Research on the cost-savings of physical therapy vs advanced imaging has been making news in professional circles, and now it's making an even more public splash.
On March 27, The Washington Post published an article summarizing the findings of research that compared health costs for patients with uncomplicated low back pain (LBP) who were referred to physical therapy with patients referred for advanced imaging. As reported in PT in Motion News, the results showed that physical therapy typically resulted in dramatically lower subsequent costs than a first referral for imaging. The original research article was published in the journal Health Services Research (abstract only available for free).
The Post article characterized the reasons for the differences as being "more likely found in the heads of patients and doctors than in anyone's back." Post reporter Lenny Bernstein writes that patients with uncomplicated first-time LBP can "pressure" physicians for a referral, and physicians may comply—sometimes with a referral for advanced imaging, sometimes for a referral to physical therapy.
The lower health care costs associated with physical therapy have a connection with how patients respond to physical therapy's more proactive, patient-focused approach, according to the Post.
In summarizing comments from Julie M. Fritz, PT, PhD, FAPTA, the study's lead author, the Post describes physical therapy as an approach that "focuses on educating patients about what might be causing their back pain, assuring them that most problems subside in time, and engaging them in their therapy."
The study theorizes that as opposed to physical therapy, a referral for imaging early on can lead to a different patient attitude, one that often results in more testing, more physician visits, and greater use of medication. After 1 year, the imaging-first approach can result in average costs over 3 times higher than a physical therapy-first approach, according to the study.
Fritz is quoted in the article saying that "We think this is an area where our profession has something to offer, especially when it's timed correctly," adding that advanced imaging can be appropriate thing to do, but "just not early in the course of care for most patients."
Available at the APTA Learning Center: pre-recorded CE on manipulation for LBP presented by study author Julie M. Fritz, PT, PhD, FAPTA; also "Manual therapy management of the lumbopelvic spine" presented by Josh Cleland, PT, DPT, PhD, OCS, and Shane Koppenhaver, PT, PhD, OCS, FAAOMPT.
The APTA Physical Therapy Outcomes Registry (Registry), a major initiative that aims to create the most comprehensive electronic repository for physical therapy outcomes, is now ready to move to the next phase in its development—filling important staff and appointed positions solely dedicated to the program.
Recently, APTA announced 2 leadership opportunities—a staff-hired registry director and a Board of Directors-appointed scientific director. Both roles will play an important part in the debut of the full-scale project, tentatively set for early 2016.
The Director, Physical Therapy Outcomes Registry is responsible for the daily operations, business affairs, communications, and recruitment plans for the registry within APTA's Public Affairs Unit. The association is seeking candidates with demonstrated leadership and accountability who have an advanced degree (or equivalent experience) and 3-5 years' experience in data management, research, quality programs, or scientific programs.
The Scientific Director, Physical Therapy Outcomes Registry will be appointed by the APTA Board of Directors to serve a 2-year term beginning July 1, 2015. This position will oversee the scientific integrity of the registry, and will appoint and lead a scientific advisory board to develop and maintain standards and policies for the registry. An honorarium is provided. More details on the position can be found in the application form (follow link under "Involvement Opportunity").
Application deadline for the board-appointed scientific director position is April 20.
Now in beta-testing, the Registry is designed to be a "hub and spoke" system in which outcomes information from a wide range of sources will be aggregated across patient populations and clinical settings. More information on the Registry, how it works, and its potential impact on health care is available at the program's website.
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 firstname.lastname@example.org.
"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.
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