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  • APTA's Member Magazine Takes Home Multiple Awards

    PT in Motion magazine is continuing APTA's award-winning ways, recently earning 6 awards for feature stories published in 2016.

    The entire magazine earned an Award of Merit from the Society for Technical Communications, in addition to awards for 3 individual articles: "Managing Patients Who Are Transgender," from the July, 2016 issue, "Making a House an Accessible Home: The Role of PTs," from August, and "Raters Gonna Rate" from the issue published in September, 2015. The article on working with transgendered patients went on to win an International Summit Award of Merit from the technical writers' group.

    But wait, there's more: in addition, the American Society of Business Publication Editors recognized the article on transgendered patients with a Gold Award for general interest feature article.

    The awards continue the good run of recognitions APTA has received this year, beginning with an award from the American Medical Association for APTA's education efforts around the new current procedural terminology (CPT) coding set, followed by a prestigious Gold Circle award from the American Society for Association Executives for a video supporting the association's #ChoosePT antiopioid campaign.

    Don Tepper is managing editor of PT in Motion and wrote both the accessibility and raters articles. Freelance writer Chris Hayhurst authored the article on transgendered patients.

    PT in Motion magazine is mailed to all APTA members who have not opted out; digital versions are available online to members.

    CDC: 1 in 3 Rural Residents Has Arthritis; Over 50% of Those Experience Activity Limitations

    In brief:

    • Survey of 426,361 adults across US asked about arthritis and arthritis-attributable activity limitations (AAALs); responses were divided according to 6 categories of population descriptors, from rural to urban
    • Nearly 1 in 3 rural residents reported arthritis; rate was 1 in 5 for urban residents, 22.7% for the US overall
    • More than half (55.3%) of rural residents with arthritis reported AAAL; rate was 49.7% in urban areas
    • Higher incidence among rural residents applied to all age groups studies
    • Researchers believe interventions in rural areas may be hampered by lack of activity-friendly infrastructure

    America has an arthritis problem, and rural America is being hit especially hard—that's the finding of a report from the US Centers for Disease Control and Prevention (CDC) that estimates nearly 1 in 3 rural residents in the US has some form of arthritis, with more than half of those with arthritis experiencing activity limitations.

    The latest study, which appears in CDC's May 25 Morbidity and Mortality Weekly Report, describes the results of a detailed study of the 2015 Behavioral Risk Factor Surveillance System (BRFSS), a survey of 426,361 noninstitutionalized adults across the 50 states and the District of Columbia. Researchers asked respondents, "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" If the answer was "yes," respondents were then asked, "Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?"

    Once data were collected, researchers organized responses according to where respondents lived, assigning them to 1 of 6 categories developed by the National Center for Health Statistics: city, large fringe metropolitan, medium metropolitan, small metropolitan, micro metropolitan, and rural. Here's what they found:

    • Overall, more than 1 in 5 respondents reported arthritis (22.7%), with 43% of those reporting arthritis-attributable activity limitation (AAAL).
    • Major differences were discovered in arthritis and AAAL rates between urban and rural residents, with the rate of arthritis among rural residents at 31.8%, compared with a 20.5% rate among urban residents. AAAL prevalence was also worse in rural areas, where 55.3% of respondents with arthritis reported limitations, compared with 49.7% in the most urban areas.
    • Arthritis prevalence was higher among rural residents for nearly all age groups studied.
    • Although rates tended to increase as population density decreased, the overall correlations to demographic, health, and behavioral patterns were similar for each population area, with women, older adults, smokers, adults with less education, adults who are less physically active, and adults with higher body mass index reporting higher rates of arthritis within each population grouping.
    • AAAL rates were particularly high for rural residents who also reported a functional or work disability, with 56.7% reporting activity limitations. That rate was 42.3% among urban residents.
    • Authors speculate that the higher rates may be due to a higher prevalence of recognized risk factors in rural areas—particularly older age, obesity, and lower socioeconomic status.

    While they write that "wider use of evidence-based interventions including physical activity and self-management education in rural areas might help reduce the impact of arthritis and AAAL," authors also acknowledge that may be easier said than done. Using walking as an example of a "low impact, accessible activity proven to reduce pain and improve quality of life," they describe how lower-density environments make this more difficult through limited pedestrian infrastructure, lack of sidewalks, long distances between destinations, and sometimes even a lack of a destination itself.

    But even without plentiful pedestrian-friendly environments, the physical activity levels of rural residents could be increased if health care providers would simply suggest self-management programs and recommend that their patients be more active, they assert.

    "The higher prevalence of arthritis and AAAL among rural US residents highlights the need for evidence-based intervention approaches such as physical activity, self-management education, and vocational rehabilitation programs," authors write. "Health care providers and community organizations can help residents participate in these helpful interventions."

    APTA offers multiple resources on arthritis management through community-based programs, including an overview of evidence-based programs, and a decision aid to help physical therapists choose an appropriate program for the patient. Additionally, the US Bone and Joint Initiative (USBJI) offers a series of free public education programs aimed at helping providers increase community awareness of osteoarthritis treatment. APTA is a founding member of USBJI.

    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.

    Trump Budget Cuts to Medicaid, Research, Food Programs Cause Concern, But Will They Survive?

    With plans that include significant cuts to Medicaid, health research, and anti-poverty programs, the 2018 federal budget proposal from the Trump administration is being met with concern by APTA and most other health care and consumer organizations. However, like nearly every other budget submitted by a US President, the chances of the $4.1 trillion proposal surviving Congress intact is unlikely.

    The proposal, released May 23, combines cuts in health care, education, and anti-poverty spending with significant increases in spending on defense and border security. The President’s plan would boost 2018 discretionary spending for defense to $607 billion, with nondiscretionary defense spending set at $560 billion—an overall increase of 10% for military spending. The $2.6 billion for border security would include $1.6 billion for the construction of a border wall with Mexico.

    The budget also proposes 2% cuts across-the-board for all nondefense spending for the next 10 years, as well as significant cuts to nearly every other facet of government, including the departments of labor, interior, education, and state, which would all be cut by double-digit percentages ranging from 10.9% (interior) to 31.2% (Environmental Protection Agency). Besides defense and homeland security, the only other department slated for an increase is the Department of Veterans Affairs, with a proposed 5.8% increase.

    Cuts and other changes that may be of specific interest to physical therapists, physical therapist assistants, and students include:

    • $1.4 trillion in cuts to Medicaid—$800 billion achieved if the American Health Care Act is passed, and an additional $600 billion in reductions realized through a switch to a per capita or block grant system at the state level
    • 0.6% cut to Medicare, a cut that the Congressional Budget Office/Office of Management and Budget says would amount to an $8.7 trillion reduction over 10 years if no policies are changed
    • $5.8 billion in cuts to the National Institutes of Health, including cuts to agencies involved in research on cancer, aging, infectious disease, and child health and development (the arm of NIH that also includes the National Center for Medical Rehabilitation Research)
    • Elimination of the Agency for Healthcare Research and Quality
    • More than $10 billion in cuts to education programs, with $9 billion tied directly to cuts in the Department of Education
    • Phase-out of the public service loan forgiveness program for any student loans originating after June 30, 2018, as well as elimination of subsidized student loans
    • A 5% cut to the Office of National Drug Control Policy, which coordinates federal efforts to combat the opioid epidemic (rumors were that cuts could be as high as 95%)

    "The budget proposal we're seeing represents a dramatic shift in spending, but it is consistent with what we anticipated, given the stated priorities of the administration," said Justin Elliott, APTA vice president of government affairs. "It is important to remember that Presidential budgets are almost always viewed more as a wish list from the administration. They are very rarely enacted as presented."

    But APTA isn't making any assumptions about the fate of Trump's budget.

    "Many of the proposed cuts would have a direct detrimental impact on our patients, and are in opposition to the core values of APTA and the physical therapy profession," said APTA President Sharon Dunn, PT, PhD. "We will join with many other health care and patient advocacy organizations to work with Congress toward a budget that supports wide access to affordable health care, strengthens research capabilities, and helps to improve the overall health of society."

    APTA to Senate: House Version of AHCA Would Reduce Access to Care

    With the US Senate considering action on health care, APTA is making it clear that at least 1 of the options available—the adoption of the American Health Care Act passed by the US House of Representatives—falls short of providing "adequate, affordable, and quality health care services for all Americans."

    In a May 22 letter to Senators, APTA President Sharon Dunn, PT, PhD, reiterates that although APTA does not oppose reform of the current Affordable Care Act (ACA), the association does see deep flaws in the AHCA as narrowly passed by the House earlier this month, particularly when it comes to the bill's approach to essential health benefits (EHBs) and Medicaid. "We believe [these changes] could hinder access for millions of Americans across the country," Dunn writes. The letter is consistent with an APTA statement issued in March.

    The current version of the AHCA weakens the power of federally mandated EHBs—which include physical therapy—by allowing states to apply for waivers to reduce the requirements or eliminate them entirely. The result, according to APTA: a likely reduction in access to habilitative and rehabilitative services for millions of Americans that could have lasting societal effects.

    "Americans needing rehabilitation services and devices rely on their health care coverage to regain and/or maintain their maximum level of health, independent function, and independent living," Dunn writes. "This reduces long-term disability and dependency costs to society."

    The letter also points out the ways that the AHCA's changes to Medicaid could make a difficult situation even harder for beneficiaries.

    "Under traditional Medicaid (nonexpansion plans), physical therapy and other rehabilitative services are considered 'optional benefits' and therefore aren't always covered," Dunn writes. "APTA suggests that because of the changes proposed to Medicaid—specifically switching to a per capita or block grant system—a state's ability to fund its Medicaid program will be strained, causing optional benefits such as physical therapy to be jeopardized."

    Dunn states that the association looks forward to working with the Senate on changes that have the goal of "[ensuring] that Americans have access to adequate, affordable, quality health care services."

    Two New Bills in House Focus on Expanding Telehealth in Medicare, Opening up Possibilities for PTs

    Medicare could become a much more welcoming place for telehealth services if Congress passes 2 pieces of legislation recently introduced in the US House of Representatives. The 2 separate bills would have the combined effect of expanding where and how telehealth services can take place, which patients are permitted to receive the services, and the list of health care professional who can provide the services—a list that includes physical therapists (PTs).

    The bills—1 called the Medicare Telehealth Parity Act, and a second known as the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act—propose changes to the way Medicare handles a number of issues, from remote monitoring of patients with chronic conditions, to a reworked definition of reimbursable telehealth codes. In addition, the parity act expands the list of providers who can provide telehealth services to PTs, respiratory therapists, occupational therapists (OTs), speech language pathologists, and audiologists, while the CONNECT act would allow PTs in some bundled payment arrangements, accountable care organizations (ACOs), and Medicare Advantage plans to participate in telehealth arrangements.

    APTA has joined the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and American Medical Association, and other health care organizations in support of both bills. Representatives Mike Thompson (D-CA), Gregg Harper (R-MS), Diane Black (R-TN), and Peter Welch (D-VT) introduced the bills, and have also created the first congressional telehealth caucus. The CONNECT act was introduced in the Senate earlier in May.

    Provisions in the parity act include:

    • Removing geographic barriers to provide telehealth services in rural, underserved, and metropolitan areas
    • Expanding the list of providers eligible to provide telehealth services to include PTs, OTs, and speech language pathologists, among others
    • Expanding access to telestroke services
    • Allowing remote patient monitoring for those with chronic conditions including heart failure, chronic obstructive pulmonary disease, and diabetes
    • Allowing a beneficiary's home to serve as a site of care for home dialysis, hospice care, eligible outpatient mental health services, and home health services

    The CONNECT act's changes include:

    • Expansion of telehealth in ACOs, Medicare Advantage, and stroke treatment programs
    • Expansion of remote monitoring programs for people with chronic conditions
    • Definitions of reimbursable telehealth codes
    • Expansion of remote patient monitoring programs at community health centers and rural clinics

    APTA government affairs staff will continue to track the progress of the legislation.

    From PTJ: Urinary Incontinence Often Accompanied by Low Back Pain

    In brief:

    • Authors used 125,645 responses from the 2011–2012 Statistics Canada Canadian Community Health Survey
    • Study is the first to also examine the association between urinary incontinence (UI) and back pain in men
    • Both men and women diagnosed with UI were more than 2 times as likely to also have a back pain diagnosis
    • Incidence was similar in both men and women, but there may be some underreporting
    • Providers should perform a thorough review of systems when interviewing patients with either UI or back pain

    It isn’t just coincidence that many patients with urinary incontinence (UI) also have low back pain (LBP), according to a new Canadian study. Researchers called it "surprising" that men and women had nearly the same likelihood of having both conditions, and suggest that providers screen all adults who present with one condition for the other.

    In the April issue of Physical Therapy (PTJ), a special issue on pelvic floor dysfunction in adults, authors analyzed the 125,645 responses to the 2011–2012 Statistics Canada Canadian Community Health Survey to see if there was a true statistical relationship between UI and LBP. While previous studies have found a high prevalence of both conditions in women, none have examined the link in men.

    In the initial analysis, 1.05% of men and 2.5% of women had diagnoses of both LBP and UI. The overall incidence was 1.79%. Adults with UI were more than 2 times more likely to have LBP (OR = 2.18, 95% CI = 1.78–2.66 for men; OR = 2.21, 95% CI = 1.94–2.51, for women) than those who do not have UI. The association was stronger in patients who were overweight or who currently or previously smoked, and it increased with age.

    Authors expected the strong association between the conditions, as it has been shown in previous studies of women. But it was, they write, "surprising that the strength of the associations was so similar in men and women."

    The large sample size allowed the results to be generalized to most of the Canadian population. However, the survey did not include "people living on First Nations reservations or crown lands," those living in institutions or remote areas, or military personnel.

    While the overall prevalence of UI was lower than in previous research, this study was different because the survey asked specifically about physician-diagnosed conditions. Researchers note, "It is well documented that a majority of women with UI do not report their leakage to a health care provider." They also suggest that the lower prevalence among men may be due to the survey excluding men who reside in institutions such as long-term care facilities, where the prevalence has been found to be higher than in community-dwelling men.

    Because the survey was cross-sectional, "is not possible to determine the order which the conditions presented themselves or to determine whether the conditions developed from a common dysfunction or if they had separate, summative etiologies," authors note. However, because having UI more than doubles the risk of having LBP, they assert that it's important for health care professionals to understand the strong connections between back pain and UI. "This finding reinforces the importance of screening for these conditions in people with the other condition," they write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

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    Cardiac Bundling Program, CJR Expansion, Won't Happen Until January 2018

    The introduction of a mandatory Medicare bundling program for cardiac care that had been delayed until October has now been pushed back further to January 2018, according to a final rule by the Centers for Medicare and Medicaid Services (CMS). That delay also applies to plans to expand the comprehensive joint replacement model (CJR) already in place.

    The final rule requires 98 randomly selected metropolitan areas to participate in bundling programs for care associated with bypass surgery and heart attacks under Medicare parts A and B, and includes provisions that will incentivize the use of cardiac rehabilitation. It also includes an expansion of the CJR model beyond hip and knee arthroplasty, to include patients undergoing care for hip and femur fractures.

    However, these changes will not be implemented before January of next year. CMS says the delay “will ensure that CMS has adequate time to undertake notice and comment rulemaking, if modifications are warranted.” APTA has developed a fact sheet on the rule, and CMS offers general information and presentation slides on the topic, plus an overview of what it calls "episodic payment models."

    APTA's education efforts on bundling began well before the April 1, 2016, startup of CJR and include 2 webinars (1 on the basics of the CJR program and 1 that includes insights from PTs participating in bundled care programs), an article in PT in Motion magazine, and a webpage that contains background information as well as links to evidence-based clinical information and community programs.

    The Good Stuff: Members and the Profession in Local News, May 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!

    Six doctors couldn't diagnose the cause of Annie Karp's hip pain. A physical therapist figured it out. (The Washington Post)

    Maggie Lastukhin, PT, DPT, helps her patient fight back from a spinal staph infection that left him with quadriplegia. (WFAA8 News, Dallas)

    Rachel Feinberg, PT, helps Consumer Reports describe how physical therapy can be effective for back pain. (Consumer Reports)

    Murphy Halasz, PT, provides exercise suggestions for foot pain. (Prevention magazine)

    Wichita State physical therapy and engineering students team up to produce modified toy cars through the GoBabyGo! program. (Wichita State University, Kansas, News)

    Mike Studer, PT, talks about the role of physical therapy in addressing aging-related issues. ("Aging in the Willamette Valley" radio program, Salem, Oregon)

    "I think it’s almost inappropriate to look at it as a limitation. I look at it as an opportunity to excel." – Mariya Spencer, SPTA, who also has bilateral amputation (Tyler, Texas, Morning Telegraph)

    Dan Giordano, PT, DPT, provides his take on the "7 Best Stretches for Knee Pain." (Self magazine)

    Heidi Jannenga, PT, DPT, earns Arizona "Top Tech" award for WebPT. (Phoenix Business Journal)

    Alison Lichy, PT, DPT, explains how individuals poststroke can address feelings that they may be losing ground in recovery. (American Stroke Association Stroke Connection)

    Terri Jeurink, PT, and Ashley Vandenberg, PT, discuss pain relief exercises for expecting and new mothers. (8West, Grand Rapids, Michigan)

    "I want to touch the lives of individuals in my community that are in need of someone they can believe in." – Cruz Romero, SPT, APTA Student Assembly board of directors member and PT licensure candidate, in a feature story on his graduation from the Northern Arizona University physical therapy program (Northern Arizona University News)

    Thanks in part to direct access, Kara Bermensolo, PT, DPT, was able to speed the recovery of a patient with a compression fracture of the spine. (Bainbridge Island, Washington, Review)

    Leslie Russek PT, DPT, PhD, breaks new ground with research on Ehlers Danlos Syndrome. (Clarkson University, New York, News)

    Margaret Danilovich PT, DPT, PhD, provides her perspective on physical therapy's role in fighting the opioid epidemic. (The Hill)

    "Side effects of physical therapy are less pain, improved movement, and improved function." –Carrie Abraham PT, DPT, MPH, president of the West Virginia Physical Therapy Association, on the effectiveness of physical therapy vs opioids in treating chronic pain. (West Virginia Public Broadcasting)

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

    'Locum Tenens' for PTs Set to Begin in June

    It's official: starting June 13, physical therapists (PTs) in certain areas will be able to bring in another licensed PT to treat Medicare patients during temporary absences for illness, pregnancy, vacation, or continuing medical education, and bill Medicare for the services. And just as the new provisions begin, the old term for the concept—"locum tenens"—will be discontinued, according to the Centers for Medicare and Medicaid Services (CMS).

    In a transmittal published May 12, CMS announced that "reciprocal billing and fee-for-time arrangements" under Medicare part B will be extended to PTs in health professional shortage areas (HPSA), medically underserved areas (MUA), or in CMS-designated rural areas (any area outside of a Metropolitan Statistical Area or Metropolitan Division). The change, triggered by the passage of the 21st Century Cures Act signed into law in December 2016, was 1 of APTA's top public policy priorities.

    Under the new provisions, Medicare administrative contractors (MACs) are instructed to pay the regular PT for the services of a substitute PT, regardless of whether those services were provided through a reciprocal billing arrangement or if the PT pays the substitute in a per diem or other fee-for-service arrangement. In any case, it will no longer be called a "locum tenens" arrangement, CMS explains, because the term tends to be associated with only the fee-for-time approach, and its continued use in this expanded system could be confusing to the public.

    "The startup of these provisions is good news for PTs, but a real victory for many patients across the country who can now experience continuity of care," said Michael Matlack, APTA director of congressional affairs. "We're pleased that the work we did with our Private Practice Section resulted in this important step forward."

    It's important to note that the change is limited to certain parts of the country designated by CMS as a HPSA, MUA, or "rural area." PTs can find out if they're practicing in a HPSA or MUA by visiting the Health Resources and Service Administration (HRSA) website. Finding out about rural areas is a little trickier: the information is available on a webpage devoted to the final rule's data files. To get at the Excel file with the relevant information, scroll down to a gray "Downloads" box and open a file titled "County to CBSA crosswalk file and urban CBSAs and constituent counties for acute care hospitals." The areas left blank in the excel sheet are the ones CMS has designated as rural.

    New Canadian Guidelines Seek to Move Physicians Toward Nondrug Treatments for Pain

    Add the Canadian Medical Association to the list of organizations shifting guidelines away from opioids in the treatment of chronic noncancer pain. In a set of updated recommendations that authors describe as consistent with US Centers for Disease Control and Prevention (CDC) guidelines, Canadian physicians are being urged to pursue nonopioid and nondrug treatments as a firstline approach.

    The guidelines, published in the May 8 edition of CMAJ, are an update to opioid prescription guidelines released in 2010, in which "almost all supported the prescribing of opioids," according to the new guidelines' authors. The new recommendations take a markedly different position, advocating not just for nondrug approaches but also for lower dosages when opioids must be used, as well as for tapering programs for patients receiving high-dosage therapy of 90 milligrams or more daily.

    Researchers conducted a systematic review of literature that included analysis of multiple prescription and pain treatment guidelines, including the CDC resource. Guideline development also included meetings with stakeholders from law enforcement, medical regulation, pharmacy patient advocacy, addiction medicine, pain medicine, and several Canadian government agencies.

    In the end, 10 guidelines were developed and tagged as being either a "strong recommendation," meaning that the recommendation is appropriate for almost everyone, or a "weak recommendation," meaning that the guidance is applicable to a majority of patients but may not be appropriate for an "appreciable minority." The strong recommendations include use of nonopioid approaches, particularly with patients with substance-use disorder, as well as prescriptions for fewer than 90 milligrams per day when opioids are indicated. Authors also strongly recommend "a formal multidisciplinary program" that may include physical therapists to assist patients attempting to taper down opioid use.

    Authors describe the guidelines as "consistent" the CDC guidelines, which have been endorsed by some provincial regulatory agencies. The new recommendations are also in sync with APTA's #ChoosePT campaign, which has been adopted by the Canadian Physiotherapy Association in a collaborative effort to educate the public about physical therapy as a safe alternative to opioids for the management of pain.