broadly referred to as social determinants of health (SDOH), can seem overwhelmingly systemic, but that isn't stopping some APTA members from taking them on in a variety of creative, impactful ways.

    The article shares the work of several PT-led organizations, including Move Together, which works to provide physical therapy infrastructure to areas in need (among other programs); Mama LLC, a physical therapy consulting service focused on improving women’s health domestically and internationally; and the Arlington, Virginia, Free Clinic, led by Nancy White, PT, DPT, which has embraced SDOH-conscious practices in its programs. Author Christine Lehmann also looks at SDOH-related research being performed by PTs, as well as the ways physical therapy education is responding to the concept.

    As the article explains, SDOH can include cultural and economic variables, but other factors such as the built environment and climate change can even come into play. At the same time, the concept also calls for PTs and PTAs to change their day-to-day approach to working with patients by considering—and acknowledging—the realities of a patient's environment, from micro to macro.

    "Addressing Social Determinants of Health," featured in the July issue of PT in Motion magazine, is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Also open to all: "Looking at Physical Therapy Holistically," an article on how PTs are addressing both the body and mind in treatment, and "Providing Onsite Physical Therapist Services," a look at PTs who bring their services to patients.

    APTA, AOTA, ASHA Create Guide to Assess Habilitative, Rehabilitative Insurance Benefits

    Insurers' habilitation and rehabilitation benefits come in all shapes and sizes—which is exactly the problem, according to APTA, the American Occupational Therapy Association (AOTA), and the American-Speech-Language-Hearing Association (ASHA). That's why the 3 organizations collaborated on a guide to assessing benefit adequacy that emphasizes transparency, access, and affordability throughout benefit plans that can be all over the map.

    The guide, available on APTA's Essential Health Benefits webpage, forgoes offering a laundry list of specific benefits in favor of establishing a set of principles that the associations believe lead to appropriate coverage of habilitative and rehabilitative services. Those principles are rooted in the idea that the benefits are necessary not just to improve function but also to maintain it, and that physical therapy, occupational therapy, and speech-language pathology are the "key" services in any habilitation/rehabilitation benefit package. The collaborative document echoes many of the themes included in APTA's public policy priorities, which emphasize increased patient access, cost and coverage transparency, and use of telehealth in service delivery.

    The resource addresses how best to ensure adequate scope of coverage and access, appropriate provider qualifications, and essential benefit information needed for consumers to determine if a plan meets their needs. It also provides tips and recommendations for consumers as well as plan providers and policymakers.

    However, the guide isn't just a collection of broad statements—APTA, AOTA, and ASHA also dig into some specifics when it comes to adequate habilitation and rehabilitation coverage, including:

    • Using the definition of habilitative and rehabilitative services adopted by the US Department of Health and Human Services
    • Creating separate rather than combined visit limits for physical therapy, occupational therapy, and speech-language pathology
    • Ensuring direct access to all 3 therapies
    • Providing clear information to consumers on whether benefits can be delayed due to utilization management practices, whether telehealth is permitted, and if same-day physical therapy, occupational therapy, and speech-language pathology services are allowed

    As for recommendations for plan improvements, the 3 organizations offer 14 ideas they believe would advance "optimum value" and increase patient access to therapy services. Those suggestions include wider use of telehealth, recognition of the role of therapy providers in population and preventive health, ending policies that limit coverage of each therapy discipline to 1 condition, and stronger acknowledgement that "rehabilitative maintenance therapy and habilitative services are allowed for individuals with chronic, progressive conditions…to prevent further deterioration of function."

    Expanded Health Reimbursement Arrangement Rule May Widen Use of the Employer Offering

    A final rule from the US Department of Health and Human Services (HHS) will expand small employers' ability to offer Health Reimbursement Arrangements (HRAs), a change that may make it easier for more Americans to purchase health insurance that they don't receive from their jobs. While it's still too early to tell if the change will significantly impact patients seen by physical therapists (PTs), APTA's advice is to keep an eye open, and be aware of the nuances of HRA payment.

    The new rule, set to go into effect January 1, 2020, will allow qualified small employers to offer what's being called an "Individual Coverage HRA" as an alternative to traditional group coverage plans. The idea behind HRAs is that employers provide a monthly tax-free allowance to employees, who can be reimbursed for health care-related expenses up to the allowance limit. The changes set to go into effect next year would permit HRAs to be used to pay for health insurance purchased on the individual market, and allow employers to offer "excepted benefit" HRAs to supplement employer-sponsored insurance—even if the employee isn't enrolled in the group plan.

    HHS believes that the change will open up coverage options for more than 11 million employees and family members and increase insurance portability, according to an HHS press release. APTA submitted comments to the proposed rule that largely supported the changes, but recommended that any individual health insurance paid via an HRA must be a policy deemed compliant with the Affordable Care Act. The final rule supports APTA's position.

    Those numbers are just estimates, however, and there's no way of knowing just how the use of HRAs will shake out next year, said Kate Gilliard, APTA regulatory affairs senior specialist.

    "PTs need to understand that these HRAs will be out there, and that whether the patient can use the HRA for copays depends on how it's set up with the employer," Gilliard said. "Some HRAs are only good for premium payments, so we're advising our members to verify the details of a patient's HRA. If it's found appropriate for use, the HRA can be processed just like a health savings account or flexible spending account."

    APTA regulatory affairs staff will monitor rollout of the rule and share new information in PT in Motion News and elsewhere.