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  • From PT in Motion: Physical Therapy With Patients Who Are Transgender

    The patient or client who is transgender faces a host of issues, both physical and cultural, that can have a very real impact on how a physical therapist (PT) or physical therapist assistant (PTA) provides treatment. This month's issue of PT in Motion magazine explores some of those issues, and offers a few tips on how PTs and PTAs can uphold a core ethical principle of a profession that charges its members to respect the inherent dignity and rights of all individuals.

    In "Managing Patients Who Are Transgender," author Chris Hayhurst describes the current gaps that can occur in a PT's or PTA's understanding of the unique needs of patients who are transgender. The PTs he interviews have advice on how to narrow those gaps through the entire treatment process—from intake, to provision of services, to referral if needed.

    The article includes perspectives on how to create a practice that patients who are transgender will see as welcoming, from providing easy-to-do "clues" in the waiting area to seeing to it that intake forms are sensitively worded in ways that allow patients to express (or choose not to express) their gender identity. Hayhurst also interviews PTs who provide perspectives on how the patient who is transgender may require different approaches in the treatment room, and underscore how important it is that the PT be aware of the ways gender reassignment surgeries undertaken by a subgroup of patients can sometimes affect mobility and cause pain. Finally, the article looks at the PT's responsibility to see to it that, should a referral be required for any reason, the referred provider is also attuned to the needs of the transgender population.

    Also available as sidebars to the article: a glossary of gender terminology, an infographic that helps explain a sweep of transgender-related issues (particularly in health care), and a list of organizations and websites that advocate and educate on behalf of the LGBT population.

    "Managing Patients Who Are Transgender" is featured in the July issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    PT in Motion Magazine Recognized for Editorial Excellence

    APTA's PT in Motion magazine has earned 5 awards from 2 prominent publishing competitions in 2016.

    Association Media & Publishing's annual Excel Awards program handed out 3 awards for article writing:

    • Gold level: "Embezzlement? That Could Never Happen in My Practice," feature article from May 2015; Keith Loria (freelance writer), author; Don Tepper (PT in Motion editor), editor
    • Gold level: "Coming Clean," column in the Defining Moment series from February 2015; APTA member Adele Levine, PT, DPT, author; Eric Ries (PT in Motion associate editor), editor
    • Silver level: "A Constructive Approach," column in the Defining Moment series from September 2015, APTA member Michael Konstalid, PT, DPT, author; Eric Ries, editor

    A second competition, the APEX Awards for Publication Excellence, also recognized PT in Motion, with 2 awards for article writing:

    APTA isn't new to awards from either competition. PT in Motion (and its predecessor, PT—Magazine of Physical Therapy) have garnered previous recognitions.

    First-Ever Tests of Deep Brain Stimulation on Humans Poststroke Ready to Begin

    Researchers at the Cleveland Clinic are ready to begin human testing on the use of deep brain stimulation (DBS) for individuals poststroke, in hopes that the technology will help to "jump start" damaged areas of the brain and aid in physical rehabilitation.

    According to an article in TIME magazine, the clinic has been federally approved to begin a human trial of a DBS technique that previously has been tested only on rats. The procedure involves sending electrical pulses from a power source implanted in the subject's chest to electrodes implanted in the brain, a technology that has been successfully used for some time on individuals with Parkinson disease (PD).

    But the intent of using DBS poststroke is not the same as its use for PD, according to Andre Machado, who heads up the project.

    "The big difference is that when we are treating the motor symptoms of [PD], we’re trying to make the symptom, like a tremor, go away," Machado told TIME. "When we are treating stroke, we are really trying to make movement come back. There is something inherently different about that."

    Animal testing revealed that DBS "appears to promote the growth of new neurons in the brain," according to a 2015 article in the Wall Street Journal (WSJ), though Machado told WSJ that researchers have no expectation that the procedure will cure stroke. Instead, he said, "the expectation is that by applying stimulation, [DBS] will augment or boost the effects of physical rehabilitation."

    "The goal of this therapy is not to replace physical training, but rather to boost the effects," Machado told TIME.

    The human study is set to begin as soon as researchers identify a subject poststroke who is severely disabled and "has exhausted all other options without improvement," according to the TIME article. The focus of the initial work will be on individuals who have suffered an ischemic stroke.

    Proposed Home Health Rule Includes Planned $180 Million Reduction, Shift to Cost-per-Unit System for Outlier Payments

    The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule for the 2017 Medicare home health prospective payment system (HH PPS) that would continue a planned series of cuts that began in 2014, with an estimated overall 1% reduction, or about $180 million, scheduled for next year. The proposal, released on June 27, also includes a move away from cost-per-visit in favor of a cost-per-unit system for outlier payments, a plan to make separate payments for negative pressure wound therapy (NPWT) devices, and refinements to a value-based purchasing model used in 9 states.

    APTA regulatory affairs staff is reviewing the proposed rule and will submit comments on the proposal to CMS. PT in Motion News will publish a report summarizing those comments; in the meantime, here are some key features of the changes that may be happening next year.

    Payment. Overall, CMS projects payment adjustments would result in an estimated 1% reduction, or $180 million, in 2017. This adjustment continues a set of reductions mandated by the Affordable Care Act, which have ranged from $60 million in 2015 to $260 million in 2016. CMS arrived at the overall estimate by weighing a 2.3% payment increase against various decreases, mostly related to reductions in the 60-day episode payment rate and cuts to account for nominal growth in case mix.

    Home Health Quality Reporting Program. The proposed rule would add 4 measures to the Home Health Quality Reporting Program, but not until 2018. The new measures focus on hospital readmissions, total estimated Medicare spending per beneficiary, discharge to the community, and medication reconciliation. The proposed rule also requires home health agencies (HHAs) to submit both admission and discharge outcome and assessment information set (OASIS) data for at least 90% of all patients whose episodes of care occurred during the reporting period.

    Outlier payments. CMS is proposing a change to the way it calculates the payments it makes for episodes that go beyond the typical range of care, moving from a cost-per-visit approach to a cost-per-unit approach, with 15 minutes comprising a unit. The proposal also includes an adjustment to the fixed-dollar loss ratio, intended to keep outlier payment ratios in compliance with requirements in the Social Security Act.

    NPWT payments. The proposed rule would create a system for separate payments to HHAs for disposable NPWT devices used with beneficiaries, no longer allowing for time spent furnishing NPWT to be a part of a home health visit claim paid under the HH PPS. Instead, that element of care would be paid for separately, in line with rates in the CMS outpatient prospective payment system.

    Value-Based Payment Model. HHAs in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington would continue their participation in a value-based payment system with a few tweaks to some reporting processes and timeframes. Beginning in 2018, the HHAs in these states will receive payment increases or reductions based on 2016 performance data. The adjustment process will continue each year from 2018 to 2022, with the range of payment adjustment increasing incrementally, from a potential 5% increase or decrease in 2018 to an 8% adjustment upward or downward in 2021 and 2022. CMS anticipates saving $380 million through reductions in unnecessary hospitalizations and skilled nursing facility usage through this model.

    Study: Primary Prevention Key to Decreasing Disparity in Black-White Stroke Mortality Rate

    Reducing the stark disparity in stroke mortality between black and white Americans requires a focus on risk prevention in primary care and public health, say authors of a new study. But, they add, those efforts need to "go further upstream" by examining the reasons for the higher prevalence of stroke risk factors among black Americans, including consideration of what authors call "nontraditional risk factors."

    While overall stroke mortality and risk factors such as hypertension have declined over the years for both groups, black Americans at age 45 are more than 3 times as likely as their white peers to die of the disease. Although this difference has existed for decades, it wasn’t clear, based on evidence, where and how to target interventions accordingly.

    The big question, according to authors, has to do with whether black Americans are having more strokes than white Americans, or whether strokes are more often fatal for black Americans. The answer could help health care providers, including physical therapists, understand the best way to approach this public health issue.

    Enter the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a longitudinal cohort study of 30,239 black and white individuals aged 45 years and older. Between 2003 and 2007, 12,212 black and 17,470 white participants were assessed for risk factors via phone interview and in-home visits. Researchers followed up with the participants every 6 months for risk surveillance, and also documented any health risks or events from medical record data. Results were published in the journal Stroke (abstract only available for free).

    Among participants, aged 45–54, the black-to-white ratio of stroke mortality—the percentage of people who die from stroke among that population—is approximately 3:1, but by age 75 the rate is roughly equal. The ratio of stroke incidence showed a similar pattern. However, researchers found that the "fatality" of stroke—that is, the percentage of people who die from stroke among the population of people who experience a stroke—is not significantly different between blacks and whites. In other words, a black American who has a stroke isn't more likely to die from the stroke than a white American, but black Americans are more likely than whites to experience a stroke in the first place—at least until late in life when rates even out.

    According to the researchers, the findings mean that primary prevention, not secondary prevention, should be the main focus in efforts to reduce the disparity.

    Stroke risk factors such as diabetes, they say, account for 40% of this disparity in stroke incidence, and the remaining 60% could be related to: "awareness, treatment, and control of risk factors," such as hypertension, which may have a "more potent effect" in black individuals; nontraditional risk factors, such as depressive symptoms or higher rate of environmental exposures; or measurement error and confounding.

    Authors also acknowledge that there are "substantial black-white differences in care after stroke" but note that in this study, at least, there was no difference in case fatality after stroke.

    Researchers hope this study will lead to better-targeted research and patient care in the future. They write, "We are at the early phase of processes to understand these alternative pathways that potentially contribute to the black-white disparity in stroke incidence, and we need to redouble our efforts to the investigation of these pathways."

    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.

    Last Chance to Register for Online Access to Major Health Policy Research Gathering

    Time is almost out to register for online attendance at a first-of-its-kind gathering of some of the profession's top physical therapy health policy and services researchers.

    The Center on Health Services Training and Research (CoHSTAR) is offering a 2-day Summer Institute on Health Services Research June 28-29 at Boston University. Specifically targeted toward training physical therapists in health policy and health services, the institute is CoHSTAR’s first national conference since its inception in 2015. In-person attendance has reached capacity, but CoHSTAR is offering live online access to the conference on June 29. Registration deadline is June 28.

    Events during the institute will include presentations on integrated health care systems, pragmatic trials, health care industry collaboration, and hospital and academic collaboration, as well as discussions of ongoing CoHSTAR research projects. Presenters include Kristin Archer, PhD, DPT, Katherine Berg, PT, PhD, Gerard Brennan, PT, PhD, Tony Delitto, PT, PhD, Pamela Duncan, PT, PhD, Kelley Fitzgerald, PT, PhD, Michael Friedman, PT, MBA, Julie Fritz, PT, PhD, James Irrgang, PT, PhD, Alan Jette, PT, PhD, Diane Jette, PT, DSc, Michael Johnson, PT, PhD, Vincent Mor, PhD, Ken Ottenbacher, PhD, Linda Resnik, PT, PhD, and Mary Stilphen, PT, DPT.

    CoHSTAR was created through a $2.5 million grant awarded by the Foundation for Physical Therapy, a grant that received $1 million in support from APTA. In addition to the summer institute, CoHSTAR sponsors visiting scientists, offers fellowships, and provides other training sessions.

    New Reports Underscore the Severity of the Opioid Epidemic

    In what's becoming a grim and all-too-familiar pattern, new reports and studies continue to point to alarming trends in the use and abuse of opioids across the US. Combined, they create a picture of a country in the throes of an epidemic that reaches all societal levels, with laws that do little to curb the rise in abuse, and a federal drug regulatory agency that has "opened the gate wide" for the overproduction of prescription opioids.

    Here's a rundown of a few of the studies and reports that surfaced recently:

    Nearly 1 in 3 Medicare beneficiaries received an opioid prescription in 2015.
    A report from the US Department of Health and Human Services (HHS) estimates that 12 million Medicare beneficiaries—about 30%—received a prescription for a commonly abused opioid in 2015, at a cost of over $4 billion in Medicare part D spending. The 4% increase over 2014 rates represents a very modest slowdown from 2013, but the long-range trend shows a 165% increase from 2006. Each Medicare beneficiary who was prescribed a commonly abused opioid received an average of 5 prescriptions a year. The opioids with the highest part D spending were OxyContin, hydrocodone-acetaminophin, oxycodone-acetaminophin, and fentanyl.

    Nonmedical use of prescription opioids more than doubled between 2002 and 2013.
    According to a study in the Journal of Clinical Psychiatry (abstract only available for free), nearly 10 million Americans—about 4.1% of the population—reported using opioids without a prescription or not as prescribed in 2012-2013, a 161% increase from the 2001-2002 study period. Overall, 11% of Americans report nonmedical use of prescription opioids at some point in their lifetime, up from 4.7% in 2001-2002. The estimated number of Americans with prescription opioid use disorder has increased by 125%, with 2.1% of the population (4.8 million) reporting the disorder in their lifetime in the 2012-2013 study. Ten years prior, that rate was 0.9%.

    Tighter controlled substance laws aren't having an impact on opioid abuse, at least among Medicare beneficiaries with disabilities.
    A study in the New England Journal of Medicinelooked at opioid abuse and overdose rates among Medicare beneficiaries with disabilities, and compared those rates with various state laws enacted to curb abuse over a 7-year period. The study focused on beneficiaries aged 21-64 with disabilities—a population that accounted for nearly 1 in 4 deaths from opioid overdose in 2008. What they found was that laws that limit the prescribing and dispensing of controlled substances had little effect on outcomes. "Effective and safer alternatives for chronic pain management are needed, as is a comprehensive response to opioid addiction," authors write.

    The DEA is being questioned about its role in the growth of opioid use and abuse.
    The Washington Post reports that during a US Senate Judiciary Committee hearing, US Drug Enforcement Administration (DEA) Administrator Chuck Rosenberg received a harsh line of questioning from Sen Dick Durbin (D-IL) over the ways in which the agency may have contributed to the current opioid crisis through a decision to "flood America with opioid pills, far beyond any medical purpose." Durbin reported that DEA's production quotas for opioids increased dramatically from 1993 to 2015, with oxycodone production increasing from 3.5 tons to 150 tons, and the production of hydrocodone, hydromorphone, and fentanyl increasing by 12 times, 23 times, and 25 times, respectively. "I think we're part of the problem," Rosenberg admitted at the hearing.

    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.

    Photos From NEXT 2016 Now Available

    Capture your memories of the 2016 NEXT Conference and Exposition and save on words by the thousands: hundreds of photos from the event are now available online, and browsing couldn't be easier.

    Simply go to http://davidbraun.photoreflect.com and click on the "NEXT 2016" link. Enter password vestibular, then click "GO" and the day/event of your choice. Select your photos and order through the shopping cart.

    Note: once you've clicked on a thumbnail, you can select the size and quantity of the print, or, if you want a digital download, click on the "digital products" button. Questions? Contact photographer David Braun.

    Specialist Certification Exam Application Dates Approaching

    Physical therapists who plan to take the 2017 American Board of Physical Therapy Specialties (ABPTS) examination for specialist certification need to get the application process started soon, by either July 1 or July 31, depending on the specialty area.

    The application process for Cardiovascular and Pulmonary, Clinical Electrophysiology, and Women's Health certification must be started by July 1. Geriatrics, Neurology, Orthopaedics, Pediatrics, or Sports applications must be started by July 31. The initial online application form takes about 1-2 hours to complete.

    Application forms and information are available on the ABPTS website.

    Individuals who successfully achieve board certification in 2017 will be recognized during the 2018 Combined Sections Meeting.

    If you need additional information contact the specialist certification department.

    About the Oncology specialist program: the 2016 APTA House of Delegates voted to create a clinical specialization in Oncology; however, the specialist certification process is not yet in place.

    Medicare Fraud Dragnet Identifies a Record $900 Million in Illegal Billing

    The federal government has announced the largest-ever Medicare fraud sweep, a takedown that involves 301 individuals connected to alleged fraudulent billing totaling $900 million.

    The defendants were announced by the US Justice Department on June 22 on charges including conspiracy to commit health care fraud, violations of antikickback laws, money laundering, and aggravated identity theft. In addition to violations connected to home health care, fraud charges were also associated with psychotherapy, durable medical equipment, drug prescribing, occupational therapy, and physical therapy. Home health-related fraud represents about 50% of the cases, with pharmacy fraud accounting for 25%.

    The sweep was led by the Medicare Fraud Strike Force in 36 federal districts, but also included 23 state Medicare fraud control units and cases brought by 26 US Attorney's offices. In terms of payments based on fraudulent claims, a CNN report shows that Florida led the list with $237 million, followed by Texas at $193 million, California with an alleged $162 million, and Michigan at $114 million. Other states associated with larger payment amounts were Illinois ($12 million) and New York ($86 million). The remaining $96 million was spread out over other states.

    Among the cases involving physical therapy were 5 individuals in New York charged with illegal activities involving some $86 million in fraudulent physical therapy and occupational therapy claims. According to a DOJ press release, the individuals under indictment in this case "filled a network of Brooklyn clinics that they controlled with patients by paying bribes and kickbacks. Once at the clinics, these patients were subjected to medically unnecessary therapy." The defendants are alleged to have used over a dozen shell companies to launder the money they received from Medicare.

    "As this takedown should make clear, health care fraud is not an abstract violation or benign offense—it's a serious crime," said US Attorney General Loretta Lynch in the DOJ press release. "Above all, [the alleged offenders] abuse basic bonds of trust—between doctor and patient, between pharmacist and doctor, between taxpayer and government—and pervert them into their own ends."

    The federal actions are supported by funding made available through the Affordable Care Act, which provides an additional $350 million for stepped up enforcement efforts, and toughens sentencing for those found guilty of fraud. To date, nearly 1,200 individuals have been charged through the national takedowns, which DOJ claims involve more the $3.4 billion in fraudulent billings. Last year, a similar dragnet uncovered an estimated $712 million in fraudulent billing.

    "These alleged actions by individual providers and facility owners are not reflective of the values of the professions they are a part of, and we commend the Obama administration for their efforts to root out fraud and abuse and protect taxpayer dollars," said Justin Moore, PT, DPT, APTA's executive vice president of public affairs. "The physical therapy profession has always taken a leadership role in advocating for responsible, patient-centered care—it guides everything we do, and APTA is constantly focused on supporting those values and ensuring the integrity of physical therapist practice."

    APTA has been active in the physical therapy profession's efforts to eliminate fraud, waste, and abuse, and in 2014 APTA launched the Integrity in Practice Campaign, a broad initiative that seeks to position physical therapy as a leader in responsible patient-centered care. At the campaign's center is the APTA Center for Integrity in Practice website, a 1-stop source for information on how PTs, physical therapist assistants (PTAs), and students can keep standards high. Resources include a primer on preventing fraud, abuse, and waste; a free course on compliance; and other information on regulation and payment systems, evidence-based practice, ethics, professionalism, and fraud prevention.