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  • 2020 APTA Federal Advocacy Forum Will Feature Impressive Line-up; Registration Closes March 16

    APTA is gearing up for this year's APTA Federal Advocacy Forum, where members will have the opportunity to go to Capitol Hill to advocate on key legislation affecting the profession, including patient access to care, student loan forgiveness via the National Health Service Corps, prior authorization, and the proposal by Medicare to cut reimbursement to physical therapy in 2021.

    But the advocacy trip is just one part of the forum: The event also features educational sessions and opportunities to hear from speakers with important insights on political action and advocacy. This year's speaker lineup includes:

    Paul Begala. Begala, the forum's keynote speaker, is a political analyst and commentator at CNN. An affiliated professor of public policy at Georgetown University, Begala served as counselor to President Bill Clinton.

    Bradford Fitch. Monday's breakfast will feature Bradford Fitch, president and CEO of the Congressional Management Foundation, a nonprofit, nonpartisan organization that advises congressional offices on how to improve operations and advises citizens on how to improve communications to Congress. Fitch has spent 30 years in Washington as a journalist, congressional aide, consultant, college instructor, internet entrepreneur, and writer/researcher. Fitch is the author of several books, including Citizen’s Handbook to Influencing Elected Officials and Media Relations Handbook for Agencies, Associations, Nonprofits and Congress.

    Theresa Marko, PT, DPT, MS. Theresa Marko is one of the profession's most dynamic advocates. Marko is a member of APTA's Public Policy & Advocacy Committee, the American Academy of Orthopaedic Manual Physical Therapists’ Practice Committee, and the Private Practice Section's Government Affairs Committee. Marko regularly goes to the District of Columbia and her state capitol in Albany to lobby for issues important to the physical therapy profession. She has been a guest speaker on patient and physical therapist advocacy at Columbia University and LaGuardia College, and recently authored a blog post for APTA on the importance of advocacy.

    Thomas Barba, PT, MPT. An active leader and volunteer in the profession, Barba serves as Federal Affairs Liaison for the Michigan chapter of APTA, Federal Advocacy Key Contact for the APTA and the Private Practice Section, and a member of the PPS Annual Conference Program Work Group. In addition, Barba is a member of the Michigan chapter board of directors and serves on the advisory boards for Delta College PTA Program and Bay Area ISD for Health Professionals.

    Want to get a feel for what the Federal Advocacy Forum is all about? Check out the video recap of the 2019 forum on the APTA Federal Advocacy Forum webpage. And if you're in the mood for a little pre-Forum inspiration don't miss this great read from a veteran advocate Eva Norman, PT, DPT, "You Cannot Complain if You're Not Involved."

    Updated Guideline for Management of Hand, Hip, Knee OA Strongly Recommends Exercise-Based Approaches

    In this review: 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee
    (Arthritis Care & Research, February, 2020)

    The Message
    Although researchers were not able to recommend precisely what kind and how much, exercise interventions in general have once again emerged as one of the most strongly recommended approaches to treating knee, hip, or hand osteoarthritis, according to an updated practice guideline issued by the American College of Rheumatology and the Arthritis Foundation. The recommendation for exercise is the result of an extensive review of physical, psychosocial, and pharmacological approaches that evaluated the evidence base for their use. Other strongly recommended approaches for all three types of OA included self-management programs and oral nonsteroidal anti-inflammatory drugs, or NSAIDs. Weight loss (when appropriate) and tai chi were also strongly recommended approaches for individuals with hip or knee OA.

    The study
    Authors based their recommendations on an extensive review of studies, most of them randomized controlled trials, conducted through August 2018. The literature identification, review, and ultimate recommendation process involved five teams that included both provider subject matter experts and patient panel, ending with a voting panel that included PTs, rheumatologists, an internist, occupational therapists, and patients.

    Analysis was focused on approaches available in the U.S. and used what’s called the GRADE system that resulted in recommendations for or against a particular approach, accompanied by a note of either "strong" or "conditional" support for each recommendation, as well as an intended range of patients (hip, knee, or hand OA alone or in combinations). APTA members Carol Oatis, PT, PhD; Louise Thoma, PT, DPT, PhD; and Daniel White, PT, were among the authors of the guideline.

    Findings
    The recommendations were divided into two broad areas: physical, psychosocial, and mind-body approaches; and pharmacologic management. Here are a few of the recommendations included in the guideline.

    Physical, Psychosocial, and Mind-Body

    • Exercise, self-management programs (strongly recommended for hip, knee, or hand OA).
    • Weight loss, tai chi (strongly recommended for hip or knee OA).
    • Cognitive behavioral therapy, acupuncture, thermal interventions (conditionally recommended for hip, knee, or hand OA).

    Pharmacologic Management

    • Oral NSAIDs (strongly recommended for hip, knee, or hand OA).
    • Intraatricular glucocorticoid injections (strongly recommended for hip or knee OA).
    • Acetaminophen, Tramadol, Duloxetine (conditionally recommended for .hip, knee, or hand OA).

    The guideline also includes strong and conditional recommendations for approaches limited to a specific OA location, including balance exercises (conditionally recommended for knee or hip OA), yoga (conditionally recommended for knee OA), and topical NSAIDs (strongly recommended for knee OA).

    Approaches recommended against using

    As with the recommended-for approaches, the guideline contains a mix of strong and conditional recommendations against certain approaches, usually applicable to some but not all three OA locations. Among the approaches authors recommend against using:

    • Massage therapy, transcutaneous electrical stimulation, modified shoes, lateral and wedged insoles (conditionally recommended against for knee or hip OA).
    • Fish oil, vitamin D, glucosamine (strongly recommended against for knee, hip, or hand OA).
    • Platelet-rich plasma treatments, stem cell injections (strongly recommended against for hip or knee OA).

    Why it matters
    As the most common form of arthritis, OA is a leading cause of disability among older adults and a condition that can be present for decades. Authors view the guideline as a tool for pursuing a "comprehensive, multimodal approach … offered in the context of shared decision-making with patients to choose the safest and most effective treatment possible."

    More from the study
    Authors write that while "current evidence is insufficient to recommend specific exercise prescriptions," the evidence is strong that exercise can lessen pain and improve function. The guideline urges providers to provide exercise advice "that is as specific as possible" for the patient, and assert that "overall, most exercise programs are more effective if supervised, often by physical therapists and sometimes in a class setting."

    The "self-management programs" are described by authors as those that "use a multidisciplinary, group-based format combining sessions on skill-building … education about the disease and about medication effects and side effects, joint protection measures, and fitness goals and approaches."

    One of the more notable changes in the most recent version of the guideline was around the use of glucosamine, a popular supplement thought to improve joint health. While glucosamine was a conditionally recommended approach in the previous guideline, authors moved it to "strongly recommended against" status due to "a lack of efficacy and large placebo effects."

    Keep in mind …
    Authors point out that in addition to a lack of clarity as to what types and dosages of exercise were most beneficial for OA (and for which joints), the current guideline also was unable to assess factors such as optimal footwear types, broader outcomes such as falls prevention, and the "role of integrative medicine, including massage, herbal products, medical marijuana, and additional mind-body interventions."

    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 Volunteer Opportunities Available

    Ready to step up your participation in APTA? Calls are now open for several Board of Directors-appointed groups.

    The Board is seeking volunteers for the reference, ethics and judicial, finance and audit, public policy and advocacy, and scientific and practice affairs committees; as well as APTA awards subcommittees on advocacy, education, lectures, practice and service, publications, research, scholarships, and Catherine Worthingham Fellows. Deadline for making your interest known is February 28, 2020, for all groups except the Reference Committee, which has a March 1 deadline. More information on the opportunities can be found on APTA's volunteer groups webpage.

    To apply, visit APTA Engage, the association's volunteer portal. In addition to the Board-appointed groups, the site features a dynamic list of opportunities ranging from one-time, low time-commitment, locally based options to long-term volunteer positions at both the chapter and national levels.

    Tip: Even if you're not interested in current openings, consider creating an APTA Engage profile soon to make the process that much easier when other opportunities present themselves. Questions? Contact denakilgore@apta.org.

    CMS Coding Reversal Update: Providers Can Start Checking in With MACs

    It's official: Medicare Administrative Contractors for CMS have been notified of the agency's decision to reverse coding methodology decisions that prevented PTs from billing an evaluation and therapeutic activities or group therapy activity delivered on the same day, and to apply that decision to claims made back to the beginning of the year. The announcement means that providers can begin resubmitting or appealing claims that were denied while the now-defunct system was in place — but the contractor responsible for coding implementation says to check with your Medicare Administrative Contractor first.

    In a February 5 communication to APTA, Capitol Bridge LLC stated that CMS had "instructed the Medicare Administrative Contractors [known as MACs] to implement the replacement edit files and make claim adjustments," and announced that those replacement files are now available on both the Medicare Procedure-to-Procedure coding updates webpage and the Medicaid National Correct Coding Initiative Edit Files webpage. Capitol Bridge is the CMS contractor for the National Correct Coding Initiative, or NCCI.

    "Providers may check with their MAC about claim adjustments, appeal claims denied due to the [Procedure-to-Procedure, or PTP] edits to the appropriate MAC, or resubmit claims due to the PTP edits after implementation of the replacement edit file with January 1, 2020, retroactive date, as permitted by the MAC," Capitol Bridge writes. It advises providers to contact their MAC with questions about individual claims.

    APTA regulatory affairs staff will remain in communication with CMS and the NCCI contractor on the change and will share any new information that becomes available. For additional information, visit APTA’s webpage on the NCCI.

    Lawmakers Want Answers From CMS on Planned 2021 Payment Cuts

    Explain yourself: That's the message of a bipartisan letter to CMS signed by 99 members of the U.S. House of Representatives who are concerned about the agency's plan to make cuts to Medicare that include an estimated 8% reduction in payment to PTs. APTA led efforts to inform legislators of the issue.

    And if that's not enough to get CMS to take another look at the planned cut, maybe a letter from a prominent U.S. senator might help.

    In a February 5 letter, the representatives write that their constituents have concerns about whether the planned cuts will reduce access to health services. In order to respond to those concerns, the legislators are asking about the process CMS used to reach the decision to reduce the reimbursement for services furnished by certain providers in 2021 in order to accommodate increases to values of the office/outpatient evaluation and management codes, known as E/M codes.

    The letter specifically asks CMS to explain the methodology and data the agency used to calculate the estimated impact to each specialty level impact associated with the coding change, and to provide a description of the factors the agency considered in deciding how much it would reduce each of the 36 other professions selected for cuts.

    The legislators also pressed CMS on its statement that it would consider additional information before making a final decision, asking what kind of information would be of the most value, and whether CMS considered how the proposed changes could impact access to care — and if so, how.

    The letter requests that CMS respond to Congress by February 21.

    But the pressure on CMS isn't just coming from the House: Thanks to the efforts of Brenda Mahlum, DPT, the APTA Federal Affairs Liaison for the Montana Chapter, Senator John Tester (D) also sent a letter to the agency describing his concerns that the cuts "will compromise patients' access to care, particularly in the most remote areas of my state and across the country."

    "Medicare beneficiaries increasingly rely on physical therapy and occupational therapy services as part of a coordinated model of care," Tester writes, adding that the planned cuts run the risk of drying up access to care in underserved and rural areas that are already struggling to meet health care needs. "Payment decisions like the ones in this final rule will limit provision of services," Tester adds. "The physical therapists and occupational therapists in Montana operate on very narrow margins, and any reimbursement reductions may jeopardize their ability to remain open and serve their patients."

    Justin Elliott, APTA's vice president of government affairs, sees member engagement as the driving force behind the legislators' efforts.

    “We are grateful to Representatives Buddy Carter and Lisa Blunt Rochester for their leadership on this bipartisan House letter to CMS, and even more grateful to the APTA members who urged their legislators to get on board,” Elliott said. “The large number of bipartisan signatories to the letter should demonstrate to CMS that the public needs more information to understand what policy goal this flawed proposal is trying to achieve. We understand and support the desire for increased payment for the E/M codes. However, we believe it's inappropriate to reduce payment to physical therapists and 36 other provider groups as the way to pay for it.”

    Be sure to check out APTA’s resources on this issue. Ready to add your energy to APTA advocacy? Join us for the APTA Federal Advocacy Forum, March 29-31 in Washington, D.C.

    PTJ: New CPG Supported by APTA Provides Guidance on PT Treatment of Individuals With Heart Failure

    In this review: Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure
    (PTJ, January 23, 2020)

    The Message
    A new clinical practice guideline supported by APTA and developed by the Cardiovascular and Pulmonary Section of APTA includes nine evidence-based action statements for the evaluation and management of patients diagnosed with heart failure and two clinical algorithms to support clinical decision making. Physical therapy interventions can improve activity level, participation, and quality of life, as well as reduce hospital readmissions for individuals with heart failure, authors write, and PTs should "work collaboratively with other members of the health care team" to achieve these goals.

    The Study
    Authors developed the algorithms and action statements based on 127 systematic reviews, meta-analyses, and previously published CPGs that tested interventions used by physical therapists, reviewed randomized controlled trials, tested outcomes relevant for physical therapist practice, and included only patients who acquired heart failure as adults.

    A team of Cardiovascular and Pulmonary Section members representing both educators and clinicians appraised the quality of CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE II) tool, systematic reviews using the Assessment of Multiple Systematic Review (AMSTAR) tool, and RCTs using the University of Oxford Centre for Evidence-Based Medicine critical appraisal tool. Members of the CPG’s Guideline Development Group formulated and graded nine key action statements, which were then reviewed by internal and external stakeholders for comment.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Cardiovascular and Pulmonary Section — with funding and tools for CPG activities related to drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).

    Findings
    Nine broad action statements were recommended by the authors based on evidence strength identified as "strong" or "moderate." Each statement includes specific details on benefits, risks, benefit-harm assessment, role of patient preferences, and a summary of the supporting evidence. The recommendations for physical therapy prescriptions include specific parameters, which are detailed in the CPG.

    For all patients with heart failure:

    • PTs should advocate for a "culture of physical activity as an essential component of care in patients with stable heart failure." (Strong recommendation)
    • "Make appropriate nutrition referrals, perform medication reconciliation, and provide appropriate education on preventive self-care behaviors to reduce the risk of hospital readmissions." (Strong recommendation)

    For patients with stable, Class II to III heart failure as defined by the New York Heart Association:

    • PTs should prescribe aerobic exercise training. (Strong recommendation)

    For patients with stable, NYHA Class II to III heart failure with reduced ejection fraction, also known as HFrEF, PTs should prescribe:

    • Resistance training for the upper and lower body. (Strong recommendation)
    • Neuromuscular electrical stimulation. (Strong recommendation)
    • Inspiratory muscle training with a threshold (or similar) device (Strong recommendation)
    • High-intensity, interval-based exercise — HIIT — for patients without contraindications. (Moderate recommendation)

    For patients with stable, NYHA Class II to III HFrEF, PTs may prescribe:

    • Combined aerobic and resistance training. (Moderate recommendation)
    • Combined inspiratory muscle training and aerobic exercise training. (Moderate recommendation)

    Authors developed two separate algorithms for patients with heart failure: the first to help PTs determine whether a patient is stable enough to proceed with an intervention and recognize when a person's signs and symptoms may require emergency medical treatment, and the second to assist in identifying which of the CPG's action statements are "most appropriate for a particular patient based on participation, activity, endurance, and signs of exercise intolerance."

    Why it Matters
    Noting the increasing readmissions rate and rising health care costs associated with heart failure, authors hope the CPG will "provide physical therapists with evidence-based recommendations that assist in improving functional capacity and [health-related quality of life] and reducing hospital readmissions for individuals with HF."

    As "integral members of the interprofessional team assisting with early detection of HF exacerbation and directing medical follow-up," PTs are urged by the authors to "work within their health care systems to determine how these or similar algorithms for identification of HF exacerbation can be utilized within their specific contexts and patient care environments."

    More From the Study
    In addition to their recommendations, authors described a number of areas needing further research, including but not limited to associations for variations in outcomes; effectiveness of specific exercise options; and appropriate exercise, dosing, and parameters for patients in different care settings. Small sample sizes, strict patient selection criteria, lack of functional outcome measures, study in limited settings, and other factors in existing research limited findings and recommendations in some areas.

    Keep in Mind …
    As with most CPGs, authors caution therapists that the recommendations are directed at a patient population but can't "address each unique situation of an individual patient."

    Authors also point out that the second algorithm, developed to help determine which recommendations are most appropriate for a particular patient, is based on expert opinion. The Guideline Development Group notes that the available research "did not address specific examination-based criteria for when any of the interventions reviewed herein are appropriate."

    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.

    Mining Data to Shape Practice

    What's in a number? By itself, maybe not much. But collect a whole bunch of the right numbers and analyze them in the right ways, and you may be on the road to improving PT practice.

    In this month's issue of PT in Motion magazine: a look at how predictive analytics, sometimes referred to as probabilistic thinking, is shaping physical therapy in terms of both future practice and the here-and-now.

    "The Power of Predictive Analytics" explores how "using yesterday's patient data to make informed case decisions today" is surfacing in ways big and small, from large-scale operations that involve hundreds of clinics to a physical therapy education program that asks its students to collect outcomes during their clinical internships. The article also looks how APTA's Physical Therapy Outcomes Registry is positioned to become a significant source for predictive analytics.

    The PTs and other experts interviewed for the article agree on the potential for predictive analytics to change the ways PTs treat their patients. But Intermountain Healthcare's Stephen Hunter, PT, DPT, the hospital system's director of process control, believes that the benefits extend beyond the PT and into payment systems as well.

    "We certainly can go to payers with this data because we have outcomes every visit," Hunter says in the article. "We can go to a payer and say 'Look, you're only approving us for six visits for low back pain. But if you look at our data from thousands of patients, we can make a bigger difference if we get eight visits.' And most payers know that if patients don't improve in physical therapy, they're going to require more expensive care."

    "The Power of Predictive Analytics" is featured in the February issue of PT in Motion magazine and is open to all viewers — pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA.