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  • From PTJ: PTs, PTAs, Students Report High Rates of Inappropriate Sexual Behavior by Patients

    Inappropriate sexual conduct happens everywhere, and physical therapy settings aren't immune to the problem, according to a new article e-published ahead of print in Physical Therapy (PTJ) that looks at instances in which patients are the perpetrators of the conduct. The article is based on a survey of 892 physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy students which found that 84% had experienced inappropriate patient sexual behavior (IPSB) at some point during their careers or training, and that 47% experienced IPSB within the past year. (Editor's Note: Articles e-published ahead of print are not the final version. The final version of this article will be published in the November issue of PTJ.)

    The study, which authors describe as the largest of its kind to focus on IPSB among PTs, PTAs, and students, found that there has been little progress on the issue since a similar 1997 study of PTs only, in which prevalence of IPSB over the length of a career averaged 81% to 86%. The high rates "warrant practitioner and student education, as well as workplace policy and support," authors write.

    Authors define IPSB as instances in which a patient engages in any of a range of behaviors, "from leering and sexual remarks to deliberate touch, indecent exposure, and sexual assault." For the purposes of the current study, IPSB was categorized into 3 groups: mild (such as being leered at or being given a romantic gift), moderate (including sexually suggestive gestures or being propositioned for sexual activity) and severe, which includes indecent exposure, physical touch, harassment outside the workplace, and forced sexual activity.

    Mild IPSB at some point during their careers was reported among 77% of respondents, with "patient made a sexually flattering or suggestive remark" experienced by 68.8% of those who encountered that level of IPSB. "Patient stared at you or your body parts in a way that made you feel uncomfortable" was experienced by just over half of the respondents (55.5%) who experienced mild IPSB. More than 1 in 3 (34.6%) reported patients asking for dates.

    Among the 58% of respondents who reported moderate IPSB, 52% reported instances in which a patient "made [an] overtly sexual remark or joke, asked you questions or commented on your sex life, or shared a sexual fantasy about you." Close to 31% of the respondents reported a patient making sexually suggestive gestures, and 11.2% said that they were propositioned for sex by their patients.

    Severe forms of IPSB were reported by 37.2% of respondents, with 20.3% of that group saying that a patient had purposefully touched or grabbed them in "private areas" or in "a clearly sexual manner." Among this group, 7.7% reported instances in which patients followed, watched, or harassed a respondent, while 0.9% reported experiencing threats of forced sexual activity or an attempt at forced sexual activity, and 0.3% reported being forced to submit to sexual activity.

    Some of the risk factors authors identified for IPSB among physical therapy clinicians include fewer years of direct patient contact, routinely working with patients with cognitive impairment (PWCI), female practitioner gender, and male patient gender. Of those risk factors, clinical experience was the most predictive risk factor, followed by managing patients with PWCI.

    The study found that women were more than twice as likely as men to have experienced IPSB, and clinicians who treated mostly male patients had a 400% greater chance of exposure to IPSB. Additionally, being new to the profession also put respondents at higher risk: 58% of physical therapy students experienced IPSB, compared with 42% of physical therapy professionals.

    Still, authors point out, these risk factors only account for up to 15% of the total variance, meaning that the possibility of a PT, PTA, or student experiencing IPSB during any given year is a very real one for nearly all areas of the profession.

    In a related PTJ podcast interview with Editor in Chief Alan Jette, PT, PhD, FAPTA, to be released in November, Jill S. Boissonnault, PT, PhD, and Ziádee Cambier, PT, DPT, 2 of the study's coauthors, discussed the characteristics of IPSB and management strategies to mitigate or address the issue.

    Physical, sexual, psychological, and racial abuse are all serious issues for health care providers, but, Cambier notes, “it makes sense to separate them out for more in-depth research” because there are “real differences” in risk factors and responses to the particular type of abuse.

    While workplace training can “help people prepare” for IPSB, says Cambier in the podcast, it does not prevent the events from happening. Establishing clearly stated workplace policies and supports may help to prevent or address IPSB, including options and procedures for staff such as:

    • When employees can have a second staff member in the room
    • When and how to transfer patients or terminate care
    • How to issue warning letters
    • How to use behavioral contracts

    Most important, Boissonnault states in the podcast, is training supervisors to offer support. The study includes responses to open-ended questions that show varying levels of attention to IPSB among supervisors, from 1 respondent who reported feeling "very supported by my clinical instructor and other staff" to others who felt that when they reported IPSB, they were not taken seriously by supervisors, not helped, or even punished for reporting the inappropriate behavior.

    Some respondents even reported instances in which the supervisor tacitly or actively participated in IPSB, including 1 male clinical instructor who did not intervene when a patient commented on the respondent's physical appearance, and actually joined another patient in giving the respondent dating advice.

    "He definitely didn't have enough training on the topic," the respondent wrote. "When I discussed my experiences with 2 female classmates, I found that every 1 of us had been harassed on our summer internships."

    APTA has taken a strong position on sexual harassment, and provides a webpage to help members recognize harassment and understand their rights.

    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.

    Just Taking a Walk Can Extend Your Life, Say Researchers

    Experts have long encouraged moderate or vigorous walking to improve overall health. However, new research published in the American Journal of Preventive Medicine shows that even some walking is better than none for reducing all-cause mortality in older adults.

    Few studies have explored the potential association between walking and mortality rates in the aging adult population. Researchers attempted to focus on this relationship by analyzing data from participants in the American Cancer Society’s Cancer Prevention Study Nutrition Cohort. The present study compared baseline 1999 physical activity survey data from 62,178 men (mean age, 70.7) and 77,077 women (mean age, 68.9) with death rates and causes from 1999 through 2012.

    The survey asked participants about a variety of types of physical activity, including pace and frequency of walking. Authors report that 5.8% of men and 6.6% of women had no physical activity at baseline. These "inactive" individuals were compared with individuals assigned to 3 groups for whom walking was their sole form of physical activity: an "insufficiently active" group (walking fewer than 2-3 hours a week), a "minimum up to twice [the standards]" group (2-6 hours per week); and an "exceeding recommendations" group (over 6 hours per week).

    Researchers found that even a small amount of walking had an impact on health, with the all-cause mortality rate for inactive individuals 26% greater than for the "insufficiently active" group. And things got better the more people walked: Compared with the insufficiently active group, participants who walked 2-6 hours per week were 20% less likely to have died by the end of the study, and those who walked more than 6 hours per week were 22% less likely.

    Walking as the only form of physical activity, even at fewer than 2 hours per week, also was significantly associated with lower rates of death from respiratory disease, cardiovascular disease, or cancer compared with inactivity. Interestingly, authors note that these effects were similar when comparing by participant sex, baseline age, BMI, prevalent disease status, and leisure-time sitting.

    "Engaging in any walking or other [moderate-to-vigorous physical activity], even if not meeting the minimum recommended levels, is associated with lower mortality compared with inactivity," authors write. Walking is an "ideal activity" for most people, they say, because it is "simple, free, and does not require any training."

    Authors also cite some disturbing facts, asserting that physical inactivity accounts for 6%–10% of the world’s noncommunicable diseases and 11% of United States (US) health care expenditures. In addition, they write, the percentage of US adults over age 65 is expected to reach 20% by 2030.

    Getting people to walk more may take more than sparking interest and motivation—it may also require stronger efforts to create environments that walking easy, or merely possible. According to 1 recent assessment, that part of the equation is missing in much of the country: a National Physical Activity Plan Alliance "report card" on walking and walkability says that the US is falling short when it comes to the pedestrian-friendliness of its communities. APTA is an alliance member.

    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.

    Therapy Cap Breakthrough? Legislators Reach Bipartisan Agreement on Repeal

    Editor's note: An earlier version of this story indicated that the KX modifier would not be required for claims less than $3,000. This story has been updated to reflect that the modifier will be required to accompany all claims over $1,980.


     After 20 years of opposition from APTA and 17 years of 11th-hour congressional patches to an inherently flawed policy, the Medicare therapy cap may be on its way out for good.

    But nothing's certain yet, and there are many details still to be worked out.

    On October 26, APTA representatives attended a meeting on Capitol Hill during which lawmakers from the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan agreement to end the therapy cap. The road from proposal to actual repeal can be long, and success isn't guaranteed, but if the proposal survives it would represent a major victory for patients and the physical therapy profession.

    Details are still emerging, but the current proposal would eliminate the $1,980 hard cap on physical therapy and speech-language pathology services (as well as the $1,980 cap on occupational therapy) on January 1, 2018, with claims above the $1980 threshold requiring the KX modifier. At the same time, the threshold for targeted medical review would be lowered from the current $3,700 to $3,000 through 2027. While the threshold amount for medical review would be lowered, the US Centers for Medicare and Medicaid Services (CMS) would not receive any increased funding to pursue expanded medical review.

    In more potential good news for patients and the physical therapy profession, the proposal does not include prior authorization requirements, a provision that had been included in earlier repeal attempts.

    APTA staff are reviewing the proposal in detail, but according to APTA Vice President of Government Affairs Justin Elliott, the basics look promising. Repeal of the therapy cap has been a central focus of APTA's public policy efforts since the cap’s introduction in 1997.

    "This is an important step, particularly because this is a bicameral, bipartisan agreement between the House and the Senate," Elliott said. "That kind of backing provides very real momentum for the repeal effort."

    Crossing the finish line, however, is not a sure thing, and there are many details that need to be worked out, not the least of which is the need for legislators to identify "pay fors"—cuts and offsets that can be offered up to cover the increased costs that may be associated with elimination the cap, Elliott said.

    In a joint statement from the House and Senate committees involved in the agreement, leaders characterized the proposal as a "major breakthrough" that solves a serious Medicare problem.

    "Arbitrary caps on these important services have never made much sense, as it is an important medical service that can both help patients avoid surgery or, when surgery is needed, help them recover their quality of life," the leaders said. "Now we must shift our work to ensuring that this important policy is fully offset."

    US Receives Failing Grades on Walking and Walkability

    Ask any kid: you know you're in trouble when the high point on your report card is a C among 2 Ds, 5 Fs, and an "incomplete." That's precisely the spot the US is in when it comes to walking and walkable communities, according to a recently released report card from the National Physical Activity Plan Alliance (NPAPA). APTA is an alliance partner.

    Released this fall, the Walking and Walkable Communities Report Card reflects the NPAPA's assessment of “the extent to which the US population and US communities meet selected standards for participating in walking and providing physical and social supports for behavior." The NPAPA used a similar approach in 2014 when it released a report card on physical activity across the country that reflected an overall 1.5 GPA. Like the earlier report card, the results this time around aren’t honor roll material.

    The best the country could muster, according to the alliance, was a “C” for “adult walking behavior”—the number of adults who report walking on a regular basis for work, recreation, or planned exercise. Assessors were looking for the percent of adults who reported walking for 10 minutes or more at least once in the preceding week: the 63.9% of respondents who reported meeting that mark earned the US its highest grade. The narrative that accompanies the report card points out that walking prevalence has not increased much between 2010 and 2015, though women did experience a 2.6% rise during that time.

    It was all downhill from there.

    In the areas of “pedestrian policies” and “walkable neighborhoods,” the alliance gave the US a D grade for each. Pedestrian policies fall short, says the alliance, because communities aren’t doing enough to support a “complete streets” model that ensures streets are built to support all forms of transportation, not just automobiles. The low grade for walkable neighborhoods reflects the fact that only 16 states report that 30% or more of residents live in a highly walkable neighborhood.

    But the most prevalent grades, by far, were Fs, with 5 failing grades issued by the alliance. According to the report card, the US earned Fs on children and youth walking behavior, pedestrian infrastructure, safety, institutional policies, and public transportation. A grade of “incomplete” was assigned to walking programs because there is no system in place that monitors the prevalence of those programs across the US, according to the alliance.

    Dianne Jewell, PT, DPT, PhD, who served on the advisory panel for the report card, says the report card should be understood more as a way to encourage serious dialogue and advocacy for walking and community walkability, and less a hard-nosed assessment.

    “These grades should be viewed thoughtfully,” Jewell said. “I see them as flares indicating serious potential hazards ahead if we don’t address the issues in each domain, rather than as absolute indicators of performance.”

    "We now have a consolidated baseline picture of our successes and challenges in supporting walking and walkability, and we now can measure change over time,” Jewell added. “There are important lessons underneath those grades, including data on differences in walking behavior by age, gender, and ethnicity, as well as some examples of state-level successes in some of the walkability domains.”

    Jewell has since stepped down from the NPAPA. These days, Chris Hinze, PT, DPT, serves as APTA’s representative to the group.

    Like Jewell, Hinze believes that the report card points to the need for societal change. And he thinks physical therapists (PTs) and physical therapist assistants (PTAs) can play an important role in making that change happen.

    “With their expertise in human movement, PTs, PTAs, and students can and should be key voices in this discussion,” Hinze said. “First, PTs and PTAs should educate themselves on social determinants of health—specifically, how the built environment influences health and health-related behaviors. Then they should consider becoming advocates for policies and infrastructure that encourage active transportation in their communities.” Hinze points to a comprehensive set of strategies and tactics developed by NPAPA that can help inform and guide PTs and PTAs in this work.

    For both Hinze and Jewell, the bottom line is clear: things need to change, and soon.

    “For decades, communities have largely been designed around the automobile, with human movement an afterthought—this needs to change,” Hinze said. “Cities and communities need to be intentional with their policies, planning, and design to make active transportation a safe and convenient choice for moving about."

    “If we can’t even meet the minimum threshold of safety, then efforts in other areas will ultimately be limited,” Jewell said. “Common sense says injury or fatality while walking or cycling should be socially unacceptable without the need for debate, yet we still favor policies and infrastructures designed for motorized vehicles moving at speed with a minimum of interference. Until that perspective changes, I think we will only see small, incremental improvements in many of these grades.”

    Want to learn more about the NPAP and the work of the NPAPA? Check out this video, and read the entire National Physical Activity Plan , a revised roadmap for community-level change.

    APTA Expands Efforts to Address the Opioid Crisis

    The country’s response to the national opioid crisis is evolving: President Trump announced that he will soon declare opioid abuse a national emergency; cities are lining up to sue pharmaceutical companies; and state attorneys general are pressing insurance companies to better support nondrug approaches to pain treatment.

    Meanwhile, APTA has been bringing the physical therapy profession’s voice and perspective to the national dialogue on how best to reshape the health care system’s approach to pain treatment and management.

    The association has been active in responding to opioid abuse since 2015, when APTA was invited to join a White House initiative under then-President Barack Obama. In 2016, APTA launched the #ChoosePT opioid awareness campaign, a high-visibility effort that was championed by individual members and state chapters, and received both state and national recognition.

    So what’s APTA been up to since then? A lot.

    We were at the table for the first-ever Integrative Pain Care Policy Congress.
    Sponsored by the Academy of Integrative Pain Management (AIPM), this recent event brought together representatives from organizations including APTA, the American Pharmacists Society, the American Osteopathic Association, BeaconHealth, Kaiser Permanente, the National Association of Social Workers, the American Cancer Society, and Aetna for discussions and presentations on how to best address conflicting pain care guidelines.

    APTA Director of Regulatory Affairs Kara Gainer, JD, represented the association, participating in a panel discussion on how to strengthen state-level policy on integrative pain management.

    We’re helping to draft a national playbook on opioid prescribing and effective pain management.
    The association is working with 40 other organizations as the Opioid Stewardship Action Team, a group assembled by the National Quality Forum (NQF), a health care research and advocacy group. APTA is a member of NQF.

    According to NQF, the goal of the team is to work on “strategies and tactics to support appropriate opioid prescribing practices and more effective pain management, particularly for individuals with chronic pain and those at risk of dependence and addiction.” That work will result in a “playbook” in March 2018 that NQF hopes will help to establish a more cohesive approach to pain management. In addition to APTA, task force participants include representatives from the US Centers for Disease Control and Prevention (CDC), the American Nurses Association, Kaiser Permanente, the US Centers for Medicare and Medicaid Services, Magellan Health, the American Society of Health System Pharmacists, and the Substance Abuse and Mental Health Services Administration. Alice Bell, PT, DPT, an APTA senior payment specialist, is representing the association on the task force.

    We’re keeping members in the loop, adding to evidence-based resources for pain management, and planning for next steps in advocacy.
    Policy-based approaches to the opioid crisis were front-and-center at the most recent APTA State Policy and Payment Forum in September, which featured a presentation by representatives from the National Journal. APTA also is thinking about the future and is working through its Public Policy and Advocacy Committee to develop a roadmap for where the association can have the biggest impact on policy.

    At the same time, APTA continues to add resources to put physical therapists in touch with the best evidence on pain assessment, treatment, and management through PTNow. The association is engaged in activities related to reviewing and developing CPGs, including reviewing CPGs related to opioid therapy for chronic pain from external groups and supporting the Education Section and Orthopaedic Section of APTA in the development of a CPG focusing on patient education and counseling for the management of chronic pain.

    APTA members have been awarded federal research grants to study pain treatment.
    The US Departments of Defense, Health and Human Services, and Veterans Affairs have created an interagency partnership that aims to focus on research related to nondrug approaches to pain treatment for military and veteran personnel. The partnership’s first order of business: providing grant awards to fund research projects. APTA members Julie Fritz, PT, PhD, FAPTA, and Steven George, PT, PhD, each were named as recipients in the first round of grants.

    According to a press release from the partnership, Fritz will research a “stepped care” approach to the treatment of low back pain. George will conduct a planning and demonstration project to improve access to nondrug therapies for low back pain through the Department of Veteran’s Affairs health care system.

    #ChoosePT continues to gain momentum.
    The video supporting the #ChoosePT campaign is still making the rounds nationally, while, more recently, #ChoosePT ads are appearing on national news websites during October. Additionally, the campaign toolkit was updated with several new graphics and resources—including the opportunity to purchase #ChoosePT t shirts at cost.

    The campaign also has advanced through the efforts of members. Most recently, APTA collaborated with student volunteers in New York to bring the #ChoosePT message to the Today Show in September and Good Morning America in October.

    We’re reaching out to other stakeholders.
    Over the past year, APTA staff and representatives have met with representatives from the Food and Drug Administration, the Department of Veterans Affairs, the Health Resources and Services Administration, CDC, and several other agencies and groups to discuss the importance of patient access to nondrug approaches to pain. Coming up: meetings with the Indian Health Service and the Administration for Community Living.

    APTA President Sharon Dunn, PT, PhD, believes there’s good reason for the association’s multifaceted approach to the issue.

    "We need to change the culture around pain management in this country—that’s going to require raising public awareness through efforts such as the #ChoosePT campaign, but it’s also important that individuals and organizations throughout the health care space are actively engaged in working to enhance understanding of safe and effective pain management through interdisciplinary care,” Dunn said. “It’s important that APTA and the physical therapy profession participate in these efforts because we bring a unique perspective to the conversation.”

    Researchers Find No Evidence for Popular Treatment for UI, POP

    There are solid evidence-based treatments for pelvic floor dysfunctions such as urinary incontinence (UI) and pelvic organ prolapse (POP), but 1 treatment popular in Europe, South America, and Canada isn’t among them. In fact, researchers write, the treatment—called abdominal Hypopressive technique (AHT)—is at best an approach still “in development,” with no significant data to back it up.

    In an article published in the British Journal of Sports Medicine (BJSM) (abstract only available for free), researchers described their attempts to track down studies on AHT, a group of breathing and posture exercises created in the 1980s. The exercise involves diaphragm inspiration followed by total air expiration and gradual contraction of the transversus abdominis (TrA) and intercostal muscles. Proponents of AHT believe the decreased abdominal pressure created through the exercise sparks a reflex response of muscles in the abdominal wall and pelvic floor, which in turns reduces UI and POP.

    But according to authors of the BJSM article, there’s a problem: no published evidence exists that supports the effectiveness of AHT. Searches on multiple research databases including PubMed and the Physiotherapy Evidence Database (PEDro) turned up only 2 studies that involved AHT—an experimental study that added AHT to a regiment of pelvic floor musical training (PFMT), and a randomized controlled trial involving the addition of AHT to PFMT among 58 women with stage II POP. Both studies found no effect from the addition of AHT.

    “At this stage, AHT is based on a theory with 20 years of clinical practice,” authors write. “We conclude that at present, there is no scientific evidence to recommend its use to patients.”

    Carrie Pagliano, PT, DPT, vice president of the APTA Section on Women ‘s Health, says while it’s true that the evidence isn’t there for AHT as a standalone or first-line treatment, clinicians shouldn’t be quick to dismiss some of the principles that underlie AHT.

    “There is some anecdotal, case-by-case support for this technique, and clinicians that use it in practice do identify Hypopressives as a small component of treatment,” Pagliano said. “Despite the small number of studies with little support for AHT, this shouldn’t discount the use of Hypopressives in conjunction with a thorough evaluation of the patient and a sound critical hypothesis.”

    While not as prevalent in the US, AHT is described by authors of the BJSM study as a treatment that has “worldwide huge interest [among] the public and clinical community.” The approach is marketed through a website that offers provider training on the technique, and is now taught by more than 1500 coaches in 14 countries, according to the BJSM article.

    In contrast to AHT, there is an approach that does in fact have high-level evidence for effectiveness, according to the reseachers: PFMT. Still, they write, “despite the strong evidence for PFMT for [UI and POP], several other exercise regimens have been proposed and advocated.”

    The problem, authors point out, is that for AHT, what’s being advocated hasn’t yet been associated with a strong foundation in research.

    “This particular treatment currently illustrates the phenomenon that not all recommended treatments are evidence based,” authors 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.

    APTA Report: Use of Direct Access Among PTs Is Widespread, but Barriers Need to Be Addressed

    Some form of direct access to physical therapist (PT) services has been a reality in all 50 states since early 2015. But just how much of a reality is it? That’s another question.

    A recent report from APTA analyzed data from a 2015 survey of nearly 6,000 PTs from all states and the District of Columbia to get a sense of how direct access was being implemented—or not implemented—and what might be standing in the way of broadest possible use. Analyses found that while direct access is happening to some degree across the country, a combination of institutional barriers, state-level restrictions, and varying levels of understanding of the concept among PTs may be hindering its growth.

    According to the report, 1 of the biggest impediments to widespread use of direct access is the fact that some states restrict the practice through provisions that include limiting the number of sessions that can be provided without a referral, only allowing for a certain number of days to pass between startup of physical therapy and obtaining a referral, and placing special requirements on PTs who want to engage in direct access. Not surprisingly, PTs in states with unrestricted direct access tend to have higher engagement levels than those working under restrictions.

    But that’s not the only thing standing in the way of more widespread use of direct access. The report points out that the barriers most often cited by PTs in the survey had to do with the policies of supervisors or facilities requiring referral even when the state allows direct access. Nearly 2 out of 3 respondents said that their employment setting required referrals regardless of state law.

    In addition to those very real restrictions, direct access also may face a perception problem among some PTs, with 60% of respondents reporting that concerns about reimbursement were among the biggest barriers to increased direct access use—a number at odds with the fact that “claims for direct access are not routinely denied” by payers, according to the report. And that low rate of denial is in line with respondents’ estimates that only 7.5% of their direct access claims were denied (though 41% said they didn’t know for certain that their claims were denied due to lack of referral).

    good news is that even with those real and perceived barriers, direct access is being used widely among PTs, with 50% of respondents reporting some use of direct access. In states with unrestricted direct access, the rate climbs to 65.5%. Most of the use (69%) is occurring in private and hospital-based outpatient clinics and group practices.

    Among other details from the report:

    • The most frequently cited services associated with direct access include “traditional patient and client management,” with 93.3% of users listing those services. Fitness, prevention, wellness, and health promotion was listed by 43.8% of PTs who engaged in direct access, and 39.3% of users listed screenings as an associated activity.
    • Of the 73% of direct access-using PTs who market direct access, 69.7% do so through direct marketing to patients, with 53.1% listing participation in community events, and 48% reporting that they provided education on direct access to referral sources.
    • Respondents reported self-pay patients as the highest users of direct access, at 44.1%. Patients with commercial coverage were estimated at 25.3%.

    “This report provides a snapshot of direct access use and perceptions at a particular point in time,” said Elise Latawiec, PT, MPH, APTA senior practice management specialist. “We anticipate that its use has increased since 2015, and we will continue to advocate for states to drop restrictions, to increase patient access. At the same time, it’s important for PTs to gain a solid understanding of direct access and promote its benefits to the institutions and facilities that are imposing restrictions that aren’t required by state law and regulation. As we move to a value-based environment, direct and early access to therapy services will play a critical role in the profession’s ability to deliver on lowering overall health care costs.”

    Want to learn more about direct access? Check out APTA’s “Direct Access in Practice” webpage for a wide range of resources from podcasts and videos to tips on preparing for direct access in your practice setting.

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

    “I feel like a million dollars and I’m off all medications. That’s the number 1 thing.” – Rick Kenney, survivor of a motorcycle crash, who opted for physical therapy instead of painkillers for his recovery. (Monmouth, New Jersey, edition of app.com)

    Idaho State University assistant PTA program coordinator Darin Jernigan, PT, and students including Shayla Bitter, SPT; and Krishaun Turner, SPT are delivering the #ChoosePT message to the local community. (Idaho State University Journal)

    Maura Daly Iverson, PT, DPT, provides insight on how physical therapy can help individuals with psoriatic arthritis. (everydayhealth.com)

    Trever Wagner, PT, explains how sports specialization among high school athletes can increase injury risk. (Rapid City, South Dakota, NewsCenter1)

    Mark Bishop PT, PhD, testifies before the Florida Senate Committee on Health Policy on opioids and his research on the topic (testimony begins at 1:01:51). (thefloridachannel.org)

    Matthew Mesibov, PT, describes why it’s important for senior living facilities to include more space for rehabilitation. (McKnight’s Senior Living)

    Kimberly Castle PT, PhD, University of North Georgia associate professor of physical therapy, shares her perspective on DanceAbilities, the class she founded to give her PT students a way to get involved in the community by providing dance opportunities for children with special needs. (University of North Georgia News)

    Anne Haneman, PT; and Joanne Haug, PT, discuss the ways boxing training can help individuals with Parkinson disease. (Doylestown, PA, Intelligencer)

    “I want to shout it from the rooftops so you all can hear me: Don’t settle with incontinence! Why suffer with pain? Don’t ignore prolapse! There are PTs out there doing amazing work, and there is a very good chance they can help you.” – Erin Savre on the work of pelvic floor physical therapists. (Albany, New York, Times-Union)

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

    Foundation Funding Opportunities Available for 2018

    The Foundation for Physical Therapy (Foundation) is now accepting applications for 2 major funding programs.

    Eligibility and application information for the postprofessional 2018 Promotion of Doctoral Studies (PODS) Scholarship and the New Investigator Fellowship Training Initiative (NIFTI) (a $100,000 award over a 2-year period) is posted on the Foundation website. The deadline to apply is January 10, 2018, by 12:00 pm, ET.

    Applicants are encouraged to start the submission process early to allow for potential questions to be answered. Award recipients will be notified in June.

    Contact Jordan Rochon for more information, or call 800/875-1378, ext 3167.

    Important tip: thoroughly read through all instructions and funding mechanism deadlines before beginning your application. Want to stay on top of what's available? Sign up for the F4PT Alert and be first to know about Foundation funding opportunities.

    Study: CMS Should Pay Closer Attention to Chronic Wounds

    In its push toward outcomes-based models, the US Centers for Medicare and Medicaid Services (CMS) needs to take a closer look at wound care, say authors of a new study that estimates nearly 15% of all Medicare beneficiaries experience chronic nonhealing wounds at an annual cost of nearly $32 billion. And the researchers believe those numbers are on the conservative side.

    The study, recently published in Value in Health, analyzed data from Medicare’s 5% Limited Data Set during 2014 for details on claims in which wounds were the primary or secondary diagnosis. Researchers looked at costs, both in aggregate and by care setting, for 12 types of wounds: arterial ulcers, diabetic foot ulcers, diabetic infection, chronic ulcer, pressure ulcer, skin disorders, skin infection, surgical wounds, surgical infection, traumatic wound, venous ulcers, and venous infection. Here’s what they found:

    • In 2014, approximately 14.5% of Medicare beneficiaries were diagnosed with at least 1 type of wound or wound infection—that’s about 8.2 million patients.
    • Surgical wound infections were the largest category, at 4% of beneficiaries, followed by diabetic wound infections (3.4%) and nonhealing surgical wounds (3%). Pressure ulcers were associated with 1.8% of beneficiaries; venous ulcers were present in 0.9% of Medicare patients.
    • Although Medicare’s episode-of-care payment system makes it hard to tease out exactly how much is spent on care associated with each of various conditions a patient may have experienced, authors were able to generate a 3-tier set of estimates based on whether the wound was a primary or secondary diagnosis. Overall costs were estimated at $28.1 billion annually under the most conservative model and up to $96.8 billion under a model that assumed the wound “was always the underlying cause of the service.” Mid-range cost estimate was $31.7 billion.
    • In terms of wound type, the highest costs were associated with surgical wounds ($11.7 billion, $13.1 billion, and $38.3 billion in the 3-tier model), followed by diabetic foot ulcers ($6.2 billion, $6.9 billion, and $18.7 billion).
    • Mean Medicare spending per wound was $3,415, $3,859, or $11,781 depending on the estimate models, with arterial ulcers and pressure ulcers registering the highest rates of spending per wound.
    • Spending on wound care for hospital outpatients was nearly twice as high as inpatient spending, with estimate models at $9.9 billion, $11.3 billion, and $35.8 billion.

    Authors believe that that data point to the need for CMS to question assumptions that have played into how it establishes episode-based measures that do not encompass wound care and are rooted in inpatient models.

    “The construction of these episode groups reveals 2 important misconceptions,” authors write. “The first is that chronic nonhealing wounds represent a less significant burden [than] other conditions, and the second is that the primary driver of cost is the hospital inpatient stay. Our data dispute both assertions. Not only does chronic wound care represent a large portion of the Medicare budget, but our data suggest there has been a major shift of costs from hospital inpatient to hospital outpatient settings.”

    Authors acknowledge that more analysis is needed to arrive at clearer estimates of costs associated with wounds, but they believe the study’s results could be the basis for the development of “more appropriate quality measures and reimbursement models, which are needed for better health outcomes and smarter spending for this growing population.”

    The study was funded by the Alliance of Wound Care Stakeholders. APTA is a member of the alliance.

    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.

    CMS Sets Dec 1 Deadline for PQRS Appeals

    Did you participate in the Physician Quality Reporting System (PQRS) in 2016? You can check on your 2016 reporting results and find out if you're subject to any payment adjustments for 2018. But take note: if you’ve received a payment reduction notice and think the decision was made in error, you need to submit a request for review by December 1.

    The Centers for Medicare and Medicaid Services (CMS) released the reporting results—known as the Annual Quality and Resource Use Reports (QRURs)—as well as the feedback reports for online viewing on September 18. The 2016 PQRS feedback report contains all detailed information used to determine your 2016 reporting results and indicates if you are subject to the 2018 PQRS negative payment adjustment.

    More recently, CMS sent out individual notices to providers it believes did not meet PQRS requirements in 2016. Those providers are subject to Medicare Part B payment reductions beginning in 2018.

    If you have been identified for a 2018 payment reduction based on the report, and you think that decision was made in error, you'll need to ask for an informal review. CMS offers instructions on that process on the PQRS Analysis and Payment webpage. To make your appeal as effective as possible, be sure to thoroughly review your QRUR and provide detailed reasons why you think the reduction decision was a mistake—and don’t forget the December 1 deadline. APTA staff are available to answer emailed questions about the process at advocacy@apta.org.

    You can access the QRUR reports through the CMS "enterprise portal," but to do that you'll need an enterprise identity management (EIDM) account (CMS provides instructions for creating an EIDM). Also available: a user guide to the reports.

    For additional assistance regarding EIDM or the data contained in the PQRS feedback reports, contact the QualityNet Help Desk at 866/288-8912 (TTY 877/715- 6222) 7:00 am–7:00 pm CT, Monday through Friday, or by email at qnetsupport@hcqis.org. If you are having trouble accessing the PQRS feedback reports, contact the Physician Value Help Desk at pvhelpdesk@cms.hhs.gov or 888/734-6433.

    PQRS ended in 2016 and became part of the Merit-based Incentive Payment System (MIPS). For more information on the transition, check out PT in Motion magazine’s 2-part series on MIPS in the 2017 April and May issues.

    APTA Part of the Effort to Save Rural Hospitals

    Hospitals that serve rural areas are disappearing. APTA is supporting efforts to stop and even reverse that trend.

    "Medical deserts are appearing across rural America, leaving many of our nation's most vulnerable populations without timely access to care," according to the National Rural Health Association (NRHA), which estimates that between the 79 rural hospitals that have closed since 2010 and the additional 673 facilities that are on the brink of shutting their doors, the US is at risk of losing a third of its rural hospitals in the near future.

    The primary drivers behind the decline, according to NRHA, are federal cuts that began with the 2013 budget sequestration and so-called "bad debt cuts" imposed on facilities with certain levels of Medicare beneficiaries unable to make their cost-sharing payments. The organization is working to stop those and other damaging cuts, and APTA has joined in that effort. APTA is a member of NRHA.

    Like NRHA, APTA is advocating for passage of the Save Rural Hospitals Act (HR 2957). Introduced by Rep Same Graves (R-MO), the measure would stabilize rural hospitals by ending many of the Medicare cuts that are threatening the survival of the facilities. Additionally, the legislation introduces a new delivery model that would allow small rural hospitals and critical access hospitals (CAHs) to be recognized as community outpatient hospitals (COHs), a designation that would open up more possibilities for emergency and outpatient care in rural areas. To date, the legislation has 18 cosponsors in the House.

    APTA's support of the legislation is consistent with its positions on US Centers for Medicare and Medicaid (CMS) proposed rules for next year's outpatient and inpatient prospective payment systems. In the proposed outpatient rule—still not finalized—CMS says it will back off on enforcement of requirements for direct supervision of outpatient therapeutic services for critical access and small rural hospitals. The finalized inpatient payment rule includes language making medical record reviews a "low priority" when it comes to the requirement that physicians must certify that a patient admitted to a CAH will be discharged or transferred within 96 hours of admission. APTA supported both measures as much-needed changes that would help ease burdens on rural hospitals and CAHs.

    The association also is facilitating communication between physical therapists and physical therapist assistants who support rural hospitals and CAHs: recently, APTA launched a "rural health hub," an online community that allows members to share thoughts, questions, and strategies on working to keep rural care alive. Email advocacy@apta.org with your name and member number to gain access.

    "Rural hospitals are vital to the health and wellbeing of more than 62 million Americans," writes APTA President Sharon Dunn, PT, PhD, in APTA's letter of support for the Save Rural Hospitals Act. "Keeping these rural hospitals open is a necessity for so many Americans who need essential health care services."

    APTA will continue to advocate for passage of the legislation and is monitoring its progress. Updates will appear in PT in Motion News.

    New 'Rehab Therapists Give Back' Effort Helps Channel Donations to Hurricane Victims in Florida, Texas, and Puerto Rico

    Though the storms themselves have passed, people affected by Hurricane Harvey, Hurricane Irma, and Hurricane Maria will struggle with the devastation for the foreseeable future. Physical therapists (PTs), physical therapist assistants (PTAs), and other rehabilitation professionals now have an opportunity to come together as a unified community to help those in need.

    Earlier this month, electronic medical records system provider WebPT announced the launch of "Rehab Therapists Give Back," an online giving program with the goal of raising $1 million for people affected by recent hurricanes that destroyed parts of Houston, Texas, Florida, and Puerto Rico. Accessible through a GlobalGiving website, the initiative allows donors to contribute any amount to any of 4 relief funds.

    To help kickstart the campaign, WebPT made a $10,000 donation to the effort. APTA followed suit by committing a $10,000 donation match, which was met within 24 hours.

    "Many of our members have been asking about where they could make a relief donation," said Justin Moore, PT, DPT, APTA's chief executive officer. "The Rehab Therapists Give Back campaign is an ideal opportunity to join other professionals in showing our commitment to helping people rebuild their lives."

    Another future opportunity to give to a different cause through GlobalGiving: keep an eye on the new Health Volunteers Overseas (HVO) GlobalGiving website for future fundraising efforts that support education for the health care workforce in resource-scarce countries. APTA is a supporter of HVO, and several APTA members have participated in HVO efforts to support physical therapy in places such as Haiti, Rwanda, and Myanmar.

    State-Level PT Advocates Honored at Policy and Payment Forum

    From expanding direct access provisions to including physical therapists (PTs) in concussion management teams and to securing fair copay laws, some of the physical therapy profession's biggest wins have been at the state level, thanks in large part to individual leaders who refuse to give up. APTA acknowledged some of those leaders at this year's State Policy and Payment Forum, held last month in Detroit.

    This year, 3 PTs were honored for their service to the profession at the state level:

    Cristina Faucheux, PT, was presented with an APTA State Legislative Leadership Award for her work on behalf of the physical therapy profession in Louisiana, particularly her leadership in a successful effort to expand direct access in the state. In addition to all the necessary relationship-building at the statehouse, Faucheux's multi-session direct access effort also included mock hearings to help supporters hone their messages, and quick, thorough responses to misinformation campaigns launched by opponents of the legislation. Ultimately, the expanded provisions were signed into law in 2016.

    Joanne Zazzera, PT, DPT, also earned an APTA State Legislative Leadership Award. In 2016, the APTA Hawaii Chapter lacked a lobbyist, but when Zazzera saw an opportunity to make legislative inroads toward including PTs in recognized concussion management teams, she seized it and became the solo force in organizing members to advocate for the change. Her efforts paid off when PTs were included in the final bill, which passed in 2016. Since then Zazzera has been organizing the chapter's government affairs committee and establishing work groups to map the chapter's long-term advocacy strategies.

    Chris Marsh, PT, was honored with the APTA State Legislative Commitment Award. Marsh, whom APTA President Sharon Dunn, PT, PhD, described as a "force" for the Missouri Chapter, has a long list of advocacy accomplishments that include passage of legislation prohibiting physician-owned physical therapy services, the establishment of direct access in the state, adoption of fair copay laws, and the inclusion of PTs among the professionals able to provide certification of disability for parking tags and license plates. Most recently, Marsh led the Missouri Chapter's successful efforts to adopt the Physical Therapy Licensure Compact.

    The APTA State Policy and Payment Forum is an annual 2-day event that focuses on advocacy and legislative issues at the state level.

    2017 State Forum Awards
    From left: Chris Marsh, PT (MO), winner of this year's legislative commitment award; Joanne Zazzera, PT, DPT (HI), legislative service award winner; APTA Board of Directors member and Treasurer Jeanine Gunn, PT, DPT; APTA Vice President Lisa Saladin, PT, PhD; APTA President Sharon Dunn, PT, PhD; APTA Board of Directors member Anthony DiFilippo, PT, DPT, MEd; Cristina Faucheux, PT (LA), legislative service award winner.

    APTA to Submit Feedback on USPSTF Draft Falls Prevention Recommendations

    The United States Preventive Services Task Force (USPSTF) issued draft recommendations for falls prevention in community-dwelling adults age 65 or older, and APTA will issue formal comments after receiving feedback from member experts from the Academy of Geriatric Physical Therapy and the Academy of Neurologic Physical Therapy.

    APTA members are encouraged to submit their own comments as well.

    Based on an evidence review, USPSTF concludes with moderate certainty that both group and supervised individual exercise can reduce risk for falls. Regular exercise should include aerobic and strengthening activities, as well as balance and gait training.

    The task force found only a small net benefit to routinely providing a multidisciplinary assessment and a customized “multifactorial” combination of interventions, such as exercise, psychological interventions, and physical therapy, among others; however, authors acknowledge that, for certain older patients with a history of falls and comorbid conditions, an “in-depth multifactorial risk assessment with comprehensive management” may be appropriate. Authors also write that vitamin D supplementation has no benefit in falls prevention.

    Want more on falls prevention? Check out the falls-related resources at PTNow, including a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. APTA also offers resources at its Balance and Falls webpage.

    Rates of Cancer Associated With Overweight and Obesity Register Significant Increases from 2005 to 2015, Says CDC

    America's obesity and overweight problem is also a cancer problem. According to the US Centers for Disease Control and Prevention (CDC), the US has witnessed a 7% increase in overweight- and obesity-related cancers (other than colorectal cancer) over 10 years, with some types of overweight- and obesity-related cancer rates increasing from 26% to 40%.

    The findings appear in an October 3 CDC report on a study of data from the United States Cancer Statistics (USCS) data set between 2005 and 2014. Researchers tracked incidence rates for 13 types of cancer associated with overweight and obesity: cancers of the esophagus, breast, endometrium, gallbladder, gastric cardia, kidney, liver, ovary, pancreas, thyroid, meningioma, plasma cells (myeloma), and colon/rectum. Researchers looked at overall rates as well as rates by age, sex, and race/ethnicity. Here's what they found:

    • Overall, the overweight/obesity-related (OOR) cancer rate declined by 2% between 2005 and 2014, but that doesn't tell the whole story. Researchers believe that the overall decrease was largely driven by a 23% decline in colorectal cancers, which have a high rate to begin with. Authors think that more widespread detection and removal of precancerous polyps are responsible for the drop in that cancer type.
    • When colorectal cancer is excluded from the data, OOR cancer rates show a 7% increase between 2005 and 2014, with thyroid cancer rates increasing by 40% and liver cancer rates increasing by 29%.
    • Besides the decline in rates for colorectal cancer, a few other cancers showed declines during the study period, including ovarian cancer (16% drop), and meningioma (29% drop); however, these declines weren't enough to offset the overall increase.
    • OOR cancers accounted for 40% of all cancers diagnosed in 2014.
    • OOR cancers accounted for 55% of cancers diagnosed in women and 24% of cancers diagnosed in men in 2014.
    • OOR cancer rates were higher among non-Hispanic blacks and non-Hispanic whites compared with other groups.

    Authors believe that growing rates of obesity and overweight in the US—now estimated at about 1 in 3 Americans—threatens to overwhelm efforts to reduce overall cancer rates, and that more needs to be done to promote healthy diet and increased physical activity.

    "Without intensified nationwide efforts to prevent and treat overweight and obesity, the high prevalence of excess weight might impede further declines in overall cancer incidence," authors write. "These efforts include investing in addressing both social and behavioral determinants of health."

    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.

    From PT in Motion: Going 'Fixer Upper' on Your Clinic

    You have the right team, the right tools, and the right training to serve your patients. But is the clinical space you're offering making the most of those assets?

    This month's issue of PT in Motion magazine includes a feature article on how physical therapists (PTs) are rethinking the design of their clinics, from a University-sponsored overhaul of a 10,000-square-foot facility to an individual PT (and his brother) rehabbing an old tire store into a state-of-the-art space.

    "Physical Therapy By Design" explores the ways PTs have created patient-centered layouts that combine functionality with aesthetics to make their clinics welcoming and efficient. Sometimes working in partnership with architects, sometimes working alone, the PTs interviewed for the article have at least 1 thing in common: a willingness to question old assumptions about how a physical therapy clinic should look.

    The article includes examples of design changes both big and small—from moving walls to adding PT equipment baskets containing scissors, tape, goniometers, and the like at every bed. A second piece provides basic tips on what to think about when you begin considering a redesign.

    "Physical Therapy by Design" is featured in the October issue of PT in Motion and is open to all viewers—pass it along to nonmember colleagues to show them 1 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.

    Making the Profession's Voice Heard on Home Health: Multifaceted Advocacy Efforts Deliver Strong Message to CMS

    While the US Centers for Medicare and Medicaid Services (CMS) considers what to do with a proposed rule that APTA says creates "perverse financial incentives" for reductions in care in home health (HH), APTA and its members can be satisfied that the association, its components, and individual members mounted a strong, multifaceted education and advocacy effort that is likely to grab the agency's attention.

    The focus of the efforts is to stop CMS plans for a new HH payment system that reduces episodes of care from 60 to 30 days and shifts to a new case-mix model, called the Home Health Grouping Model (HHGM), that removes therapy service-use thresholds from the payment mix. CMS estimates that the combined effects of the proposed changes would result in a $950 million payment reduction to the HH payment system beginning in 2019.

    APTA identified glaring problems in the proposal almost immediately after it was released in late July and collaborated with the APTA Home Health Section to launch a series of advocacy efforts to ensure that CMS would receive a clear, unified, and strong reaction by the September 25 public comment deadline. Those efforts included:

    • A joint webinar with the APTA Home Health Section
    • Multiple meetings with policymakers on Capitol Hill, resulting in separate letters from Senator Orrin Hatch (R-UT) and 49 Senators, both telling the agency not to move forward with the HHGM proposal
    • Strategy discussions with other organizations, including the National Association for Home Care & Hospice and the Partnership for Quality Home Healthcare
    • Alerts to the PTeam, the association's advocacy network
    • Grassroots alerts to 4,300 members urging them to contact their member of Congress about stopping the HHGM plan
    • Meetings with CMS representatives in which APTA was joined by representatives from the American Occupational Therapy Association and the American Speech-Language-Hearing Association to discuss shared concerns
    • Educational sessions on the HHGM at the APTA State Policy and Payment Forum held in mid-September
    • A podcast created with Talus Media
    • The creation of a template letter for members to use in writing to CMS about the proposed rule

    A final decision on the proposed rule isn't likely to be released until sometime in November, but CMS records show that APTA's grassroots advocacy efforts made an impact, at least when it comes to the contents of the CMS inbox: as of the comment deadline, CMS reports that it has received 1,349 comments on the HH rule.

    "At this stage we don't know where CMS is going with the HHGM," said Kara Gainer, APTA's director of regulatory affairs. "But the level of collaboration and individual effort throughout the association, combined with our cooperative efforts with other organizations opposed to the rule, has sent a very clear and forceful message to CMS. We think this proposal will harm patients, and we hope CMS is getting that message loud and clear."

    CMS Shelves Controversial Orthotics and Prosthetics Proposal

    The US Centers for Medicare and Medicaid Services (CMS) has killed a controversial proposal that would have restricted many physical therapists (PTs) from furnishing custom orthotics and prosthetics. The proposal was opposed by APTA and a host of other provider and patient advocacy organizations.

    The proposed rule, issued in January, would have required PTs to be "licensed by the state [as a qualified provider of prosthetics and custom orthotics], or…certified by the American Board for Certification in Orthotics and Prosthetics…or by the Board for Orthotist/Prosthetist Certification." The association voiced its opposition to the CMS plan, characterizing the proposal as a set of unnecessary requirements that would limit patient access to appropriate care.

    The March 13 deadline for comments passed, and CMS issued no further communication on the proposal until last month, when a notice that the proposal was being withdrawn from the White House Office of Management and Budget’s “Unified Agenda” indicated that the proposal was no longer under active consideration by CMS. On October 3, notice that the proposal would be officially withdrawn appeared in the Federal Register, with the withdrawal document itself scheduled to be published the next day.

    The withdrawal represents a win for thousands of PTs who would have been saddled with significant additional regulatory and financial burdens in order to qualify as a provider. In addition to its direct comments to CMS, APTA's advocacy efforts included meetings with CMS and the creation of a template letter to be used by many members to voice their individual opposition to the proposal.

    VA Wants to Move Telehealth Beyond State Borders and Into Vets' Homes

    The US Department of Veterans Affairs (VA) would like to remove barriers to telehealth and allow its providers—including physical therapists (PTs)—to conduct telehealth activities across all 50 states and in non-federal sites, including patients' and providers' homes.

    In a proposed rule, the VA describes how its current telehealth program is limited by many state professional licensure laws and regulations, which restrict telehealth activities to within state borders. Additionally, writes the VA, many VA medical centers only allow telehealth on federal property out of concern that its providers will run afoul of state regulations, thereby eliminating the possibility of a patient receiving telehealth at home.

    If adopted, the new rule would change all that. State laws would be preempted by federal provisions that would allow a VA provider to conduct telehealth services with a patient in another state, and in any location. According to the VA, preemption is a more practical way to expand telehealth than if the agency were to lobby state legislatures for changes to individual state laws.

    The VA hopes that the change will help improve veterans' access to mental health services, but it also believes that expanded telehealth will improve care across the board, including ensuring that patients in more remote areas can receive needed services.

    "Monitoring general medical conditions in the beneficiaries' homes empowers beneficiaries to take a more active role in their overall health care without adding the stress of commuting to a medical facility to receive the same type of care," the VA writes. "Telehealth is particularly important for beneficiaries with limited mobility, or for whom travel to a health care provider would be a personal hardship."

    APTA will be commenting in support of the proposed rule, and will notify members of any developments.