The US Senate's decision to adjourn without taking up the sustainable growth rate (SGR) repeal bill passed by the House on Wednesday gives physical therapists (PTs) and their supporters more time to press lawmakers for a repeal of the Medicare outpatient therapy cap. That's the good news.
The not-as-good news? The current extension for SGR and exceptions to the therapy cap expire on March 31, and the Senate doesn't reconvene until April 13.
So where does that leave PTs—and patients—who could face a $1,940 limit on reimbursement on outpatient physical therapist services beginning April 1? And what about the SGR-related 21% cuts set to kick in?
What you need to know about the March 31 therapy cap deadline
The bottom line is that if a PT's patient in Medicare part B exceeds the $1,940 therapy cap after March 31 and Congress has not passed legislation extending the therapy cap exceptions process, Medicare will not pay for the services above the cap.
Gayle Lee, JD, APTA senior director of health finance and quality, advises PTs to consider issuing an advance beneficiary notice of noncoverage (ABN) form to any patient likely to exceed the $1,940 cap after March 31, just in case.
The ABN provides the patient with a warning that services may not be provided for under Medicare, and allows the patient to choose whether to continue treatment (and pay out of pocket) or to stop treatment before the cap is exceeded. Background information on the ABN (.pdf), as well as forms and instructions, are available online from the Centers for Medicare and Medicaid Services (CMS).
"The ABN process is an important one until there is resolution on this issue," said Lee. "Having an ABN in place allows PTs to collect payment from the patient for services above the cap—if the ABN isn't issued to the patient, and Medicare doesn't pay the claim, the provider is liable for the services and can't collect payment from the beneficiary."
Lee suggests that in addition to the ABN, PTs should consider waiting things out.
"There is a strong likelihood that Congress will adopt legislation addressing the therapy cap in the coming weeks," she said. "In the interim, PTs may want to also consider holding claims that exceed the cap and give Congress the time to make changes."
Where things stand with the SGR (and therapy cap) in Congress, including payment cuts
On Thursday, March 26, by a 392-13 vote, the House approved a bill that would permanently end the SGR, and sent the legislation to the Senate. As reported earlier in PT in Motion News, the House bill does not include a permanent repeal of the therapy cap, instead extending the exceptions process through 2017. The separation of therapy cap repeal from SGR repeal is a "risky approach for Medicare beneficiaries," according to a coalition of organizations, including APTA, that has been advocating for an end to the cap.
On Friday, March 27, the US Senate adjourned for its spring recess without taking up the bill, with Senate leader Mitch McConnell telling Reuters that "we'll return to it very quickly when we get back" on April 13. APTA is urging its members to capitalize on the break by redoubling efforts to contact senators and their staffs.
Because no Senate action was taken on the bill and Congress has not approved a temporary "patch" to the SGR, Medicare payment rates are scheduled to be cut by 21% after March 31.
Providers, however, may not experience those cuts. Recently, CMS issued guidance that under current law they hold claims for 14 calendar days—enough time to allow Congress an opportunity to reach agreement on both the SGR and therapy cap when members return.
What happens now, and what you can do
For APTA members, the uncertainty over what happens during the congressional break is tempered by the possibility that the extra time will lead to an even better SGR bill, one that includes an end to the therapy cap. But much will depend on grassroots efforts.
"We believe there is a very real opportunity for a permanent solution," said Mandy Frohlich, APTA vice president for government affairs. "APTA will work with legislators over the next 2 weeks to push for a full repeal of the therapy cap in a final SGR package, but we need direct involvement from our members."
APTA is offering assistance for members through both the association's legislative action center and the APTA Action App. The association also encourages members to reach out to patients and colleagues to make contacts as well, and provides a patient action center to help them.
To add real-life urgency to the issue, APTA is also asking for members to contact its advocacy staff with their stories of how the therapy cap impacts their ability to provide adequate services to patients, and the risks involved with arbitrary limits on outpatient therapy reimbursements. Send your stories to email@example.com.
"We're at a critical juncture," Frohlich said. "We need members to keep up the drumbeat with legislators."
Physical therapists (PTs) and physical therapist assistants have long understood the value of the PT-PTA relationship and how that relationship can be put to best use in patient and client care. Now there's a 1-stop source for explaining that value to others.
Recently, APTA unveiled The Physical Therapist–Physical Therapist Assistant Team: A Tookit (.pdf), a 54-page e-publication that touches on some of the most important elements of the PT-PTA relationship, from educational requirements to work with third-party payers.
Designed to serve as a resource "to share with payers, employers, patients and clients, and any other interested party," the toolkit is part primer, part compendium, with appendices that include sample appeal letters to payers, a list of minimum required skills of the PTA, and a problem-solving algorithm for the PTA.
The toolkit is available free to APTA members, and joins a suite of APTA resources on PTA Patient Care and Supervision.
APTA is pleased to announce the next phase in its effort to improve direct access: you.
Beginning the week of March 30, APTA will conduct a survey of its physical therapist (PT) members to find out how direct access is being used in their practices, and what obstacles still exist. Your participation is key.
Surveys will be sent via email over the course of the week, so keep an eye out (and check those spam filters). And be sure that your member profile is set to receive surveys. Profile options can be checked and adjusted here.
While last year's achievement of some form of direct access to physical therapist services in all 50 states was a big win for the profession, there is still much work to be done to eliminate barriers. Your responses will guide the association's strategies for working with payers, legislators, and policymakers to remove direct access restrictions, and will help to shape APTA resources and educational offerings.
This year's recipients of the Foundation for Physical Therapy's (Foundation) Service Awards have advanced the cause of physical therapy research in a variety of ways, from providing funds to partnering with the Foundation, and from helping behind the scenes to leading its work.
The 2015 awards and winners are:
"Each of our service award recipients has played a vital role in the Foundation’s ability to carry out its mission to fund and publicize physical therapy research," said Foundation Board of Trustees President Barbara Connolly, PT, DPT, EdD, FAPTA, in a Foundation news release. "We recognize that much of the hard work and support of these individuals and organizations occurs behind the scenes, and we are extremely appreciative."
This year’s recipients will be recognized during the Foundation’s gala on June 4, 2015, during the NEXT conference in National Harbor, Maryland.
She won 39 Grand Slam tennis titles, defeated Bobby Riggs in 1973's famous "Battle of the Sexes," and was named 1 of the "100 Most Important Americans of the 20th Century" by LIFE magazine.
And in June, Billie Jean King will deliver the keynote address during the opening event of APTA's NEXT Conference and Exposition in National Harbor, Maryland, just outside of Washington, DC. King's keynote address will be a highlight of the NEXT opening event, Wednesday, June 3, at 7:00 pm ET.
Registration for NEXT is open, with early-bird discounts expiring April 2.
A trailblazer throughout her life, King is a perfect fit for NEXT, which is defined by its innovative content and access to the physical therapy profession's transformative thinkers.
King is remembered by many for her illustrious athletic career, which included a record 20 titles at Wimbledon, plus the famous match with Riggs that has been recognized for its profound effect on society and the women's movement. King's championship spirit stayed with her off the court, as a leader in the fight for LGBT equality and recognition, as an advocate for those infected by or at risk for HIV/AIDS, and as a member of the President's Council on Fitness, Sports and Nutrition, among other endeavors.
While at NEXT, join hundreds of PTs and PTAs to support the profession during PT Day on Capitol Hill, June 3-4. Registration deadline is May 14.
Physical therapists (PTs) in Washington, Oregon, Idaho, and Utah are in for some good news: Regence insurance company has announced that it is abandoning its tiered system for utilization management (UM) that divided PTs and chiropractors into 3 groups with different allowances for preapproved visits. The system will be suspended on July 1.
Instead of the tiered system, all providers will receive an initial authorization for 6 visits, with additional visits approved when providers demonstrate medical necessity. According to Regence, the change is based on Regence data supporting 6 as the number of visits that covers most episodes of care.
Regence plans to send letters to providers informing them about the change at the end of March.
Chapter representatives from the 4 affected states and APTA staff began regular discussions with Regence and CareCore (Regence's UM vendor) about problems with the program since its launch more than a year ago. The discussions were aided by feedback provided by individual PTs through an APTA initiative calling for provider accounts of problems with UM systems.
“We think there will be many fewer gaps in patient care with the elimination of tiering,” said Pete Rigby, PT, Washington Chapter payment chair. “We’ll continue to work with Regence regarding the ideal number of preapproved visits.”
Encountering difficulties with UM and utilization review (UR)? APTA is collecting your experiences to strengthen its advocacy efforts around third-party UM and UR administrators. Fill out the online feedback form, and staff will contact you for more information.
The back is back.
Last week, PT in Motion News reported on a new study supporting the idea that initial referral to a physical therapist (PT) for new uncomplicated low back pain (LBP) resulted in lower overall costs and utilization than referral for advanced imaging. Since then, more articles have surfaced that question imaging as a "go to" strategy for the condition.
According to an article in HealthDay News, a March 17 study published in JAMA (abstract only available for free) concludes that for older adults, receiving diagnostic imaging for new back pain not only fails to produce better outcomes but actually tends to increase the costs associated with health care over time.
"Although early imaging is not associated with better pain and function outcomes, it is associated with greater use of health care services, such as visits [and] injections," study author Jeffrey Jarvik, MD, MPH, is quoted as saying in the HealthDay article, adding that it's a difference that "translates into a nearly $1,500 per patient additional cost, for no measurable benefit."
In another small study e-published ahead of print in the journal Spine (abstract only available for free), researchers analyzed the results of 300 blinded MRI scans conducted by medical radiologists, chiropractors, and chiropractic radiologists to assess both the consistency of readings across disciplines and, secondarily, the ability to diagnose LBP in the first place based on imaging.
Their findings? There was "considerable misclassification in all 3 groups," and agreement between chiropractic and medical radiologists was "modest at best."
"This study supports recommendations in clinical guidelines against routine use of MRI in low back pain patients," authors write.
The findings contained in both articles echo the results of a study by physical therapist researchers Julie M. Fritz, PT, PhD, FAPTA, Gerard P. Brennan, PT, PhD, and Stephen J. Hunter, PT, PhD, OCS, that found initial referrals for physical therapy for patients with new episodes of low back pain (LBP) resulted in less than half the cost of an imaging-first approach, and generated lower costs associated with use of health care resources over time.
The study, published in the journal Health Services Research (abstract only available for free), cited average savings of nearly 72% when physical therapy was used as the first-referral option.
"This is one of many studies demonstrating that physical therapy is a cost-effective alternative to medication and surgery," said APTA President Paul Rockar Jr, PT, DPT, MS, in a news release about the research. "Patients benefit from an active approach to their care and, in turn, society is transformed through the benefits from reduced financial burdens on our health care system."
Available at the APTA Learning Center: pre-recorded CE on manipulation for LBP presented by study author Julie M. Fritz, PT, PhD, FAPTA. 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.
As the Department of Health and Human Services (HHS) continues its evolution away from fee-for-service payments and toward "value based" models, a new opportunity to shape that evolution is being offered to providers, payers, the public, and other stakeholders.
It’s called the Health Care Payment Learning and Action Network (Network), and APTA will be there from the start.
On March 25, HHS debuted the Network, which it describes as "a forum for public-private partnerships to help the US health care payment system (both private and public) meet or exceed … Medicare goals for value-based payments and alternative payment models." Those goals call for 90% of Medicare payments to be tied to quality or value within 3 years.
Plans are for a series of (mostly) online meetings—1 or 2 per year for all participants and more for various work groups. APTA representatives are participating in the program, beginning with the March 25 kickoff meeting, which featured remarks from President Barack Obama and HHS Secretary Sylvia Burwell. Both stressed the importance of gaining input from providers and payers.
According to HHS, the participants in the Network will identify areas of agreement around how health care will move toward new payment models; collaborate to "generate evidence, share approaches, and remove barriers”; and develop approaches and implementation guides for payers, providers, and consumers. Participants will also be expected to help create definitions for various alternative payment models.
"The transition to alternative and value-based models is already happening and is only going to accelerate over the next 2 to 3 years," said Gayle Lee, JD, APTA senior director of health finance and quality. "The Network that CMS is offering is a good way for PTs to stay connected with the conversation about that transition and to contribute a provider's perspective."
The association will share information and other learning opportunities as the Network continues its work.
New ways of providing and paying for care are at the heart of APTA's transformative vision. Check out the association's Innovations in Practice webpage for the latest resources.
March 25, 2015: This story was expanded from its original March 24 version to include quotes from the APTA president as well as links to a press release and updated information on the APTA website.
Legislation now introduced in the US House of Representatives that would end the flawed sustainable growth rate (SGR) is missing a permanent repeal of the therapy cap. According to APTA advocacy staff, it's a troubling omission for physical therapists (PTs), and one that has sparked renewed calls for member action from APTA.
The bill ready for House consideration repeals the SGR, but only includes a 2-year extension of the therapy cap exceptions process. Supporters of therapy cap repeal believe that the best chance of ending the cap exists when it's tied to an SGR repeal bill.
Although APTA supports SGR repeal and other features of this particular bill, "We don't view a 2-year extension of this policy as a win," said Mandy Frohlich, APTA vice president of government affairs. "It separates the therapy cap repeal from the SGR repeal, which is problematic."
In an action alert issued on March 24, APTA warned that the exclusion of a permanent therapy cap repeal in the SGR legislation "is a missed opportunity for a long-term solution and puts beneficiaries in a dire situation when this [proposed 2-year] extension expires." Members are being urged to contact their legislators to call for a permanent repeal of the cap to be included with any bill that would repeal the SGR. APTA has posted the latest information on the issue at the association's therapy cap webpage.
The association also joined the American Occupational Therapy Association and the American Speech-Language-Hearing Association in issuing a news release that calls the separation of a permanent repeal of the SGR from a permanent therapy cap repeal "a risky approach for Medicare beneficiaries." Occupational and speech-language-hearing therapies are also impacted by the therapy cap.
"If Congress fails to include a permanent solution for the therapy cap in this bill, it will have purposely missed the only significant opportunity in almost 20 years to fix this critical patient issue," said APTA President Paul Rockar Jr, PT, DPT, MS, in the joint news release. "A bipartisan solution has been negotiated. These policies were created together. They should be fixed together."
In the (likely) event that Congress does not complete its work on this bill before it recesses on March 28, it is unclear how lawmakers will respond to a looming March 31 deadline that would trigger 21% cuts in Medicare payments via the SGR. It is possible that legislators would approve a short-term extension of the current fixes, but no formal proposals have been released.
Even if the SGR bill is approved by the House in the coming days, the Senate would be pressed to take it up before Congress recesses. The break, coupled with some Democrats' concerns about other provisions in the legislation, could open a window that would allow grassroots and lobbying efforts to have a greater impact.
Though the current SGR legislation lacks the crucial therapy cap element, it does include some provisions that are generally supported by APTA. Among them:
However, the lack of a permanent repeal of the therapy cap represents a glaring flaw in the legislation, according to Frohlich.
"It's more important than ever for members to speak up on this issue," said Frohlich. "We will continue to work with Senate champions to slow this down to correct this policy."
The legislative landscape around the SGR and therapy cap continues to change. APTA will monitor the situation and update members as events warrant; however, the need for grassroots efforts on the therapy cap remains urgent. Find out how you can take action.
Whether in academic research journals, political advocacy reports, or the sports page, discussions about concussion and traumatic brain injury (TBI) weren't hard to find last week.
The common thread? Something APTA has been stressing for years: more attention needs to be paid to all aspects of brain injury diagnosis and management.
In a widely covered announcement, 24-year-old Chris Borland, a successful rookie linebacker for the San Francisco 49ers professional football team, announced that he is retiring from the sport after 1 season because of concerns about potential health risks associated with head trauma.
"From what I've researched and what I experienced, I don't think it's worth the risk," Borland said in an interview for ESPN's "Outside the Lines."
"I just want to live a long, healthy life, and I don't want to have any neurological diseases or die younger than I would otherwise," Borland told ESPN.
According to an article in the New York Times (NYT), Borland's announcement "stands out because of how explicit he was regarding his concerns about head injuries." The frankness comes as the National Football League "scramble[s] to find a response" to mounting evidence "linking blows sustained on the field with long-term cognitive disability," according to the NYT.
Response to head injury was also the focus of a recent article in the Journal of Pediatrics (.pdf) that looked at public school principals' knowledge of concussion management, specifically around "return to learn" (rather than return to play) decisions.
In a survey of 695 high school principals in Ohio, researchers found that among the 465 administrators who responded, approaches to—and knowledge of—concussion management varied widely.
While 37.2% of the principals reported having received "some form" of concussion training in the past year and were supportive of providing training to faculty, researchers found that issues such as school size, funding, and available staff contributed to inconsistencies.
One example: only 32% of respondents said that they provide a written concussion plan to families and health professionals, with only 24.3% stating that the plan includes potential academic adjustments and accommodations. In contrast, authors write, research from Michigan found that 62% of school coaches provide a plan to families about postconcussion protocols for student athletes.
Authors cite progress in the ways schools respond to concussion in youth sports, but write that the academic environment needs to make up ground. "Not all concussions are sports related, and not all students with concussions are athletes," authors write. "Schools and health professionals must be prepared to monitor and accommodate students with concussion, regardless of athlete status."
The need for broad understanding of youth concussion management—and, in fact, all mild brain injury as well as TBI—was what brought APTA advocates and staff to Washington, DC, last week to participate in congressional briefings and provide information to legislators and congressional staff during a "Brain Injury Awareness Fair" on Capitol Hill. APTA representatives also spoke with lawmakers about the importance of the SAFE PLAY Act, now in congress, that aims to improve concussion management in schools. The act includes physical therapists in the list of professionals qualified to make return-to-play decisions.
Find more resources on APTA's Traumatic Brain Injury webpage, read the clinical summary on concussion available for free to members on PTNow, and direct patients and clients to the Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Looking for continuing education on concussion management in today's environment? Check out the prerecorded webinar "Managing Concussions with an Interprofessional Team" available through the APTA Learning Center.
Michael Hurlbut, right, APTA senior congressional affairs specialist, gets the APTA word out during the Brain Injury Awareness Fair held on Capitol Hill last week.
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