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  • Federal Advocacy Forum Coming Just in Time; Registration Open Through February 24

    Talk about timing: APTA's 2017 Federal Advocacy Forum, set for March 26-28, will bring physical therapists (PTs) and physical therapist assistants (PTAs) together in Washington, DC, just as bills close to the heart of the physical therapy profession emerge on Capitol Hill—including a repeal of the Medicare therapy cap, and better Medicare coverage for lymphedema supplies.

    And there's still time to get in on the action, but hurry, because the registration deadline is February 24.

    As in previous years, the Forum will allow attendees to get the very latest on regulatory and legislative issues affecting the physical therapy profession, to hear from decision-makers on Capitol Hill, and to get tips on how to effectively communicate with elected officials. Then, participants will be offered the opportunity to apply what they've learned by making in-person visits to Senate and House offices.

    The Forum takes place not long after 2 important bills were introduced in Congress: 1 proposal that would permanently repeal the therapy cap on Medicare beneficiaries receiving PT services, and another piece of legislation that would extend Medicare coverage to supplies used in the treatment of lymphedema. Both bills are consistent with APTA's most recent public policy priorities.

    Other activities at the Forum include an evening reception, awards presentations, and breakout sessions on state and federal advocacy, regulatory affairs, and student action. Guest speakers include Brad Fitch, president and chief executive officer of the Congressional Management Foundation, a nonprofit organization that works with legislators and their staff on management issues and techniques.

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    Physical Therapy Outcomes Registry Open for Business, Ready to Make History

    After several years of careful development, APTA has launched what it predicts will be a new chapter in the history of the physical therapy profession: the Physical Therapy Outcomes Registry (Registry). The project aims to build an extensive nationwide repository of patient and practice data that APTA Chief Executive Officer Justin Moore, PT, DPT, describes as "a bridge from our proud past in physical therapy to fully realizing our potential in the future."

    The Registry collects and aggregates electronic health record data from participating physical therapist (PT) practices, allowing PTs to make improved, data-informed clinical decisions, track and benchmark outcomes against industry data, and demonstrate the value of PT services. It's the most extensive resource of its kind designed specifically for use in the physical therapy profession.

    Speaking at the Registry's February 15 launch event held at the APTA 2017 Combined Sections Meeting, APTA President Sharon Dunn, PT, PhD, described the platform as "a resource that will elevate the care we provide our patients, that will better visualize our value, and that will help define our future, both as individual therapists and as a profession."

    "Ultimately, that means making a difference in people's lives," Dunn added.

    In a video dispatch on the launch, Jay Irrgang, PT, PhD, FAPTA, who heads up the scientific advisory panel that oversaw the development of the database, described the Registry as a singular source of data "from the profession, for the profession," adding that information from the Registry has the potential to impact not only practice, but quality improvement initiatives, payment, and research.

    The extent of those impacts? To a large degree, that's up to the profession itself, Moore told the audience at the launch event.

    "The Physical Therapy Outcomes Registry has the potential to become one of the most significant developments in the history of our profession, but only if we, as a profession, make use of it," Moore said. "The Registry is a bridge to our full potential. It's up to us now to walk across it."

    Visit the Registry website  to find out how it works, and learn how you can use the Registry to transform your practice—and the profession.




    Analysis of Hospital System's LE Joint Replacement Bundling Programs Reveals Significant Drop in Expenditures

    In brief:

    • Analysis of Medicare payments related to 3,942 LE joint replacements in a 5-hospital network participating in voluntary bundling programs between 2008 and 2015.
    • During study period, average expenditures on replacements without complications dropped by 20.8%; expenditures on replacements with complications dropped by 13.8%.
    • Treatment population, severity of illness, and outcomes remained stable during study period; volume rose steadily.
    • Just over half (50.2%) of the savings were related to reduced in-hospital costs—predominantly due to a 30% reduction in the cost of implants. The remaining 48.8% of savings were related to a decreased use of IRFs and SNFs.
    • Use of home health care (including physical therapy in that setting) increased by 9% during study period.

    It may be too soon to judge the cost-effectiveness of Center for Medicare and Medicaid Services' (CMS) mandatory hip and knee replacement bundling programs, but if the experience of 1 hospital system that participated in earlier voluntary programs is any indication, facilities have reason to expect overall Medicare expenditures to drop, say authors of a new study. Their analysis of nearly 4,000 patients who participated in bundling programs between 2008 and 2015 revealed an average 20.8% reduction in expenditures for joint replacements without complications, with the bulk of those savings due to reduced implant prices and the decreased use of institutional postacute care.

    The study, published in JAMA Internal Medicine (abstract only available for free), tracked Medicare claims related to lower extremity joint replacement among patients in the Baptist Health System (BHS), a 5-hospital network in San Antonio, Texas. During the study period, from 2008 to 2015, BHS participated in 2 voluntary bundling programs offered by CMS—the Acute Care Episode (ACE) demonstration, and later, the major joint replacement of the lower extremity (MJRLE) bundle offered through the Bundled Payment for Care Improvement (BCPI) program. A total of 3,942 patients (average age 72.4) participated in the programs.

    Researchers found that between 2008 and 2015, average Medicare episode payments for joint replacements without complications decreased from $26,785 to $21,208—a 20.8% drop during a time period in which nationwide payments rose by 5%. Among the 204 cases with complications, expenditures were reduced by 13.8% on average, from $38,537 to $33,216. Authors of the study say that patient age, proportion of male patients, and severity of illness did not change significantly during that time; however, volume did rise steadily, from 192 to 246 episodes per quarter.

    Authors cite 2 major factors contributing to the savings: first, BHS was able to find less expensive implants that brought the price down by nearly 30% during the study period, (a change that accounted for 80.5% of all in-hospital savings). Second, BHS reduced spending on inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) by 54% and 24.3%, respectively. In the end, the savings associated with internal hospital cost reductions represented 51.2% of overall savings, and decreased use of IRFs and SNFs represented the remaining 48.8%.

    According to the authors, the overall BHS results may be related to the amount of experience the system has with bundling, which allowed it to build "data infrastructure and an orthopedic working group to track hospital and [postacute care] variation." Another important factor: something authors call "organizational and market characteristics" that included the "availability of home-based services such as physical therapy allowing BHS to safely reduce institutional [postacute care]." During the study period, per-episode spending on home health care rose by 9%.

    The BHS move away from institutional postacute care has not escaped notice: in 2015, National Public Radio featured the BHS bundling model, reporting that "the loss to the nursing homes and other post-discharge providers was [BHS'] gain."

    Authors of the study acknowledge the limitations associated with a focus on only 1 hospital system, but assert that their study "provides important data for hospitals implementing joint replacement bundles," particularly under the CMS Comprehensive Care for Joint Replacement (CJR) model now required in 67 metropolitan areas.

    In that sense, authors say, the BHS study could be a catalyst for large-scale changes.

    "If such approaches are successfully implemented on a broad scale with similar results, the magnitude of savings that could accrue to Medicare—and possibly private payers—would be substantial," authors write. "In turn, the success of CJR participants could accelerate the shift toward bundled payments for more conditions and procedures."

    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.

    The Good Stuff: Members and the Profession in Local News, February 2017

    "The Good Stuff" is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Cristin Beazley, PT, describes the need for baseline concussion testing among youth athletes, and shares an innovative program to do just that in partnership between Sheltering Arms Hospital and FC Richmond, Virginia. (Richmond Times-Dispatch)

    Sheila Klausner, PT, MS, offers tips on how to become a runner. (Apopka, Florida Voice)

    Viral video: Hunter Christ, PT, uses zydeco dancing to get his patient moving. (KATC3, Denham Springs, Louisiana)

    William Carey University (MS) PT students help with cleanup after a devastating tornado. (WDAM7, Moselle, Mississippi)

    Robyn Wilhelm PT, DPT, discusses the role physical therapy can play in treating pelvic floor dysfunction. (Shape magazine)

    PT students at Central Michigan University joined with med students to explore ways to work together to improve treatment services. (Mt. Pleasant, Michigan Morning Sun)

    PTJ Editor in Chief Alan Jette, PT, PhD, FAPTA, discusses the future of the journal. (Oxford University Press blog)

    Sarah Morrison, PT, MBA, MHA, takes over as CEO of The Shepherd Center. (Atlanta Journal-Constitution)

    California State University-Long Beach PT students donate adaptive tricycles. (Long Beach, California Post)

    Marilyn Moffat, PT, DPT, PhD, FAPTA, explains the ways exercise can help individuals with Parkinson disease. (New York Times)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Revised Physician Guidelines Shift to Non-Drug Approaches as First-Line Treatment for LBP

    In brief:

    • In a revision of clinical guidelines, the American College of Physicians is recommending nonpharmacologic approaches over the use of medications as first-line treatment for acute, subacute, and chronic LBP.
    • Changes are based in part on new evidence showing that acetaminophen and antidepressants were no better than placebos.
    • Guidelines recommend that physicians advise patients that pain is likely to diminish through exercise and maintenance of as many daily activities as possible.

    The latest advice on low back pain (LBP) from the American College of Physicians (ACP) makes it clear: patients with acute LBP will generally improve over time regardless of treatment, and that when treatments are necessary, nondrug approaches including exercise are preferred for all but the most stubbornly chronic manifestations of the condition. The new guidelines represent a shift from ACP's previous position, which called for the use of medication as part of first-line treatment.

    The guidelines, released on February 13, include 3 recommendations—1 each for acute (fewer than 4 weeks) or subacture (4 to 12 weeks) LBP, chronic LBP (more than 12 weeks), and chronic LBP that persists after the use of nonpharmacologic therapy. Researchers analyzed studies on the effectiveness of both pharmacologic and nonpharmacologic treatments among the 3 types of LBP. Drug-based treatments studied ran the gamut from acetaminophen to opioids, including antidepressant medications. Nonpharmocologic treatments reviewed included spinal manipulation, multidisciplinary rehabilitation, massage, "exercise and related therapies, and various physical modalities," among other approaches.

    In the end, what researchers found had less to do with breakthrough understandings of the effectiveness of exercise and maintaining daily activities—benefits of which were reestablished through a systematic review conducted as part of guideline development—and more to do with a weakening of evidence supporting the use of medications.

    "The [review that served as the basis for the previous guidelines published in 2007] concluded that acetaminophen was effective for acute low back pain," authors write. "However, [the 2017] update included a placebo-controlled RCT in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo," with the same results surfacing when it came to the use of antidepressants. On the other hand, they add, "many conclusions about nonpharmacologic interventions are similar between the 2007 review and the update."

    At the acute and subacute levels, the new guidelines strongly recommend that physicians advise patients that the pain is likely to improve over time, and discuss the use of "superficial heat, massage, acupuncture, or spinal manipulation." At the chronic level, the guidelines strongly recommend "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (supported by moderate-quality evidence), tai chi, yoga, motor control exercise," and other approaches that include low-level laser therapy and spinal manipulation (supported by low-quality evidence). In all cases, they write, "it is important that physical therapies be administered by providers with appropriate training."

    For patients with chronic LBP that persists after nonpharmacologic approaches have been tried, the guidelines make a "weak" recommendation for considering nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, with tramadol or duloxetine as a second-line therapy. "Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and related benefits with the patients," authors add.

    The updated guidelines generated wide media coverage, including stories from CBS News, NBC News, and the New York Times, which characterized the recommendations as "bucking what many doctors do."

    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.

    Lymphedema Treatment Legislation Returns to Congress

    The possibility of Medicare paying for lymphedema treatment supplies, a longtime target of APTA advocacy efforts, is back on the table at the US House of Representatives with the reintroduction of a bill that would expand coverage.

    Last week, Reps Dave Reichert (R-WA), Earl Blumenauer (D-OR), Leonard Lance (R-NJ), and Jan Schakowsky (D-IL) introduced the Lymphedema Treatment Act (HR 930), legislation that would expand the range of compression supplies covered by Medicare for lymphedema treatment. A companion bill is expected to be filed in the Senate in the coming weeks.

    “Individuals suffering from lymphedema should have equal access to treatment," said Rep Reichert in a press release announcing the introduction. “Closing the Medicare coverage gap for compression garments is a common-sense way to give patients real hope to fight back and live with the best possible quality of life.”

    Similar legislation was introduced in 2015 but never made it to a full vote in either the House or Senate, even though the bill had 261 cosponsors in the House. During the lead-up to that push, APTA representatives participated in a congressional hearing to educate lawmakers and staff on the bill.

    APTA staff will monitor the legislation’s progress and update members with news and advocacy opportunities.

    Study: Personal Approach Is Important to Patients With Chronic Pain, but Partial Telerehab Could Offer Acceptable Alternatives

    In brief:

    • First telemedicine study to use discrete choice experiment to examine patient preferences and priorities.
    • Survey recipients included 300 chronic pain patients on a wait list for a rehab center in The Netherlands.
    • Experiment included 15 choice tasks combining 6 telerehab treatment characteristics.
    • Patients preferred face-to-face treatment and frequent physician consultation to web-based sessions.
    • Most-preferred scenario included 75% video instruction and infrequent physician consultation, accompanied by remote monitoring and feedback technology.

    While the emergence of telemedicine holds great promise for improving access to effective, cost-efficient care, its success depends on providers designing such services “with the patients’ perspective in mind,” say experts in a study in the Journal of Medical Internet Research. The Dutch researchers found that chronic pain patients were willing to forgo face-to-face time with physicians when “remote feedback and monitoring technology is offered.”

    Authors wanted to learn about chronic pain patient preferences for telerehabilitation, including how much human contact was important to recovery and what treatment characteristics were most valued by patients. Based on qualitative interviews and a focus group, they devised a “discrete choice experiment” to learn more about treatment characteristics such as amount of preferred human contact and treatment mode and location, as well as what type of “telerehabilitation scenario they are most likely to accept as an alternative to conventional rehabilitation.”

    Researchers randomly distributed 3 different versions of a survey questionnaire, each of which included 15 scenarios in which the patient had to choose rehab program A, B, or “I choose not to be treated.” Scenarios included either clinic-based or home-based rehab, and included varying levels of human contact, physician consultation, treatment mode and location, web-based and face-to-face instruction, feedback and monitoring technology, program flexibility, and health care premium reduction.

    From the results of the 103 survey responses, authors found that all 6 of the treatment attributes were “significant determinants” in patients’ preferences. Patients preferred face-to-face treatment over web-based sessions, and would choose physician contact every session, as opposed to only some sessions. Patients also preferred the use of feedback and monitoring technology, flexible exercise times over fixed times, and exercise at a gym rather than at home.

    The scenario patients were most “willing to accept” included individualized, gym-based exercise; 75% video instruction; consulting with a physician in 1 out of 4 sessions; use of feedback and monitoring technology; fixed sessions; and no health care premium reduction. Authors note: “Remarkably, [this scenario] is the only scenario that outweighs the utility of conventional care,” indicating patients’ willingness “to accept both a reduction in consulting frequency and face-to-face consulting when remote feedback and monitoring technology is offered.”

    The least-preferred scenario: home-based care with minimal physician contact and a high degree of self-management required, with patients consistently leaning toward conventional treatment over all home-based scenarios. Authors suggest that this desire for personal contact may be attributed in part to the psychosocial nature of treatment for chronic pain, in which “patient-provider communication plays such an important role” and “empathy and emotional support are considered essential.”

    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.

    Find out how a better understanding of pain can transform practice: join a March 16 live webinar on musculoskeletal pain principles presented by 2016 Maley Lecturer Steven George, PT, PhD.

    2017 NEXT Registration Opens

    Groundhog-based prognostication aside, spring is in fact right around the corner and June isn't far behind, which means APTA's NEXT Conference and Exposition is getting ready to arrive on the scene in Boston, Massachusetts.

    APTA has opened up registration for NEXT, set for June 21-24. Again this year, NEXT is shaping up to be a can't-miss event, where the profession's thought leaders and experts come together to offer programming with an emphasis on interactivity and direct engagement.

    Programming highlights for 2017 include sessions on clinical reasoning, creative mobility technology, generational perspectives, and mindfulness in pain treatment. In addition to all the new topics, attendees can still expect annual favorites such as the McMillan and Maley lectures, and the almost-too-much-fun-for-a-conference Oxford Debate, returning to celebrate its 10-year anniversary.

    It all adds up to an event that will ignite your passion for the profession. Register today and experience NEXT 2017 for yourself.

    Think we're just making this stuff up? We're not. Check out news and video from the 2016 NEXT  for a taste of what you missed.

    Ready to Step Up to APTA Committee Service? Now’s Your Chance

    Ready to take a lead in shaping the future of APTA? The call for volunteers to serve on APTA committees is open now through March 1. Members interested in serving on the Ethics and Judicial, Finance and Audit, Leadership Development, and Public Policy and Advocacy committees, an Awards subcommittee, or the Reference Committee are encouraged to let APTA know of their willingness to participate.

    APTA relies heavily on its volunteers. We need the skills, passion, and varied perspectives to build an energetic, inclusive, and innovative corps of volunteer leaders.

    Apply through the Volunteer Interest Pool by updating your profile, then click "Apply for Current Vacancies" to answer questions specific to the committee. Your profile and thoughtful responses to the application question will be read carefully and will help us select the most appropriate, diverse, and inclusive teams possible. For more information, contact Appointed Group Pool.

    Judge Lays Out What CMS Must Do to Correct Jimmo Education Failings

    The 2013 settlement agreement reached in theJimmo v Sibelius case was supposed to have debunked the "improvement standard" myth once and for all—provided, of course, that the Centers for Medicare and Medicaid Services (CMS) did the debunking and educated Medicare contractors and others on the importance of stopping inappropriate coverage denials. Last year, a federal judge ruled that CMS fell short on those efforts. Now that same judge has spelled out just what CMS must do to make things right—and by when.

    In a ruling released February 2, US District Court Judge Christina Reiss told the Secretary of Health and Human Services that CMS has until September 4 to complete a series of steps that would make it clear to Medicare contractors, Medicare Advantage plan administrators, and others that the so-called "improvement standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy.

    These education efforts were supposed to have taken place after the 2013 Jimmo settlement around the improvement standard—a standard that CMS claims it never explicitly supported yet somehow became common practice among contractors. In August, 2016, Reiss found that the postsettlement CMS efforts "reflect[ed] virtually no effort to educate participants" and ruled that "corrective action" should be taken at once. After CMS and plaintiffs failed to agree on the specifics of a plan, Reiss issued the most recent ruling that lays out just what CMS needs to do.

    The decision requires CMS to take the following steps:
    • Publish a new webpage specifically related to the Jimmo settlement
    • Publish a statement that disavows the improvement standard
    • Publish a list of frequently-asked-questions on the issue
    • Develop and administer trainings for providers and adjudicators
    • Conduct a national conference call to clarify the coverage policy

    In addition, Reiss sided with the opponents of CMS when it came to the exact wording of the statement that would be issued. According to the ruling, CMS will be required to use verbatim language that includes the words "the Medicare program will pay for skilled nursing care and skilled rehabilitation services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)."

    APTA actively supported efforts to press for better education by CMS and provided a declaration to the Center for Medicare Advocacy, 1 of the plaintiffs representing Medicare beneficiaries. Additionally, APTA maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.