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  • Study: Early Physical Therapy for Neck Pain Makes Sense for Patients, PTs, and Payers

    According to a new study, providing physical therapy within 4 weeks after an individual first experiences neck pain is a win-win-win proposition for physical therapists (PTs), payers, and most importantly, patients. Researchers found that getting to a PT early not only achieved more improvement per $100 spent, but actually doubled a patient's odds of decreased disability compared with patients who were treated after a delay of more than 4 weeks.

    Researchers tracked 1,531 patients using an outcomes management system maintained by Intermountain Healthcare, a private nonprofit system, to analyze changes to disability and pain scores through an episode of neck pain. Patients were included if they had 2 more visits to a PT over fewer than 180 days, and if they recorded scores of 10 or greater on the Neck Disability Index (NDI) and 2 or greater on the Numerical Pain Rating Scale (NPRS).

    Patient records were then divided into 2 groups: 1 group of 451 patients who reported experiencing symptoms for fewer than 4 weeks, and a second group of 1,080 patients who reported symptoms that were present for 4 weeks or longer. Here's what researchers found:

    For the early therapy groups, the odds of achieving a minimal clinically important difference (MCID) in disability doubled for the early-therapy group—and increased by nearly as much for pain.
    Researchers found, on average, that patients were twice as likely to achieve at least a 19 percentage point change in the NDI, and were 1.82 times more likely to record a drop of at least 1.3 points on the 10-point NPRS.

    The greater decreases in disability and pain translated into more bang for the health care buck.
    Early-therapy patients averaged a 2.27 percentage point improvement in disability scores per $100 spent, compared with later-therapy patients, whose disability scores dropped by 1.22 percentage points per $100.

    PTs and patients were able to achieve more improvement per-session when physical therapy started earlier—what authors describe as "more efficient care."
    On average, early-therapy patients saw disability scores drop by 3.44 percentage points per visit, compared with a 1.81 percentage point drop for the later-therapy group. Pain scores followed a similar pattern, with pain dropping by .57 points for the early-therapy patients, compared with a .42 percent drop for the later-therapy group.

    Authors of the study, published in BMC Health Services Research, write that the findings support the "value proposition" for early physical therapy, with benefits reaching payers, PTs, and patients: payers realize lower costs, PTs can make a bigger difference, and patients experience changes that not only improve their lives, but lower their indirect costs through decreases in work absenteeism and disability.

    Researchers conclude that, similar to earlier research supporting early physical therapy for treatment of low back pain, their study contributes to the conversation around health care's shift away from fee-for-service models, and toward value-based care.

    "Policymakers and payers contribute to the value equation by designing health policies that promote access and use of timely, appropriate, health care services," authors write. "The implication of these findings suggests that a health care system that provides pathways for patients to receive early [PT] management of neck pain may realize improved patient outcomes, increased efficiency in delivery of care, and greater value."

    Authors of the study include Maggie Horn, PT, DPT, MPH, PhD, Gerard Brennan, PT, PhD, Steven George, PT, PhD, Mark Bishop, PT, PhD, and Jeffrey Harman, PhD.

    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.

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    Anti-Identity Theft Changes to Medicare Cards Coming

    How might changes to Medicare card numbers affect your practice? The Centers for Medicare and Medicaid Services (CMS) has some thoughts, but would like your input, too.

    On Wednesday, July 27, CMS will host a "listening session" to discuss its social security number removal initiative (SSNRI), a plan to end Medicare card numbers that are based on a beneficiary's social security number. The change is mandated under the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) as a way to reduce opportunities for identity theft.

    The session will run from 1:00 pm to 4:00 pm, ET, and will include a presentation on the SSNRI by CMS staff as well as a question-and-answer period. Registrants will be sent the CMS presentation in advance.

    Participants can register online, and are advised to call in 15 minutes before the session starts. CMS will also be accepting written comments on the SSNRI through August 3.

    HHS: 29% of Rehab Hospital Patients Experience Adverse Events, Temporary Harm During Stays

    Close to 1 in 3 Medicare beneficiaries in independently-run rehabilitation hospitals experience adverse or temporary harm events during their stay—and nearly half of those events are preventable, according to a new report from the Department of Health and Human Services (HHS) inspector general.

    The report, part of a series that also analyzed adverse events in acute care hospitals (ACHs) and skilled nursing facilities (SNFs), involved reviews of a "representative sample" of 417 Medicare beneficiaries who were discharged from independently-run (as opposed to hospital-based) rehab hospitals in March 2012. Nurse screeners identified cases that indicated adverse events, and a panel of physicians evaluated the events to rate severity, as well as to assess the possibility that the event could have been prevented. Here's what they found:

    Overall, the rehab hospitals' rates were in line with ACHs and SNFs.
    Earlier HHS studies found harm rates of 27% for ACHs and 33% for SNFs. The 29% harm rate for the rehabilitation hospitals isn't much different.

    46% of the events were "clearly" or "likely" preventable, 51% weren't, and the remaining 3% were unclear.
    The 46% rate was further broken down according to whether the event was "likely" preventable (38% of all cases) or "clearly" preventable (8% of all cases). The 51% of "not preventable" events were described as ones in which "harm could not have been avoided given the complexity of the patient's condition or care required." Authors of the report write that when it came to the preventable events, "reviewers frequently cited as factors the provision of appropriate treatment in a substandard way and failure to adequately monitor a patient's progress" as elements leading to the event.

    Out of 158 events, 112 were classified as "temporary harm events," with the rest described as more serious "adverse events" that resulted in longer stays, transfers to ACHs, permanent harm, interventions to sustain the patient's life, or death.
    Authors estimate that temporary harm events make up about 18% of all events. Less than 1% of patients experience an event that leads to death, while 1.7% experience a "cascade event"—a series of multiple harm events related to a single cause.

    Falls were associated with 4% of all events.
    Of the 158 adverse events studied, 6 were related to falls. Pressure ulcers were cited in 8%, venous thromboembolism, deep vein thrombosis, or pulmonary embolism in 2%, and edema/volume overload in 1%.

    Nearly 1 in 4 Medicare patients who experienced an event were transferred to an ACH.
    That ratio includes both patients admitted as inpatients and patients who had outpatient emergency department visits only. Authors estimate that those ACH admissions and visits cost Medicare about $92 million annually.

    As for what to do about lowering the rates of harm, authors recommend that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) include rehabilitation hospitals among its targets for education and training. Additionally, the report calls for AHRQ and CMS to collaborate on the creation of a list of potential events that would "go beyond conventional postacute care issues (eg, falls, pressure ulcers) and include a comprehensive range of possible patient harm, emphasizing the unique case mix in rehab hospitals and the rehabilitation needs of affected patients." According to the report, CMS and AHRQ have agreed with the recommendations.

    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.

    $12.5 Million PCORI Grant Will Fund Research on Team Approach to Pain Management

    A recently announced $21 million grants program includes a $12.5 million award for a project that will investigate the effectiveness of interdisciplinary teams that include a physical therapist (PT) in creating "integrative" pain management options to avoid reliance on opioids.

    The grants program, sponsored by the Patient-Centered Outcomes Research Institute (PCORI), will support research related to the management of chronic pain, with a goal of reducing opioid use. The largest award was provided to a University of Minnesota project that will evaluate 2 approaches in the treatment of veterans with chronic pain: one approach that pairs a pharmacist and supervising physician to determine a medication plan and create a telemedicine-based care program, and a second approach that establishes a team including a physician, psychologist, and PT to create a plan "that encourages integrative pain management options, such as exercise, in addition to medication," according to a PCORI news release.

    The second grant award, for $8.5 million, will go to a University of Wisconsin-based research team investigating the effectiveness of mindfulness meditation and cognitive behavioral therapy in the treatment and management of low back pain.

    This is not the first time PCORI has acknowledged the role of PTs in improving patient outcomes. Early in 2015, the group—an independent, nonprofit organization authorized by Congress in 2010—announced nearly $28 million in support for 2 research projects led by PTs.

    Opioids in the News: Congress Passes Opioid Bill, Medical Marijuana for Pain, the Path From Pain to Addiction, More

    The opioid abuse epidemic, and its relationship to the US health care system's approach to pain treatment, continues to make news. Here are some of the latest reports and features.

    The good news: Congress passed a bill addressing the opioid epidemic, and Obama has promised to sign it.
    The compromise bill awaiting President Barack Obama's signature is largely focused on providing help for the addicted, including allowing more people to have access to naloxone, the drug that can reverse an opioid overdose. The legislation also establishes a grants program, administered through the Department of Health and Human Services, that helps states and community organizations improve treatment and recovery programs, and allows police to divert the addicted to treatment rather than jail.

    The bad news: the bill lacks adequate funding.
    While some legislators applauded the bill as a good first step in battling the epidemic, critics pointed out that the bill does not include funding. Members of Congress say they will take up funding in a separate bill.

    A tragic story of 1 man's journey from pain, to prescription opioid addiction, to heroin.
    Oregon National Public Radio reports on John, a carpenter who now lives in his truck and uses heroin to counter pain from an old injury. Initially treated with opioids, John's prescriptions were reduced, leaving him in pain and ready to seek out illegal drugs.

    Wearable technologies could play a role in the fight against opioid abuse.
    A company has developed a wristband equipped with biosensors that can help identify when an individual with an addiction has relapsed.

    Could the use of medical marijuana for pain treatment help to decrease opioid use rates?
    In "What Can't Medical Marijuana Do," the Atlantic looks at claims that in states with legal medical marijuana, opioid prescriptions for pain treatment are as much as 12% lower than in states that prohibit medical marijuana.

    One state's attempt to curb opioid abuse through its Medicaid program has created controversy …
    Maryland Medicaid beneficiaries with opioid addictions had been receiving suboxone film to help curb their cravings. Claiming that the drug, delivered in the form of a paper strip, is too easily diverted and winds up being itself abused, the program has switched to Zubsolv tablets. Individuals who receive the treatment say it doesn't work nearly as well. "This is taking patients who are stable, who are doing really well, and saying we're going to do something to disturb how well you're doing," 1 physician told National Public Radio.

    … While other states look at the relationship between opioid addiction and housing.
    Government and community leaders from some Northeast states gathered recently to talk about how individuals addicted to opioids often face homelessness or substandard housing, and how improvements in affordable housing could in turn decrease drug use.

    APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign, an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign will unfold throughout 2016 and include national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    PTA Advanced Proficiency Program is the Focus of Upcoming Webinar

    Physical therapist assistants (PTAs) and students interested in learning more about APTA's PTA Advanced Proficiency Pathways (APP) program are invited to join a free webinar coming up July 21.

    Now the association's sole postgraduation proficiency recognition program for PTAs, the APP program uses multiple approaches to help applicants gain and demonstrate proficiency in areas of interest that include acute care, cardiovascular and pulmonary, geriatrics, oncology, orthopedics, pediatrics, and wound management. Participants take online core courses common to all of the APPs as well as self-select content-specific courses for the particular program pathway, followed by experiences with a qualified mentor of the participant's choosing. A dedicated program mentor designated by APTA makes sure that participants stay on the pathway and arrive at advanced proficiency as efficiently as possible.

    To help potentially interested PTAs get better acquainted with APP, the association will conduct a free webinar hosted by APTA Director of Postprofessional Credentialing Derek Stepp on July 21 from 12:00 pm to 1:00 pm, ET. Stepp will provide an overview of the program, as well as details on the steps needed to fulfill the requirements for completing it.

    No reservations are required. To sign up for the webinar, simply visit the APP webpage near the July 21 start time and click the "join the webinar" link. For more information on the webinar or the program in general contact Derek Stepp.

    A recorded copy of the webinar will be posted at the APP webpage as it becomes available.

    Study: African Americans With OA 34% Less Likely to Have Office-Based Therapy

    Authors of a new study on disparities have found that, after controlling for socioeconomic variables, African Americans with osteoarthritis (OA) are 34% less likely to have an office-based physical therapy or occupational therapy visit than other racial and ethnic groups studied. The reasons behind the disparity, however, are not easy to pin down.

    The study, published in the Journal of Racial and Ethnic Health Disparities (abstract only available for free), analyzed 2008-2010 data from the Medical Expenditure Panel Survey-Household Survey, which is a set of surveys of US households, employers that offer insurance plans, and medical providers. In the end, researchers used 20,735 observations involving Americans 17 and over who reported having OA. Authors tracked respondents' answers to whether they had an office-based therapy visit, comparing them with overall numbers of office-based therapy visits for any reason, and analyzing responses in terms of race/ethnicity and socioeconomic variables.

    The bottom line: overall, Hispanic Americans with OA are 26.5% less likely than white or Asian Americans to have a therapy visit, while odds for a visit among African Americans with OA are 44.8% less. When researchers adjusted for socioeconomic variables, the reduced odds for Hispanic Americans disappeared but remained for African Americans, with a rate of 34% less likely than the other groups studied.

    Researchers cite 4 possible reasons for the disparity: lack of availability of therapists, inconvenient locations for therapy offices, hours of office operation that may make scheduling an appointment difficult, and "cultural factors," revealed in other studies, that authors say point to "lower levels of trust in the health care system" among African Americans.

    Authors write that while the reforms of the Affordable Care Act may have increased utilization of office-based therapy services among some populations, more will need to be done to get African Americans into therapy offices in greater numbers.

    "For African Americans, it is doubtful that increased affordability for therapy services alone will erase the existing disparity," authors write. "Improved patient education and awareness of the benefits of outpatient physical therapy and occupational therapy may be necessary."

    Among other findings in the study:

    • Approximately 55.7 million US adults have self-reported OA.
    • Overall, 8% of the US adult population with self-reported OA attends an office-based therapy visit each year—about 8.3 million people. That's just over half of all American adults who report an office-based visit for physical therapy or occupational therapy for any reason, including OA.
    • Nationally, about 3% of the US population will use office-based therapy services each year.
    • Income, insurance status, and education level all helped to decrease access disparity (and essentially eliminate it among Hispanic Americans)—but that effect was much less for African Americans.

    Authors acknowledge study limitations, including a scope confined to office-based visits (versus home-health or inpatient care), and no investigation into the primary reason(s) for a reported visit. Additionally, they acknowledge that the lower incidence of joint replacement surgery among African Americans "may explain a disparity in access of office-based therapy services."

    How do health disparities affect physical therapist practice, and what are some of the driving forces behind them? Check out APTA's health disparities webpage for more insight.

    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.

    Now Available to Members: Highlights of the Proposed 2017 Medicare Physician Fee Schedule

    Get up to speed on 1 of the most extensive changes to physical therapy coding in years: APTA members can now access highlights of the 2017 proposed Medicare physician fee schedule rule, a guide that includes an explanation of the Centers for Medicare and Medicaid Services' proposal to implement a 3-level physical therapy initial evaluation code system.

    In addition to information on the new system for current procedural terminology (CPT) coding, the highlights prepared by APTA federal regulatory affairs staff touch on all of the other elements of the proposed rule that affect physical therapists, including payment rate updates, CMS' continued review of potentially misvalued codes, and proposed adjustments to physician self-referral rules and accountable care organization (ACO) quality measures.

    To access the highlights, visit the APTA Medicare fee schedule webpage, scroll down to APTA summaries, and click on the related highlights link. For a live conversation on the proposed rule, be sure to sign up for the next APTA Insider Intel live phone-in event, scheduled for August 17 2:00 pm-2:30 pm, ET.

    A final rule will be issued later in the year. APTA intends to comment on the proposed rule by the September 6 deadline.

    Bill That Adds Protections for PTs Traveling With Sports Teams Moves in House

    A bipartisan bill that helps to protect physical therapists (PTs) and other health care providers who travel across state lines with sports teams is on its way to the floor of the US House of Representatives.

    The Sports Medicine Licensure Clarity Act (HR 921/S 689) aims to provide added legal protections for sports medicine professionals when they're traveling with professional, college, or national sports teams by extending the provider's "home state" malpractice and professional liability insurance to any other state the team may visit. This week, the House Energy and Commerce Committee approved the bill for full House consideration.

    Originally, the bill's coverage was restricted to only physicians and athletic trainers. Advocacy staff at APTA worked closely with the office of sponsor Rep Brett Guthrie (R-KY) and ECC subcommittee staff to get PTs added to the list. The bill also opens the possibility of coverage for physical therapist assistants who are under the direct supervision of a PT.

    In addition to Guthrie, cosponsors include Rep Cedric Richmond (D-LA) in the House, and Sens John Thune (R-SD) and Amy Klobuchar (D-MN) in the Senate.

    ACA Anti-Discrimination Rule for Health Care Providers, Payers Takes Effect July 18

    In a combination of changes that codify longstanding guidance and expand definitions, the Department of Health and Human Services (HHS) will very soon implement an anti-discrimination rule that could alter the ways some providers and payers manage care.

    Beginning July 18, health care providers and payers that accept federal dollars will be subject to a provision of the Affordable Care Act barring discrimination in care and coverage on the basis of race, color, national origin, age, disability, and sex. As with other similar changes at the federal level, the new rules include gender identity discrimination in the definition of sex discrimination—meaning, among other things, that individuals must be allowed to enter the restrooms, hospital wards, or other gender-restricted areas that are consistent with their gender identity.

    Although the subject of media attention, the clarifications around facility use are just a small part of a rule that also codifies guidance to ensure access (including free language assistance services) to individuals with limited proficiency in English, prohibits health insurance benefit designs that discriminate against individuals who are transgender, and calls for "reasonable" accessibility changes to avoid discrimination based on disability.

    The Kaiser Family Foundation reports that the new rule does not resolve whether the definition of sex discrimination includes discrimination based on sexual orientation alone, nor does it set specific standards for medical equipment for people with disabilities.

    "The rule does not explicitly require insurers to cover gender-transition treatments such as surgery," according to an article in Modern Healthcare. "But insurers could face questions if they deny medically necessary services related to gender transition for a man who identifies as a woman, or a woman who identifies as a man."

    How can physical therapists and physical therapist assistants best respond to the needs of a patient or client who is transgender? Check out the open-access cover story on working with this population in the July issue of PT in Motion magazine.