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  • CDC Issues 'Call to Action' to Address Treatment Gaps for Children Experiencing TBI

    The US Centers for Disease Control and Prevention (CDC) sees traumatic brain injury (TBI) in children as a public health problem with a ripple effect—not only are children receiving inconsistent care at the time of injury, but variation in rehabilitation and recovery approaches can lead to disability that lasts through adulthood.

    The CDC laid out its case in a recent report to Congress that identified what it believes are the most glaring gaps in current treatment for pediatric TBI. "The management of TBI in children is complex and depends upon multiple service delivery systems that frequently do not provide systematic or coordinated care to ensure optimal recovery," the report states. "Due to the lack of robust scientific evidence identifying optimal pathways to recovery, current management is too often based on clinical practice experience rather than research."

    The agency hopes to address this issue through a "first-ever evidence-based clinical guideline on the diagnosis and management of mild TBI among children and adolescents" now in development. The CDC believes those guidelines could help to address gaps in the management of TBI in children, but it says those guidelines alone won't be enough to fix the problems in the current state of treatment.

    The report, which the CDC describes as a "call to action," identifies 8 major areas in need of improvement:

    Access to comprehensive care at the time of injury. "There is substantial variation in care among the sites where children are seen for acute injury care," the report states. "Not only are there inconsistencies in TBI assessment but also in the comprehensiveness of discharge recommendations for all severity levels of TBI."

    Long-term management. The report asserts that "there are no formal systems to monitor the health of children with TBI over time" and that "frequently children who need pediatric rehabilitation services do not receive them."

    Family support and training. According to the CDC, parents of children who experience TBI often find themselves thrust into a situation in which they have to take on multiple roles, including being an advocate for their child in health care and school systems. "Few parents understand the potential for a TBI of any severity level to become a chronic condition," says the report.

    Return to school. "Many students who sustain a TBI will need post-injury support at school…However, children and their families often experience difficulties accessing these services," according to the report.

    Return to activity. The CDC acknowledges that return-to-play guidelines have been developed for sports, but it finds a lack of similar guidelines for physical activities outside of organized sports and not much in the way of guidelines for return to activities after moderate and severe TBI.

    Transition to adulthood for children with TBI. In what the CDC describes as "a particular area of concern," the report asserts that the use of health care services tends to decline as adolescents with TBI transition to adult care, with a resultant worsening of outcomes. Making matters worse, according to the report, is the tendency for public school systems to limit post-high school transition planning to only those students covered by the Individuals with Disabilities Education Act (IDEA), and the lack of any requirements for specialized education and transition services in private schools.

    Professional training. "Many medical, educational, and other professionals who provide care and support for children after TBI received limited training specific to TBI recognition or management," the report states. "Lack of adequately trained health care providers leads to inconsistent and variable clinical assessments, inconsistent diagnoses, variable guidance about expected recovery course, and variability in management decisions early and later after injury."

    Research. According to the CDC, "we currently know very little about long-term outcomes for children with TBI." The agency calls for high-quality studies to establish parameters for duration of rest and return to physical and cognitive activity, medication use, and the management of prolonged symptoms. "A wide range of medical, behavioral, physical, and other therapies are used in the management of [mild] TBI, but definitive, high-level evidence-based guidelines do not currently exist," the CDC writes.

    The CDC estimates that in 2013, there were roughly 640,000 TBI-related emergency department visits, 18,000 TBI-related hospitalizations, and 1,500 TBI-related deaths among children 14 and younger.

    Pediatricians' Group Releases 'Choosing Wisely' List of Orthopedic Treatments to Question

    The "Choosing Wisely" collection of treatments that providers and patients should question continues to expand—this time, into pediatric orthopedics, with the American Academy of Pediatrics (AAP) issuing a list that calls for dialing back the use of imaging, ultrasound, and orthotics.

    The AAP list, developed in partnership between the AAP Section on Orthopaedics and the Pediatric Orthopaedic Society of North America, makes the following 5 recommendations:

    • Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
    • Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.
    • Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
    • Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plain radiographic examinations have been completed.
    • Do not order follow-up X-rays for buckle (or torus) fractures if they are no longer painful or tender.

    Launched by the American Board of Internal Medicine Foundation in 2012, "Choosing Wisely" is a collection of ineffective and overused treatments and tests that has grown to 540 recommendations from more than 80 specialty society partners. In 2014, APTA became the first nonphysician organization to contribute to Choosing Wisely when it released its list of "5 Things Physical Therapists and Patients Should Question."

    Spending on Health Care Projected to Increase 5.5% Annually Through 2026

    Health care spending is projected to rise by 5.3% in 2018 and continue at about that growth rate through 2026, according to estimates from the US Centers for Medicare and Medicaid Services (CMS). At the projected rates, spending on health care will represent nearly 20% of the US gross domestic product (GDP) by 2026, up from 17.9% today.

    According to the report from the CMS Office of the Actuary, the estimated increases are driven by 2 major factors: an aging US population that will increase Medicare spending, and an inflation rate on medical goods and services provided directly to patients that will outpace the overall economy's rate of inflation—2.2% compared with 1.1% annually.

    The average 5.5% annual growth in spending is higher than both the post-Great Recession rate of 3.8% from 2008 to 2013 and the 5% uptick related to the startup of the Affordable Care Act from 2014 to 2016—but it's still lower than the 7.3% annual increases experienced from 1990 to 2007, according to the report.

    Among other findings in the report:

    • Medicare spending will be the fastest-growing of all health insurance categories, increasing by 8% between 2019 and 2020, and 7.7% annually between 2021 and 2026. In contrast, private insurance is projected to grow at a slower 4.7% rate.
    • Part of the expected slower growth of private insurance can be attributed to an increased prevalence of high-deductible plans and the 2022 implementation of a tax on high-cost insurance plans, a tax that the CMS actuaries believe will spark employers to offer employee health insurance with reduced benefits and higher cost-sharing.
    • Prescription drugs will lead the way in increases to goods and services provided to patients, with a projected annual increase of 6.3% from 2017 to 2026.
    • The share of the population with health insurance will likely decline, from 91.1% in 2016 to 89.3%, the result of the elimination of the individual mandate for health insurance.
    • By 2026, government-sponsored efforts will represent 47% of all health care expenditures, up from today's 45% share. The portion of expenditures shouldered by private insurance is predicted to drop from 55% to 53% by 2026.

    The Post-Therapy Cap System: 5 Basics You Need to Know

    When Congress adopted a federal spending package that included the elimination of the hard cap on Medicare therapy services, it didn't just remove a rule—lawmakers also adopted a new system of payment thresholds and triggers, and a differential payment rate for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), among other things.

    APTA supported an end to the hard cap, which is a significant win for the most vulnerable Medicare patients, but other parts of the system that replaced it are problematic.

    The elimination of the hard cap is retroactive to January 1, 2018, but not all details of the post-cap system have been worked out, and it's possible that some may change before their implementation dates. In the meantime, here are the basic elements of the new system.  

    1. It boils down to a threshold for using KX modifiers and a trigger for possible medical review.
    The basic idea is this: outpatient therapy under Medicare now has a $2,010 threshold; services delivered beyond that require a KX modifier indicating that the service meets the criteria for a payment exception. When therapy reaches $3,000, it's subject to possible targeted medical review—although CMS didn't receive any additional funding to conduct these reviews.

    2. Physical therapy and speech-language pathology still are lumped together in the thresholds.
    Just as in the previous payment system that included a hard cap and exceptions process, the new system doesn't separate physical therapy from speech-language pathology in establishing thresholds. Those $2,010 and $3,000 limits are for physical therapy and speech-language pathology therapy combined—another element opposed by APTA.

    3. The thresholds apply to all part B outpatient therapy services—including services provided by hospital outpatient departments.
    For the brief time beginning in January when the therapy cap was in place, hospital outpatient facilities were not subject to the cap. That changed with the adoption of the budget package, and now these departments or clinics are subject to the thresholds: $2,010 for use of the KX modifier and $3,000 for potential targeted medical review.

    4. The PTA payment differential will start in 2022—along with a special claims designation.
    In the post-cap payment system, outpatient therapy services performed by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) will be reimbursed at 85% of the Medicare physician fee schedule—a change opposed by APTA. However, that's not set to happen until 2022.

    For now, claims do not include a way to designate whether a service was delivered by a PTA, but that too will change by 2022, when CMS will develop a modifier to make that distinction. Between now and then, look for opportunities to comment on proposed rules around this process, along with guidance and more details as they develop.

    5. Home health also will be subject to the PTA payment differential, absent a plan of care.
    The 85% payment differential for services provided by a PTA or OTA will apply to home health care provided to Medicare part B beneficiaries—but only when a home health plan of care is not in effect. The budget deal that resulted in the end to the hard cap also established other new rules for home health.PT in Motion News recently reported on these additional changes.

    CMS Offers Settlement Option for Providers With Denial Appeals in Limbo

    The US Centers for Medicare and Medicaid Services (CMS) is offering some providers a chance to settle backlogged claims denial appeals at 62% of net allowed amounts, but there are limits and deadlines involved.

    Called the "Low Volume Appeals Initiative," the program is part of a CMS attempt to clear a glut of Medicare appeals piling up at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council levels.

    The program is limited to providers who have fewer than 500 appeals with no single appeal exceeding $9,000. Providers begin the process by submitting an "expression of interest" form to CMS. Providers with National Provider Identifiers (NPIs) ending in an even number have from between now and March 9 to turn in the form; the window for providers with NPIs ending in odd numbers will open on March 12 and close on April 11.

    To qualify for the settlement, the appeal must meet certain criteria:

    • The appeal was pending before the OMHA and/or council level of appeal as of November 3, 2017.
    • The appeal has a total billed amount of $9,000 or less.
    • The appeal was properly filed at the OMHA or council level as of November 3, 2017.
    • The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system.
    • The claims included in the appeal were submitted for payment under Medicare Part A or Part B.
    • The claims included in the appeal were not part of an extrapolation.
    • The appeal is still at the OMHA or council level of review when an administrative agreement is fully executed.

    The final agreement would cover all claims that are approved for settlement. Once finalized by CMS and the provider, Medicare Administrative Contractors (MACs) will total the claim amounts and make a single total payment within 180 days of CMS' signature on the agreement.

    Questions about the initiative can be emailed to MedicareSettlementFAQs@cms.hhs.gov.

    Home Health Faces Challenges in Wake of Budget Deal

    A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

    The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers' negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.

    The payment unit changes echo provisions included in CMS' failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system proposed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a "perverse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode." CMS dropped its efforts to adopt HHGM in the fall.

    Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there's 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in significant reductions in reimbursement.

    But that doesn't mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA's director of regulatory affairs, the budget deal also includes a provision directing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

    "We expect that HHS will attempt to create a case-mix system similar in nature to the HHGM," Gainer said. "However, HHS has said that its revisions will be based on feedback from a technical expert panel." That panel met on February 1 and included a representative from APTA. Gainer is hoping that at least 1 more panel meeting will be held in 2018.

    So does Diana Kornetti, PT, MA, president of the APTA Home Health Section. Kornetti is also a credentialed home care coding specialist.

    "Right now, it appears that only 1 technical expert panel meeting is required by law during 2018, and that's already happened," Kornetti said. "This is the first thing that needs to change. There is no guarantee that the home health industry and its stakeholders will have any future opportunity to review and discuss the issues and concerns that will arise."

    According to Kornetti, should stakeholders get that opportunity, the case for the right kinds of changes to the home health payment will be much stronger if it's backed by documented outcomes for physical therapy.

    "Patient acuity is critical," Kornetti said. "Capturing correct and thorough data, using objective measures, will be increasingly important to establishing an accurate payment for physical therapist services. We must speak the language of outcomes moving forward as a profession—our services must show our impact on reduction of costs, while continuing to strive for increasing clinical quality."

    With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer explained. The threats to home health will be 1 of the association's targets.

    But as with any other attempt to get policymakers to listen, the effort will require participation from physical therapists and physical therapist assistants, Kornetti added.

    "A key principle in our code of ethics speaks to advocacy for those we serve," Kornetti said. "It has never been more important for the postacute physical therapist and physical therapist assistant to become informed and participate in this process. One rung of our ladder toward a fully autonomous profession is having representation at the table where decisions are being made."

    CMS Issues Coding, Other Details on Supervised Exercise Therapy for Peripheral Artery Disease

    US Centers for Medicare and Medicaid Services (CMS) has released details on how it will process claims made as a result of its decision to cover supervised exercise therapy (SET) in the treatment of peripheral artery disease (PAD).

    The expansion covers physician-referred SET for up to thirty-six 30- to 60-minute sessions over a 12-week period. The sessions must be conducted in a physician's office or outpatient facility, and must be delivered by "qualified auxiliary personnel" that includes physical therapists, nurses, and exercise physiologists. Supervision is to be conducted by a physician or "non–physician practitioner"—a physician assistant, or nurse practitioner/clinical nurse specialist.

    Although CMS announced the change in May 2017, it only recently released the nuts-and-bolts around provider coding and claims processing for Medicare Administrative Contractors (MACs). Details are available from 3 resources:

    To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit must also include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.

    Making Transformation Possible: Panelists at APTA Event Explore Paths Toward Rethinking Pain Management

    Ending the opioid crisis—or even just making a dent in it—is going to require nothing less than transforming an entire culture's attitudes about pain and its management. But panelists at a recent APTA event believe there are models and concepts out there that provide hope for a future in which multidisciplinary nondrug approaches to pain replace an opioid prescription as the norm in health care.

    At its February 5 live event, "Beyond Opioids: Transforming Pain Management to Improve Health," APTA brought together 7 panelists with a range of perspectives, from a patient whose multiple surgeries were accompanied by opioid prescriptions, to a physical therapist (PT) who works in a program that educates and empowers patients to take more control of their pain, to a congressman who is fighting to raise public awareness of addiction as a disease. The entire conversation was broadcast live on Facebook, and a recorded version is available for viewing.

    Though each speaker brought something different to the table, a few common threads emerged when it came to what it will take to truly address the opioid epidemic, particularly as it relates to pain management. Panelists tended to emphasize the need for increased and more open communication, better identification of risk factors for opioid abuse, greater use of multidisciplinary approaches to pain management, and the need for more education delivered to patients, providers, employers, and entire communities.



    Panelist Joan Maxwell's story served as a touchpoint for the night, highlighting the patient experience and bringing current weaknesses in pain management into sharp relief. Maxwell's journey as a patient began with a double mastectomy, which led to a staph infection and subsequent surgeries—9 in all over fewer than 3 years. Along the way, Maxwell experienced a stroke. And at every juncture, she was prescribed opioids, with few conversations about what to expect in terms of pain and what other ways her pain might be managed.

    Luckily for Maxwell, who is now a patient and family advisor for John Muir Health and patient-member of Patient & Family Centered Care Partners Inc, she was able to avoid addiction. Her brother-in-law, however, was not as fortunate: over the course of what Maxwell described as "2 failed back surgeries," he became addicted to opioids. His wife administers his drugs and is careful to hide the medications from him.

    "He was just a regular person like all of us," Maxwell said, "but just 1 surgery, and he was addicted."

    Maxwell holds out hope that things can change for the better, beginning with more conversations between providers and patients about pain.

    Both Grant Baldwin, director of the division of unintentional injury prevention for the Centers for Disease Control and Prevention, and Rep Donald Norcross (D-NJ) echoed Maxwell's call for better communication, albeit in slightly different settings. Baldwin told the audience that more outreach is needed to spread the word about the CDC's guidelines for chronic pain management and its recommendations for nondrug approaches as a first-line treatment, while Norcross spoke about the need for better communication to lift the stigma around addiction and help communities and the federal government focus on a disease model.

    Norcross even offered advice about getting the message out.

    "Make an appointment when your congressman or congresswoman is in your district, and give the real story," Norcross said. "This is not some urban issue that happens in the dark of night. This can happen anywhere."

    As medical director of Swedish Pain Services and president of the American Academy of Pain Medicine, Steven Stanos, DO, brought firsthand knowledge of the latest approaches to pain management. Stanos outlined an intensive multidisiciplinary process at Swedish Pain Services that involves PTs, occupational therapists, pain medicine specialists, pain psychologists, and nurses in group and individual treatment settings. Although Stanos admitted that it's a system not available to everyone, and cost can be challenging for some patients, patients everywhere should be wary of treatment that relies on pain medications only.

    "I always think that [the presence of an opioid prescription] is a marker that [patients] didn't have comprehensive care," Stanos said. "A lot of [what needs to change] is about education and unlearning maladaptive ideas."

    Sarah Wenger, PT, DPT, is doing just that through a "Power Over Pain" program that emphasizes individualized approaches to management, with a focus on education and honest conversations with patients. Wenger is a board-certified clinical specialist in orthopaedic physical therapy and an associate clinical professor at Drexel University's College of Nursing and Health Professions.

    In many instances, Wenger explained, patients need to come to grips with the idea that they may always experience some degree of pain—"I don't think zero pain is particularly realistic for any of us," she added—but that they can be empowered when they understand how to manage pain in healthy ways. "The truth is, most people don't feel really great on opioids," Wenger said.

    Echoing previous panelists’ emphasis on communication were the final 2 speakers, Tiffany McCaslin and Bill Hanlon, PT, DPT, who also is a board-certified clinical specialist in orthopaedic physical therapy. McCaslin, a senior policy analyst for the National Business Group on Health, sees a need for employers to come to grips with the impact opioids and opioid-based pain treatment is having on employees and, in turn, on the overall operation of the business itself. The concept is at the heart of a new summit program being rolled out by her organization. "We're pressing on our members to take a look at this issue with eyes wide open" and to reduce the stigma around addiction, McCaslin said.

    As a PT working in addiction recovery at the St Joseph Institute in Port Matilda, Pennsylvania, Hanlon often finds himself helping patients who have suffered from a pain treatment system that relies too heavily on opioids. But that's not the entire patient population, he explained—many of the individuals he helps don't have underlying pain but experience it for the first time in the form of withdrawal symptoms.

    In either case, he said, communication and a multidisciplinary approach are key.

    "The way we approach addiction needs to be multidisciplinary, just as the approach to managing pain needs to be multidisciplinary," Hanlon said. "And as we get all the disciplines involved and understand the psychology of the person…we can help them more and more."

    But according to Hanlon, that multidisciplinary help must begin with helping a patient to understand what's possible—without an overreliance on opioids.

    "It's about communicating with people," Hanlon said. "It's talking with people and letting them experience the wellness."

    'Choose More Movement and Better Health': APTA Releases New #ChoosePT Video

    Anyone can experience pain—but nobody should feel trapped by opioids as the only way to manage it: that's the message at the heart of APTA's newest video public service announcement (PSA) in the #ChoosePT opioid awareness campaign.

    The new PSA, which debuted during a live panel discussion on pain management, features a teenaged boy, an adult woman, and an older man each experiencing pain, attempting to manage the pain through opioids alone, and ultimately making progress with physical therapy.

    "Pain is personal, but treating pain takes teamwork," the voiceover says. "When it comes to your health, you have a choice—choose more movement and better health. Choose physical therapy."

    The PSA is part of the association's national public awareness campaign, #ChoosePT, which has won multiple national awards, including best video for the first public service announcement.

    APTA's first #ChoosePT PSA reached more than 377 million Americans via television and radio in its first year of release, and APTA’s official consumer information website, MoveForwardPT.com, was visited by more than 3.2 million users in 2017.



    BuzzFeed Features Physical Therapy 'Success Stories'

    How about a little good news? Specifically, how about a little good news from patients who credit physical therapy and their physical therapists (PTs) for transforming their lives?

    Recently, BuzzFeed published "9 Physical Therapy Success Stories That'll Make You Choke Up A Bit," a collection of first-person accounts from patients who faced a range of issues including spine facture, labrum tears, recovery from a coma, and interstitial cystitis. The reason for the project, according to BuzzFeed, was to "inspire others who are currently recovering from pain, injuries, surgery, or other problems."

    A few choice quotes from contributors:

    "Thanks to physical therapy, I am now able to postpone [knee] surgery for at least 5 years without risking harm. Even though it may be hard, physical therapy is worth it in the end."

    "It was difficult and scary, but I can honestly say physical therapy saved my life."

    "My advice to all of you is to listen to your PT and trust them."

    "Once specific thing: PTs and [occupational therapists] need more recognition and props. They have to work really hard to get some of us back to some sort of norm."

    "I owe [my physical therapist] my mobility and my life without pain."