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  • Older, Sicker, and Stressed: Survey Analysis Looks at Individuals With Chronic Pain

    An analysis of responses to a national health survey attempted to tease out the distinct characteristics of Americans with chronic pain. The portrait that emerged was of a chronic pain population that is older, under more financial stress, and more likely to live with 1 or more comorbidities compared with the average respondent.

    Editorial staff at Medpage Today conducted the review, which analyzed the results of the 2016 National Health Interview Study (NHIS), an 805-question survey administered to 33,000 Americans. The Medpage staff focused specifically on data related to pain, comparing respondents who reported daily pain with NHIS averages. Here's what they found:

    The chronic pain group was older. The median age of the daily-pain group was 59, compared with 52 years for the entire survey group. Within the pain group, about 33% were over age 65—an age range that made up 25% of the whole.

    The chronic pain group worries more about money. About 18% of the pain group reported being "very worried" about paying monthly bills, compared with about 8% of all respondents. At the other end of the spectrum, about 47% of all respondents reported being "not at all" worried about paying monthly bills, an attitude shared by only 38% of the chronic pain group.

    Comorbidities were more likely in the pain group. Respondents with chronic pain reported higher rates of hypertension, diabetes, and depression than the group as a whole. The percentage of respondents in the chronic pain group who reported hypertension approached 60%, while the whole-group average was closer to 30%. Similarly, diabetes diagnoses were reported by about 23% of respondents in the chronic pain group—twice as high as the overall rate. Respondents with chronic pain were also more likely to report taking medication for anxiety and depression at some point (nearly 40% compared with approximately 28% overall).

    The respondents with chronic pain also were more likely than the overall group to see receive regular preventive care, but the difference was slight—66% vs 64% for the overall group.

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    CMS Issues Corrections on 2017 Participation Requirement Rule for LTC Facilities

    It's not exactly a do-over, but the US Centers for Medicare and Medicaid Services (CMS) recently made more than a few tweaks to a 2017 final rule for long-term care (LTC) facilities—including changes that move compliance deadlines and reinstate unintentionally omitted requirements.

    In addition to correcting typos, the document issued by CMS also targets what it calls "technical" errors in the final rule that defines the requirements LTC facilities must meet in 2017 to participate in the Medicare and Medicaid programs. That rule, issued in October of 2016, was characterized as a sweeping change that touched on staffing, the physical plant, patient nutrition, self-assessments, and more.

    The changes include corrections to a deadline for when LTC facilities were to have compliance and ethics programs in place. The rule as originally published stated that the new programs needed to be rolled out by November 28, 2017; according to CMS, that was wrong, and the actual date for startup of the programs is 2 years later, in November of 2019. According to CMS, this change and all others "are consistent with the discussion of the policy in the October 2016 final rule and do not make substantive changes to this policy."

    A summary of the corrections is available on the Federal Register.

    Letter Helps PTs Send Unified Message to CMS on 2018 Fee Schedule, More Broad Medicare Changes

    The US Centers for Medicare and Medicaid (CMS) is looking for comments on the proposed 2018 Medicare physician fee schedule—and on Medicare as a whole. Now APTA is making it easy to seize the opportunity for the profession to speak with a unified voice.

    Just added to the APTA website: a template letter to CMS that covers both the proposed fee schedule and more general Medicare issues. The letter supports the CMS decision to make no changes to current procedural terminology (CPT) codes that were identified as possibly "misvalued," and recommends that the agency do more to increase patient access to physical therapist (PT) services, particularly in the areas of prevention, preoperative rehabilitation, and pain management.

    The letter, a Microsoft Word file, includes areas for the sender to fill in information about specific services she or he provides, practice setting, and other information. Instructions for getting the letter to CMS—electronically or by regular or express mail—are provided.

    APTA also will submit comments on the fee schedule. As in past comments on proposed rules delivered to CMS this year, the association will in its fee schedule comments include its perspective on broader changes to Medicare.

    Deadline for comments to CMS on the fee schedule is September 11.

    From Move Forward Radio: Boston Marathon Bombing Survivor Dances to the Beat of a 'New Normal'

    After losing her lower leg in the Boston Marathon bombing, former professional ballroom dancer Adrianne Haslet feared she would never step out on the floor again. "My foot was my tool … and it was completely taken away from me," she says. "I thought my quality of life would be a nothing."

    But she was determined to dance again, and even run. With the dedication of her physical therapist (PT) and the rest of her health care team, Haslet did just that. She cried when she practiced her first dance step in her kitchen.

    Now available from APTA's Move Forward Radio: a conversation with Haslet, who shared her experience of recovery and her "new normal" —including running the 2016 Boston Marathon, where "just crossing the starting line" was a victory. The NEXT 2017 keynote speaker also was featured in a MoveForwardPT video about the value of physical therapy.

    Move Forward Radio is archived at MoveForwardPT.com, APTA's official consumer information website, and can be streamed online via Blog Talk Radio or downloaded as a podcast via iTunes.

    Other recent Move Forward Radio episodes include:

    Preparing for the Latest Sports Craze: Obstacle Course Racing
    The latest sports craze of obstacle course races is full of physical demands. Physical therapist and certified athletic trainer Mike Ryan, PT, ATC, describes the allure of these increasingly popular physical challenges and how to successfully prepare for them.

    Success Story: Physical Therapist Collaborates With Surgeon to Solve Hip Impingement Diagnosis
    The pain that Annie Karp felt in her hip wasn’t intense, but it was unrelenting. For months she met with numerous health care providers in an attempt to resolve the issue. And for months she had no success, until a PT asked her a fairly simple question: "Are you a dancer?"

    Cancer-Related Fatigue and Physical Therapy
    Cancer-related fatigue isn’t unique to any type of cancer or cancer treatment, and it can occur even after treatment is complete. Marie Calys, PT, DPT, explains why exercise is 1 of the most effective ways to manage it.

    Rheumatoid Arthritis and Physical Therapy
    Unlike osteoarthritis, the effects of rheumatoid arthritis can be felt across a person’s entire body. Maura Daly-Iversen, PT, DPT, SD, FAPTA, discusses what we know about rheumatoid arthritis and how to effectively manage its effects.

    Osteoarthritis of the Hip and Knee
    Osteoarthritis can make movement difficult, and yet 1 of the best ways to manage osteoarthritis is to move. Mary Ann Wilmarth, PT, DPT, MS, doesn’t just treat people with the condition; she lives with it, too.

    Treatment of Core Muscle Injury (Don’t Call It Sports Hernia)
    These days, whenever ESPN injury analyst Stephania Bell, PT, meets an elite athlete who has undergone surgery to perform core muscle repair, she has a good idea about who might have performed the procedure.

    APTA members are encouraged to alert their patients to the radio series and other MoveForwardPT.com resources to help educate the public about the benefits of treatment by a physical therapist. Ideas for future episodes and other feedback can be emailed to consumer@apta.org.

    Recommendations for APTA Board, Nominating Committee Due by November 1

    APTA's transformational vision requires exceptional leadership. Anyone come to mind? How about you?

    The APTA Nominating Committee is seeking recommendations for the 2018 slate of candidates for elected positions. Positions open for election are Board of Directors president, vice president, and 3 directors; and 1 Nominating Committee member.

    To submit names of qualified members who would be willing to be considered for the upcoming election cycle, visit APTA's Nominations and Elections webpage and use the online form under the "2018" header. Deadline is November 1.

    Now's the time. Reach out to a leader you think should take his or her talents to a national level for APTA, and who's ready to guide the association through some exciting years ahead.

    'Insider Intel' Covers Fee Schedule, SNFs, Outpatient Payment, More

    While the proposed rule for the 2018 Medicare physician fee schedule may have grabbed the attention of physical therapists (PTs) for taking a light touch to potentially "misvalued" current procedural terminology (CPT) codes, there's more to the proposed rule than that. And there's a host of other actions from the US Centers for Medicare and Medicaid Services (CMS) that PTs need to know about as well. Are you up on all the changes?

    "Insider Intel" to the rescue.

    Now available: a free recording of the latest Insider Intel session, the call-in program that provides APTA members with the latest on payment and regulatory issues. The July 19 program covers a very active period for CMS by diving into not only the fee schedule but also news related to skilled nursing facilities, home health, hospital outpatient payment, and the status of a controversial CMS plan for prosthetics and orthotics.

    The recorded session, hosted by APTA regulatory affairs staff, includes a question-and-answer session with attendees.

    Study Says Cost Savings of Physical Therapy for LBP Are Significant

    When it comes to physical therapy for treatment of low back pain (LBP), Medicare is getting a bargain, according to authors of a new study. Researchers say that not only is physical therapy cheaper than injections or surgery in the short-term, it's an approach that is likely to save on treatment costs for at least a year after initial diagnosis, with average savings of 18% over treatments that begin with injections and 50% over treatments that begin with surgery.

    The study, commissioned by the Alliance for Physical Therapy Quality and Innovation (APTQI), focused on Medicare A and B claims data from 472,000 beneficiaries who received a diagnosis of LBP and began treatment between February and October of 2014. Researchers from the Moran Company tracked 3 treatment paths—physical therapy, injections, and surgery—and compared total costs of initial treatment as well as total costs for 12 months after diagnosis. The study also included an analysis of cost differences associated with how soon physical therapy was initiated after diagnosis, the physical therapist interventions used, and relationships between the use of physical therapy and the referring health care provider.

    "We felt it was important to look at claims data to demonstrate how a physical therapy-first approach can improve outcomes and reduce overall medical expenditures," said APTQI Executive Director Troy Bage, PT, DPT. "We've known this to be true from our experiences as physical therapists, but we wanted to investigate the hard data that bear this out."

    Here's what they found:

    From an intervention cost perspective, physical therapy wins out.
    As an initial intervention, the average total medical cost when physical therapy was used first was $3,992—19% lower than total average costs when injections were used first ($4,905) and 75% lower than the total average costs for the surgery-first group ($16,195).

    Physical therapy also is associated with savings over time.
    Researchers found that during the 12-month period after initial diagnosis, individuals who received physical therapy as an initial intervention tended to rack up fewer additional costs than the injection and surgery groups. Average 12-month spending for the physical therapy group was $11,151, compared with $13,606 for the injection group and $36,772 for the surgery group. That's an 18% and 54% savings, respectively.

    Starting physical therapy sooner correlates with lower costs.
    Beneficiaries who received physical therapy within the first 15 days of diagnosis incurred lower average treatment costs than those whose physical therapy began later, and those savings continued through the 12-month study period.

    Active physical therapist services were the most common type of services delivered.
    Active physical therapist services accounted for 82.1% of the services delivered to the physical therapy group, with 5.7% recorded as passive and the remaining 11.2% designated as other interventions.

    Primary care physicians account for the most LBP diagnoses, but orthopedic physicians are most likely to refer patients for physical therapy.
    Overall, 37% of the LBP diagnoses in the study group were made by primary care physicians, with the next highest referrer being "all other" (32%). While orthopedic physicians accounted for only 8% of the diagnoses, they referred the largest portion of their patients—about 21%—to physical therapy. Primary care physicians referred 13% of their patients to physical therapy, while pain management physicians preferred injection referrals, sending about 36% of their patients to that treatment path.

    Most patients receive no physical therapy, injections, or surgery.
    Of the 472,000 cases studied, almost 13% received physical therapy, with 11.3% receiving injections and 1.6% receiving surgery. The remaining 74.4% of patients didn't receive any of the studied treatments during the yearlong study window.

    As for the makeup of the groups studied, the group receiving physical therapy tended to be slightly older, with an average age of 68.1 compared with averages ranging from 64.1 to 66.7 for the other groups (including those who received none of the 3 services). Beneficiaries who received physical therapy were also more often women (65.5%, compared with 50.5%-61.9%) and were not as often designated as disabled, with a 29.6% rate compared with 37.9% in the injection group and 44.3% in the surgery group.

    "The results of the study highlight the importance of initiating physical therapy prior to other more expensive and invasive interventions," Bage said. "The savings identified in the study are not insignificant and clearly correlate with better outcomes."

    Authors of the study assert that the timing is right for the study, and they say the results are promising.

    "In a Medicare policy environment focused on value-based payment reform and care management strategies aimed in part at cost reduction, understanding potential cost implications of first line treatment utilization is relevant," authors write. "The findings from this report signal possible advantages of [physical] therapy as a potential cost saver relative to other treatment interventions for low back pain. These results lend promising support for the role of [physical] therapy early in the care continuum from a cost perspective."

    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.

    Proposed Home Health Rule Includes $80 Million Reduction in 2018, Potential $950 Million Reduction and Move to 30-Day Episodes in 2019

    In brief:

    • The proposed 2018 home health prospective payment system (HH PPS) includes an $80 million reduction in payments—a 2% drop from 2017
    • CMS will shift to a new payment methodology in 2019 that would establish 30-day episodes of care instead of the 60-day episodes currently used, and eliminate therapy service use thresholds in favor of payments more focused on clinical characteristics and patient information
    • 2019 changes could result in an estimated $950 drop in payment
    • Additional quality-reporting requirements to be added in 2020: skin integrity, falls, long-term care hospital patient functional assessments/care plans

    The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule for the 2018 Medicare home health prospective payment system (HH PPS) that would continue a planned series of cuts that began in 2014, with an estimated overall 0.4% reduction, or about $80 million, scheduled for next year. The proposal, released on July 25, also includes a plan to adopt a new payment model in 2019 that would shift from 60-day to 30-day payment episodes and lead to a nearly $1 billion reduction in home health reimbursements.

    Payment in 2018. The $80 million payment adjustment continues a set of reductions mandated by the Affordable Care Act, which began with a $60 million drop in 2015, a $260 million reduction in 2016, and $130 million for 2017. CMS arrived at the overall estimate by weighing a 2% payment increase against various decreases, mostly related to reductions in the 60-day episode payment rate and cuts to account for nominal growth in case mix.

    Episodes of care in 2019. In 2019 CMS would adopt a new payment methodology, known as the Home Health Grouping Model (HHGM), that would change the unit of HH payments from 60-day episodes of care to 30-day episodes of care. According to an article in Modern Healthcare, the change is based on a CMS analysis that concluded that the average length of home health care was 47 days, "but roughly a quarter of all 60-day episodes of care lasted 30 days or less."

    Therapy service use thresholds in 2019. Also part of the HHGM: the removal of therapy service use thresholds that CMS uses to make case-mix adjustments to HH payments. Instead, CMS would "rely more heavily on clinical characteristics and other patient information to place 30-day periods of care into meaningful payment categories," according to a CMS fact sheet on the proposed rule. Combined with the switch to 30-day episodes of care, CMS estimates that the adoption of the HHGM would result in a payment reduction of $950 million in 2019.

    Quality reporting in 2020. CMS is proposing the addition of 3 assessment-based quality measures beginning in 2020: changes in skin integrity postacute care; percent of residents experiencing 1 or more falls resulting in a major injury; and percentage of long-term care hospital patients who receive functional assessments at admission and discharge, as well as a care plan that addresses function.

    General comments on Medicare. As in previous proposed rules, CMS also seeks input on how the overall Medicare system might be improved—an offer APTA took up in its comments to proposed rules earlier this year.

    APTA regulatory affairs staff is reviewing the proposed rule and will submit comments on it to CMS by the September 25 deadline.

    Study: Chemical 'Marker' Sheds Light on Cognitive Benefits of Aerobic Exercise Among Older Adults

    In brief:

    • Researchers attempted to identify changes in the brain among cognitively healthy adults 65 and older who engaged in a 12-week aerobic exercise program
    • 53 participants were divided into exercise and non-exercise groups; chemical markers, proteins, cognitive function, and gray matter were evaluated at baseline and after 12 weeks
    • At the end of the 12 weeks, the only measurable difference between the groups was related to levels of total choline (tCho), a chemical associated with membrane degeneration and inflammation—exercise group's tCho levels remained stable while the non-exercise group's tCho levels rose
    • Researchers believe tCho levels could prove to be a useful marker to measure the effects of aerobic exercise on brain function of adults who are elderly

    The connection between physical activity (PA) and the slowing or prevention of cognitive decline in the elderly has been widely recognized, but an explanation of just how PA works on the brain's chemistry has been more elusive. Now researchers in Germany believe they've isolated a chemical marker that helps identify PA's neuroprotective effects.

    The research project itself was fairly straightforward: split 53 cognitively healthy individuals 65 and older into 2 groups—the first of which received 3 half-hour supervised cycle training sessions per week for 12 weeks, and the second of which did not increase their PA—and then measure a host of factors associated with cognitive decline at the beginning and end of the 12-week training program. Researchers didn't limit their investigation to chemical markers but also included evaluations of gray matter volume and cognitive performance tests. Results were published in Translational Psychiatry.

    At the end of the 12 weeks, only 1 major difference between the 2 groups was found: the amount of total choline (tCho) present in the brains of participants. A combination of 2 types of choline, tChol is associated with pathological membrane turnover and inflammation, and is often present along with elevated creatine levels in the brains of individuals with Alzheimer's disease and dementia. The tCho levels of individuals who participated in the exercise program remained stable, while the non-exercise group's tCho levels rose over the 12-week timeframe.

    Researchers were unable to identify significant differences in any other areas, including markers associated with neuronal energy reserve or brain-derived neurotrophic factor (BNF), a protein associated with brain plasticity. The study also found no changes to gray matter volume, a change other studies have noted. Authors noted, however, that those studies tended to take place over a longer time period—measurements at 12 weeks simply may be too soon to pick up those.

    As for what it is about PA that helps to tamp down the increase in tCho, researchers were unable to pin it to aerobic capacity, which did not increase significantly for the exercise group compared with the non-exercise group. Instead, they believe the effect could be due to an increase in cardiac efficiency among the exercise group.

    "Changes in fitness level … were positively associated with changes in metabolite concentrations … in the training group, thus suggesting that fitness is closely linked to cerebral brain metabolism," authors write. "Overall, the currently available data indicate that aerobic training interventions with moderate intensity may improve both brain metabolism and cardiopulmonary function."

    Authors acknowledge that their study is limited by its sample size and short timeframe, and call for additional studies with larger groups and longer study periods.

    Still, they assert, the notable difference in tCho levels could be a window into the chemistry behind the beneficial effects of PA.

    "As choline is a marker of neurodegeneration, this finding suggests a neuroprotective effect of aerobic exercise," authors write. "Overall, our findings indicate that cerebral tCho might constitute a valid marker for an effect of aerobic exercise on the brain in healthy aging."

    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.

    #ChoosePT Receives Commendation from KY House

    APTA's #ChoosePT opioid awareness campaign once again has been recognized—this time by the Kentucky House of Representatives, which issued a statement honoring APTA and its Kentucky Chapter for providing "an important opportunity" for public education on the "tremendous benefits of physical therapy."

    The commendation, issued on July 11, describes the #ChoosePT campaign as a "vital initiative" that is helping the public see the dangers of opioid use and understand that pain can be managed safely through physical therapy.

    Given that Kentucky “has suffered greatly from the effects of opioid addiction among its citizens, the #ChoosePT initiative sponsored by APTA and with the full support of the Kentucky Physical Therapy Association … is recognized as an important opportunity for citizens … to educate themselves on the tremendous benefits of physical therapy as a tool for pain management and to opt for a much safer alternative to prescription opioids," the document states.

    The House citation was made about 5 weeks after a similar recognition was issued by the Kentucky Senate. The House version was sponsored by Rep Daniel Elliott.

    In addition to state kudos, the #ChoosePT campaign also has received national attention this year, with the American Society of Association Executives honoring the entire campaign through a "Power of A" award for excellence in public awareness initiatives, and singling out the campaign's public service announcement video for a Gold Circle award as best association video of the year.

    APTA CEO Moore Testifies to Congress on Repeal of the Therapy Cap

    APTA Chief Executive Officer Justin Moore, PT, DPT, was offered an opportunity to testify on repeal of the Medicare therapy cap before a House of Representatives subcommittee on July 20. He cut right to chase.

    Calling the Medicare Part B cap on therapy services "an arbitrary barrier for Americans who are in need of rehabilitation services," Moore made the case to the House Energy and Commerce Committee's health subcommittee that now is the time to do away with the yearly ritual of quick-fix exceptions to the $1,980 combined limit on physical therapy and speech language pathology services and the $1,980 limit on occupational therapy.

    According to Moore, the fundamental problem is the same as it's been since the cap was implemented in 1997: if actually adhered to without exceptions, the payment limits would be detrimental to patients in need of rehabilitation, particularly among the most vulnerable. And the traditional workaround—instituting an exceptions process—is disruptive.

    "This pattern of yearly extensions without a permanent solution creates uncertainty for beneficiaries and providers, threatens access to care, and is not in the best interest of patients, providers, or the Medicare program," Moore told legislators.

    Moore pointed out that with 177 cosponsors, the bill to repeal the therapy cap now in the House (HR 807) has strong bipartisan support, and said that while there are costs associated with a repeal, those costs only will go up the longer Congress doesn't act. Moore also reminded legislators that the scramble to create exceptions processes has a price tag of its own. "With the money spent on these temporary patches over the past 2 decades, we could have easily paid for a permanent solution," he said.

    The effort to end the therapy cap marks the 17th attempt to move away from what originally was intended to be a temporary provision adopted as part of the 1997 Balanced Budget Act. Support for ending the cap reached its highest level yet in 2015, when repeal efforts were backed by 238 cosponsors in the House but came up 2 votes short in the Senate. The vote was for an amendment to legislative package that ended the flawed "sustainable growth rate" policy regularly requiring damaging payment cuts, avoided only by nearly annual ad-hoc "doc fix" legislation.

    In his testimony, Moore suggested that changes proposed in 2015 set the stage for viable review programs that would ensure appropriate spending without resorting to caps. The cap could be replaced with a "thoughtful medical review that is more targeted, ensures that care is delivered to more vulnerable patients, streamlines the ability to deliver that care, and ensures the long-term viability of the Medicare program," Moore said. He added that the current $3,700 review threshold is providing "appropriate oversight, and could be improved and incorporated into a permanent solution."

    Moore spoke on behalf of APTA, the American Speech-Language Hearing Association, and the American Occupational Therapy Association, which have worked together for years to end the therapy cap. He told lawmakers that the coalition advocates that any therapy cap repeal plan be based on 3 basic principles: ensuring patient access without unnecessary delays, establishing a targeted oversight systems that do not result in interruptions in care, and creating better alignment with value and performance-based models of care.

    "The therapy community stands ready to work with this committee to finally, after 20 years of extensions and moratoriums, repeal the therapy cap and find a permanent fix," Moore said.

    In an APTA video dispatch after his testimony, Moore described the targeted medical review process enacted as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as a "positive result" that should give Congress and the Centers for Medicare and Medicaid Services confidence that there are more effective ways to monitor costs. Those confidence-building MACRA results, along with the strong grassroots advocacy efforts of APTA members and enthusiasm in Congress, may be combining to make the end of the therapy cap a reality, according to Moore.

    "We're really in a good place," he said. "Both the data and what we know about the profession and its value in health care set us up for an opportunity to permanently take the therapy cap off the books."

    For its part, the House subcommittee is reportedly supportive of repeal, with subcommittee Chair Michael Burgess (R-TX) saying he hopes to avoid enacting another therapy cap exceptions process. "Much like the sustainable growth rate formula, we have a policy inherent to the therapy cap that no one supports," Burgess told the subcommittee.

    The efforts of individual APTA members boost the odds of ending the therapy cap. One way to make a difference: take part in APTA's social media blitz to Congress beginning on July 24. Watch your Facebook and Twitter feeds for messaging and instructions on letting your legislators know how they can improve patient care through putting an end to the cap. And then keep the momentum going by downloading the APTA action app, visiting the association's Legislative Action Center, and learning about other advocacy involvement opportunities.

     

     

     

     

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

    Karen Joubert, PT, DPT, who has provided PT services to Jennifer Aniston and P. Diddy, reflects on physical therapy's growing prominence in Hollywood (InStyle)

    Kimberly Steinbarger, PT, discusses kitchen tools that can make cooking easier for people with rheumatoid arthritis (US News and World Report)

    Gerard Breuker, PT, MSc, warns of the dangers of teen inactivity (Kankakee, IL, Daily Journal)

    Annita Winkels, PT, shows a local reporter how physical therapy can benefit overall health (Fox21 News, Duluth, MN)

    Joseph Trani, PT, ATC, offers suggestions on preventing knee injury (USA Today)

    Sue Stella, PT, DPT, explains the importance of physical therapy soon after a breast cancer diagnosis (WTVR6, Richmond, VA)

    Marilyn Moffat, PT, DPT, PhD, FAPTA, describes "killer arm workouts" (Business Insider)

    Raymond Halstead, PT, talks knee replacement (WBBH NBC2, Fort Myers, FL)

    Students from the Navarro College PTA program recently returned from a volunteer service trip to Haiti (Edinburg, TX, Review)

    "A qualified physical therapy professional is an excellent resource to help in learning to move and manage the body to minimize the pain and mobility loss associated with arthritis. Commitment to physical therapy can mitigate a path that would otherwise lead to surgery." –Tips on managing osteoarthritis from the Santa Rosa (FL) Press-Gazette

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

    Survey Reveals Differences in Readiness for Payment Reform Among Large Health Care Organizations

    The march toward value-based payment models may be on, but that doesn't mean everyone's moving in lockstep—or even moving at all.

    A new report from EY (formerly Ernst and Young), an accounting and management consulting firm, points out some significant differences in the ways larger health care providers are preparing—or not preparing—for value-driven care. According to the results of a survey of 700 health care executives, 67% of organizations with annual revenue between $100 million and $499 million have not implemented any value-based initiatives in their organizations. Nearly the reverse is true among the highest-earning organizations, where about 62% of the companies earning $5 billion or more a year have implemented value-based payment models, and 47% have started up bundled care models.

    "With market forces pushing for a new care delivery model, many organizations will undoubtedly be dragged into the realm of value," write authors of the report. "Relying on a series of disjointed initiatives to get there is not an effective strategy."

    APTA is working to ensure that physical therapists (PTs) have a solid understanding of what payment reform means by way of resources offered on its Payment Reform webpage. The latest addition to those resources is a short online quiz that can help members assess their readiness for payment reform.

    New National Academies Report on Pain Management and Opioids Recommends More Public Education, Reimbursement Models Supporting Nondrug Approaches to Pain Treatment

    The recommendations contained in a new National Academies of Sciences, Engineering, and Medicine (National Academies) report on pain management and the opioid crisis are wide-ranging, but a few may sound familiar to physical therapists (PTs), physical therapist assistants (PTAs), and anyone familiar with APTA's #ChoosePT campaign—namely, the need to support nonpharmacologic approaches to pain treatment through better reimbursement models, and the necessity of continued efforts to educate the public on effective alternatives to opioids.

    The positions on reimbursement and public education were among 21 recommendations included in the National Academies' report titled "Pain Management and the Opioid Epidemic," a comprehensive document that examines the opioid crisis from multiple perspectives. The overarching theme of the report: if America is serious about solving the opioid crisis, it's going to require work and change at nearly every level of health care, public policy, and even clinical education.

    In a chapter devoted to approaches to pain management, National Academies authors evaluate the current status of several nonpharmacologic approaches to pain, including acupuncture, manual therapies, and physical therapy. They assert that more research is needed on acupuncture, and that the evidence supporting chiropractic and osteopathic manipulation is "sparse." Physical therapy, they write, is in a slightly different situation: it's been proven to work, but an understanding of how it works, and guidelines for specific interventions, are harder to come by.

    "Despite the lack of strict guidelines or protocols for physical activity that may help patients with chronic pain, it appears that various types of physical activity can alleviate pain, including aerobic exercise, strength and flexibility training, walking, and manual therapy," authors write. "Exercise has been shown to be effective for treatment of many types and locations of pain, including fibromyalgia … back pain … osteoarthritis … whiplash-associated pain … and potentially even neuropathic pain."

    But there are “barriers to the successful use of exercise therapy for pain management," according to the report.

    These barriers can include patient-related factors such as lack of knowledge about exercise, but they are also within the health care system itself, including "the system's overly rigid focus on the biomedical model for pain, a lack of attention to or education about the value of exercise, a lack of supervision to ensure patient safety and comfort, and a lack of insurance coverage of the costs of exercise and physical therapy." Those barriers are among the reasons the report's recommendations include a call to facilitate reimbursement for comprehensive pain management by developing reimbursement models that "support evidence-based and cost-effective comprehensive pain management encompassing both pharmacologic and nonpharmacologic treatment modalities."

    The report also examined strategies for addressing the opioid epidemic through public education. In that section of the report, authors recount how the report's drafting committee "was struck particularly by the relative lack of attention to the impact of education of the general public … about risks and benefits of opioid therapy and the comparative effectiveness of opioid and nonopioid analgesics and nonpharmacological interventions." That gap prompted the committee to recommend that "the nation's public health leadership" including the surgeon general, US Centers for Disease Control and Prevention, and "heads of major foundations and professional organizations" evaluate and plan for a public education program on opioids and pain treatment.

    Both the need for better reimbursement models and the importance of public education on effective alternatives for pain treatment are at the center of APTA's public policy and public relations efforts. The association continues to advocate for more extensive direct access provisions, elimination of the Medicare therapy cap, and lower cost-sharing and copays for PT services, among other policy areas; and APTA's #ChoosePT campaign message has reached millions of Americans through a video public service announcement and the efforts of state chapters and individual APTA members.

    • Among other recommendations included in the National Academies report:
    • More investment in research to understand pain and opioid use disorder
    • Improved reporting data on pain and opioid use
    • Creation of "comprehensive pain education materials and curricula for health care providers"
    • Expanded treatment for opioid use disorder and improved education on opioid use disorder for health care providers
    • Additional studies aimed at a "thorough assessment of broad public health considerations"
    • A full review of currently marketed or approved opioids

    "This plan aims to help the millions of people who suffer from chronic pain while reducing unnecessary opioid prescribing," said committee chair Richard Bonnie, MD, in a press release. "We also wanted to convey a clear message about the magnitude of the challenge. This epidemic took nearly 2 decades to develop, and it will take years to unravel."

    Proposed Medicare Fee Schedule Maintains—and Sometimes Increases—Payment for Codes Related to Physical Therapy

    No cuts. And even a few increases.

    That's the major takeaway from the proposed Medicare 2018 physician fee schedule released by the US Centers for Medicare and Medicaid Services (CMS). It's a plan that settles questions about potentially "misvalued" current procedural terminology (CPT) codes by generally accepting work relative value units (RVUs) that had been proposed by an American Medical Association (AMA) advisory committee that worked closely with APTA.

    Under the proposed fee schedule, 13 of 19 CPT codes frequently used by physical therapists (PTs) will retain their 2017 RVUs, with the remaining 6 seeing slight increases. Additionally, RVUs for 2 codes associated with the management and training of patients with orthotics or prosthetics were increased, and a new code was added (977X1, intended for use on a "subsequent encounter" or different date of service from the initial encounter).

    The codes slated for increases are:

    • 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception, from .45 to .50
    • 97113: Aquatic therapy with therapeutic exercise, from .44 to .48
    • 97116: Gait training, from .40 to .45
    • 97533: Sensory integrative techniques, from .44 to .48
    • 97537: Community/work reintegration, from .45 to .48
    • 97542: Wheelchair management, from .45 to .48

    CMS also proposes leaving practice expense inputs untouched for the 19 major codes and the CPT codes related to orthotics and prosthetics.

    The proposed rule is a significant win for PTs, whose most-often used CPT codes were under scrutiny by CMS as being potentially "misvalued"—a term that usually means CMS thinks it's paying out too much. APTA made the multiyear code analysis process a top priority and worked closely with AMA's Health Care Professional Advisory Committee to develop recommendations to CMS. Those efforts included an extensive survey of PTs administered last fall.

    "The proposed physician fee schedule is an affirmation of the value of physical therapy," said Carmen Elliott, MD, APTA's vice president of payment and practice management. "We are especially grateful for the level of participation we received from APTA members in thoughtfully filling out surveys in 2016. The data AMA received were key in the development of strong recommendations with solid backing in practice."

    Other highlights of the proposed 2018 fee schedule:

    • CMS will debut "patient relationship modifiers," a set of codes intended to describe the role of the provider to the patient, such as "continuous," "episodic," "broad" and "focused." PTs will not be required to report these data in 2018 but could be required to by 2019.
    • The Medicare Diabetes Prevention Program (MDPP) expanded model would include "policies to further define the set of MDPP services, beneficiary eligibility criteria, and supplier eligibility and enrollment criteria," according to a CMS fact sheet. CMS also asks for comments on MDPP services and payment, supplier enrollment and administrative burden, and program integrity safeguards.
    • CMS continues its request for comments on how the overall Medicare system could be improved—input APTA already has provided in comments to other proposed rules.

    CMS has published a fact sheet on the proposed rule. APTA will submit comments on the proposed rule by the September 11 deadline, and will publish a PT-focused fact sheet when CMS issues a final rule sometime in late October or early November.

    Proposed Medicare Outpatient Payment Rule Allows Payment for TKA in Outpatient Settings, Increases Overall Payment by 2%

    If the proposed Medicare outpatient prospective payment system (OPPS) rule for 2018 gets adopted as-is, payment for total knee arthroplasty (TKA) will no longer be an inpatient-only arrangement, outpatient hospitals would see an overall 2% increase in payments, and ambulatory surgical centers could see a boost of nearly that much.

    APTA and other therapy groups are on record as supporters of the move toward reimbursement for outpatient-based TKA, though the association cautioned that the change would need to be accompanied by updated payment methodologies. Late last year, The New York Times described the possibility of the move toward outpatient-based TKA as one "sowing deep discord in the medical world."

    But CMS isn't stopping with TKA: the proposed rule also asks for comments on the possibility of removing total hip arthroplasty from inpatient status at some point in the future.

    The 2% payment increase to outpatient hospitals is an estimate based on a combination of a market basket update offset by adjustments related to productivity and cuts called for under the Affordable Care Act (ACA). While the increase is welcome, many hospital groups are concerned about other proposed changes that could negatively impact bottom lines, particularly a provision that would result in CMS paying 22.5% less than average sales prices for drugs purchased through the 340B program for "safety net" providers. Under the current rule, those providers receive payments that are 6% above average sale prices.

    Also of note in the proposed rule:

    • CMS would return to "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical access hospitals and rural hospitals with fewer than 100 beds. It's a move designed to help rural hospitals recruit physicians, according to a CMS fact sheet on the proposed OPPS.
    • The Outpatient Quality Reporting Program would shed 6 measures, a change that CMS estimates will reduce administrative burden by 152,680 hours and save $6.5 million in reporting costs by 2020.
    • The mandatory startup of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey would be delayed, though hospitals would be able to voluntarily report survey results next year.
    • Ambulatory surgical centers would receive an estimated 1.9% payment increase.
    • As in previous proposed rules, CMS also seeks input on how the overall Medicare system might be improved—an offer APTA took up in its comments to proposed rules earlier this year.

    APTA will review the OPPS proposed rule and submit comments on behalf of its members by the September 11 deadline. The association will provide a fact sheet on OPPS after the final rule is released later this year.

    New Version of Senate Health Care Bill Remains Problematic for APTA

    The latest version of the US Senate's health care legislation may include tweaks intended to please critics of the earlier draft, but the changes aren't enough to alter APTA's position that the bill would decrease access to care for millions of Americans.

    The revised Better Care Reconciliation Act (BCRA) is the Senate's second attempt to rollout a bill that would repeal and replace many provisions of the Affordable Care Act (ACA). The original version of the legislation was withdrawn just before the Senate's July 4th recess, when it became evident that the bill didn't have enough support to reach the floor for debate.

    The new version attempts to woo conservative opponents of the bill by weakening the ACA's requirements around health insurance and mandated essential health benefits (EHBs) that include habilitation and rehabilitation services. In a nod opponents concerned about the BCRA's effect on Medicaid, drafters of the bill also backed off proposals to eliminate some of the taxes associated with the ACA, slowed the phase-out of Medicaid expansion, and included more money for opioid addiction treatment and research.

    Technically, the provisions around EHBs—one of APTA's major areas of concern—are different from the first version of the bill. Rather than allowing states to opt for waivers of requirements that insurance policies contain the EHBs, the new version of the BCRA would allow insurance companies to offer stripped-down policies that don't include EHBs, so long as they offer at least 1 policy option that includes the required benefits. Individuals could choose cheaper low-cost, low-coverage options or more expensive policies with full EHB coverage.

    In practice, however, the results would be the same, according to Justin Elliott, APTA's vice president of governmental affairs.

    "Even with these changes, our concern remains," Elliott said. "Under this legislation, many Americans would find themselves with health care insurance that limits access to needed care, including physical therapist services. However we will continue our discussions with Capitol Hill as the legislative language evolves.”

    The bill's Medicaid provisions include a phase-out of federal funding for Medicaid expansions by 2024, and ties any later increases to inflation rates. APTA and many other organizations remain opposed to phase-out plans as presented so far, given that the changes have the potential to leave millions of Americans uninsured. The Congressional Budget Office will evaluate the entire bill and is anticipated to have estimates on uninsured rates and overall costs early next week.

    For APTA, the central concerns it voiced in its statement on the House of Representatives health care bill haven't changed. During the House debate on the bill, called the American Health Care Act, the association wrote that the provisions set the stage for a health care system that would create "unneeded barriers to care and reduce the access to care for millions of Americans." The association reiterated its position in a May letter to senators as they began their own work on health care legislation.

    Throughout both the House and Senate drafting and debate, APTA has continued to advocate for patient access to appropriate care and participated in a recent briefing on Capitol Hill educating lawmakers on the importance of habilitation and rehabilitation.

    Late this week, it remained unclear whether the Senate bill would be brought to the floor for debate.

    Payment Cuts Avoided in Proposed 2018 Physician Fee Schedule

    The proposed 2018 Medicare physician fee schedule (PFS) released today by the US Centers for Medicare and Medicaid Services (CMS) includes some positive news for physical therapists (PTs)—a proposal to maintain the values of some current procedural terminology (CPT) codes commonly used by PTs, and even increase values for a few.

    The proposed rule is a win for the profession and its ability to serve patients. CMS had been reviewing many of the CPT codes as potentially misvalued, putting them at risk for sizable reductions. The proposal includes no such reductions, a reflection of several years of work by APTA and its partners to maintain code values. Proposed increases in a few of the codes further underscore the effectiveness of those efforts.

    APTA will be advocating to maintain these proposed payment values in the final rule which will be released in November, and will submit comments to CMS by the September 11 deadline.

    CMS has also published a fact sheet summarizing the proposed rule.

    In addition to the fee schedule, CMS also released its proposed rule for the 2018 outpatient prospective payment system.

    APTA regulatory affairs staff are reviewing the proposed rules, and PT in Motion News will publish a follow-up report with more detailed information early next week.

    Photos From NEXT 2017 Now Available

    Remember when people used to take pictures of subjects other than themselves, at distances other than an arm's length away, with devices other than their phones? Actually, that never went away.

    Hundreds of high-quality professional photos from the 2017 NEXT Conference and Exposition, taken with an actual camera, are now available online, and viewing them or purchasing copies is easy.

    Simply go to http://davidbraun.photoreflect.com and click on the "NEXT 2017" link in the middle of the page under "recent photos." Enter password lordosis, then click "GO" and the day/event of your choice. Select your photos and order through the shopping cart.

    Note: once you've clicked on a thumbnail, you can select the size and quantity of the print, or, if you want a digital download, click on the "digital products" button. Questions? Contact photographer David Braun.

    Don't miss other ways to revisit NEXT (or see what you missed): check out a storify page packed with videos, photos, and social media posts, as well as an exclusive " PT in Motion News @NEXT" page that collects news stories and videos from the event.

    The Good With the Bad: Reports Show a Drop in Opioid Prescriptions and Dosage Strength, Rise in Prescription Duration and Opioid Hospitalizations

    The latest news on the opioid crisis is decidedly mixed. Reports show some reduction in prescription rates and dosages, but an overall increase in prescription length, wide variation in prescribing across the US, and prescription prevalence in 2015 that was 3 times as high as it was in 1999 and 4 times higher than in Europe in 2015. CDC Acting Director Anne Schuchat told National Public Radio that the 2015 per capita prescription opioid rates are enough for "every American [to] be medicated around the clock for 3 weeks."

    The analysis, from the US Centers from Disease Control and Prevention (CDC), came on the heels of another report from the Agency for Healthcare Quality and Research (AHRQ) showing that opioid-related inpatient stays and emergency department (ED) visits more than doubled between 2005 and 2014.

    The CDC report analyzed retail prescription data from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. The analysis also included a county-by-county look at prescription data in 2010 and 2015. Here's what researchers found:

    The good news: overall prescribing rates have dropped by 13% since 2010 peak levels.
    From 2006 to 2010, opioid prescribing rates increased from 72.4 per 100 persons to an all-time high of 81.2 per 100. By 2015, that rate had dropped to 70.6 per 100 persons. The amount of opioids also dropped from the 2010 peak of 782 morphine milligram equivalents (MMEs) per capita to the 2015 rate of 640 MMEs per capita—still 3 times higher than 1999's rate of 180 MMEs per capita.

    More good news: the drop includes a decrease in prescription of high-dose opioids.
    High-dose prescriptions (daily dosages of 90 or more MMEs) mostly were stable between 2006 and 2010, at 11.4 per 100 persons, then dropped to a rate of 6.7 per 100 by 2015.

    The bad news: prescription duration times have increased since 2006.
    While fewer people may be prescribed opioids, and while those opioids may be at lower strength, the rate of prescription supplies of 30 days or more jumped by 58% between 2006 and 2015, rising from 17.6 per 100 persons to about 28 per 100. The overall average days' supply also rose during that time period, from 13.3 days in 2006 to 17.7 by 2015—a 33% increase.

    More bad news: the positive trends aren't consistent across the US.
    A county-by-county comparison of opioid prescriptions in 2010 and 2015 revealed wide variations among counties, ranging from an average 203 MMEs per capita in the lowest-quartile counties to 1,319 MMEs per capita or more for counties in the highest quartile.

    The highest-prescribing areas tended to share certain characteristics.
    Researchers found several characteristics of the high-prescribing counties including larger percentages of non-Hispanic whites, higher rates of uninsured or Medicaid enrollment, lower education levels, higher rates of unemployment, "micropolitan" (small cities and towns) status, more dentists and physicians per capita, higher suicide rates, and a higher prevalence of diagnosed diabetes, arthritis, and disability.

    The CDC report was released not long after AHRQ published an analysis of opioid-related inpatient hospital stays and ED visits from 2005 to 2014. That report found that inpatient stays increased by 64% during the time period, with opioid-related ED visits doubling. The news was worse for women: between 2005 and 2014, inpatient rates that were historically lower than males caught up, so that by 2014, opioid-related inpatient rates for both sexes were roughly equal. The report was produced by AHRQ's Healthcare Cost and Utilization Project.

    While not directly citing the AHRQ report, authors of the CDC report did acknowledge rising overdose rates, defining the increases as "largely driven by use of illicit fentanyl and heroin" and adding that "there is no evidence that policies designed to reduce inappropriate opioid prescribing are leading to these increases."

    When it comes to the differences between counties, authors speculate that the higher prescription rates in micropolitan counties and counties with a higher prevalence of arthritis and diabetes might be related to access to nondrug pain treatments.

    "There are effective nonopioid treatments for pain whose benefits outweigh the harms," CDC authors write. "Reasons for higher opioid use in micropolitan counties might include less access to quality health care and other treatments for pain, such as physical therapy."

    Ultimately, they write, "this variation suggests inconsistent practice patterns and a lack of consensus about appropriate opioid use, and demonstrates the need for better application of guidance and standards around opioid prescribing practices." Among those standards: CDC's own guidelines for pain management, which urge the use of nonopioid approaches such as physical therapy as a first-line treatment for chronic pain.

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    From PTJ: For Patients With Nontraumatic Knee Pain, Early Rehabilitation Lowers Odds of Later Use of Opioids, Injections, Knee Surgery

    In brief:

    • Retrospective cohort study analyzed Medicare claims data for 52,504 beneficiaries with nontraumatic knee pain (NTKP) to analyze effects of early rehabilitation on later use of drugs, nonsurgical invasive procedures, and surgery
    • Patients receiving rehabilitation were divided into 3 groups: early rehabilitation (within 15 days of diagnosis), intermediate rehabilitation (16-120 days after diagnosis), and late rehabilitation (120 or more days after diagnosis); data were tracked for 1 year after diagnosis
    • Early rehabilitation patients were 33% less likely than nonrehabilitation control to engage in later use of drugs, 50% less likely to receive nonsurgical invasive procedures, and 42% less like to undergo surgery; similar differences were not found in intermediate and late-rehabilitation groups
    • Only 11% of NTKP patients received any rehabilitation at any time; of those who did receive rehabilitation, 52% were in the early group, 27% were classified in the intermediate group, and 21% received late rehabilitation
    • Authors believe results, while preliminary, support the trend toward more widespread use of early rehabilitation as a first-line treatment for NTKP

    When it comes to rehabilitation of individuals with nontraumatic knee pain (NTKP), authors of a new study concluded that it really is a case of "the sooner the better"—at least when it comes to reducing use of drugs, injection therapies, and surgeries later on.

    In a retrospective cohort study that analyzed records of 52,504 Medicare beneficiaries, researchers from the University of Pittsburgh found that patients with NTKP who received rehabilitation within the first 15 days after diagnosis were 33% less likely to use narcotic analgesics over the following year than patients who received delayed or no rehabilitation. Additionally, the early rehabilitation group was 50% less likely to move to nonsurgical invasive procedures such as corticosteroid injections, and 42% less likely to undergo later knee surgery. Results were published in Physical Therapy(PTJ) APTA's scientific journal.

    The study defined rehabilitation as "exercise or other nonpharmacological services or procedures that are recommended as early stage management options for patients with NTKP." This definition included exercise, nutritional counseling, functional training, physical agents, manipulation, and manual therapy, and was not linked to a particular service provider or setting.

    Besides the utilization patterns of early rehabilitation patients, authors of the study were also interested in overall usage of rehabilitation and whether delayed rehabilitation—defined as "intermediate rehabilitation" that occurred 16-120 days after the diagnosis or "late rehabilitation" that took place more than 6 months after the diagnosis—would make a difference in whether or not patients went on to the other interventions.

    The findings about rehabilitation prevalence were not surprising: of the 52,504 patients with NTKP, only 11% received early, intermediate, or late rehabilitation—a number consistent with other studies, authors write. Of the 5,852 patients who received rehabilitation, 52% received early rehabilitation, with 27% receiving rehabilitation 16-120 days later, and the remaining 21% having late exposure to rehabilitation.

    When it comes to later use of drugs, nonsurgical invasive procedures, and surgery, early rehabilitation seems to make all the difference compared with intermediate or late rehabilitation. Authors found that in the intermediate and late groups, the adjusted odds for receiving any of the interventions were actually higher than for patients who received no rehabilitation. While these data may seem to indicate that no rehabilitation is preferable to delayed rehabilitation, authors believe the difference may be driven by the likelihood that patients in the intermediate and later rehabilitation groups were experiencing higher levels of pain and disability for a longer time than were the early rehabilitation or control groups. Still, they explain, it's hard to say for certain, because during the years of claims data studied, data on pain and function were not included—a gap that "points to the importance of ongoing efforts to link clinical measures with health care service utilization from claims data."

    "Our findings would seem to support the recent recommendations that nonpharmacological treatment options, including those delivered by physical therapists, should be considered prior to treatment with narcotic prescription," authors write. "Developing strategies to encourage the use of rehabilitation as a first-line treatment for NTKP, as recommended by current guidelines, has the potential to positively impact a large segment of this clinical population."

    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.

    New HHA Medicare, Medicaid Participation Requirements Won't Launch Until January 2018

    It's now final: the US Centers for Medicare and Medicaid Services (CMS) has suspended startup of revised conditions of participation (CoP) for home health agencies (HHAs) until January 13, 2018. The new CoP originally were set to begin on July 13 of this year.

    According to CMS, the updated minimum standards for HHAs that serve Medicare and Medicaid would strengthen patient rights, encourage more effective communication between patients and caregivers, and result in better outcomes reporting. HHAs had expressed concerns that they didn't have enough time to prepare for the changes.

    In addition to pushing back the launch date, CMS also finalized July 13, 2018, as the phase-in date for related performance improvement projects.

    According to CMS, a preliminary draft of revised CoP guidelines will be available to HHA stakeholders in fall 2017, with a final version published in December 2017. CMS had signaled the possibility of a delay earlier this year.

    NYT Article Questions Arthroscopic Surgery, Acid Injections for Knee Pain

    New York Times (NYT) writer Jane Brody engaged in a lot of what she describes as "wishful thinking" about how best to treat her knee pain. One surgery, 1 hyaluronic acid injection treatment, and 2 knee replacements later, she's wondering what might've been had she avoided interventions that "have limited or no evidence to support them."

    In her July 3 NYT piece titled "What I Wish I'd Known About My Knees," Brody recounts her journey through meniscal tear arthroscopic surgery and "painful, costly injections," only to lead to knee replacement, and compares her results with a friend who opted for physical therapy when he was diagnosed with a meniscus tear and is now pain-free. The stories highlight what Brody calls "serious questions" about the benefits of arthroscopic procedures people pursue "in hopes of delaying, if not avoiding, total knee replacements."

    Brody cites recent guidelines, published in BMJ, that recommend conservative treatment over arthroscopic surgery for "nearly all" patients with degenerative knee disease. Brody quotes Reed A.C. Siemieniuk, MD, chair of the BMJ panel that created the new guidelines, as saying that "arthroscopic surgery has a role, but not for arthritis and meniscal tears," and that "[arthroscopic surgery for meniscal tears] became popular before there were studies to show that it works, and we now have high-quality evidence showing that it doesn't work."

    In the article, Brody also summarizes Siemieniuk's recommendations on "approaches that are known to help keep many patients out of the operating room." In addition to weight loss, avoiding activities that aggravate the pain, and using over-the-counter pain relievers if necessary, Brody writes that "most helpful of all" is to "undergo 1 or more cycles of physical therapy administered by a licensed therapist, perhaps one who specializes in knee pain. Be sure to do the recommended exercises at home and continue to do them indefinitely lest their benefits dissipate."

    From PT in Motion Magazine: Discovering a Second Career as a PTA

    When it comes to pursuing a career as a physical therapist assistant (PTA), it's never too late. Just ask the people who, often in middle age and after being successful in other areas, decided it was time to remake themselves as PTAs.

    In the July edition of PT in Motion magazine, Associate Editor Eric Ries takes a look at PTAs who have taken up physical therapy as a second career. Their stories reveal varied circumstances leading to the decision to become a PTA but a shared satisfaction with their new profession. Featured in the article are:

    • David Emerick, PTA, BBA, who ran a marine construction company and whose PTA interest was piqued when he volunteered to roleplay as a patient to help his wife, then attending PTA school herself
    • Gail Newsome, PTA, BBA, owner of a marketing company who encountered physical therapy after a breast cancer diagnosis, and who entered PTA school at 55
    • Walter Latapie, PTA, business manager and owner of an auto repair shop who says, "I used to fix cars. Now I help fix people"
    • Angie Sawdy, PTA, BS, who sold real estate with her husband but whose background in ballet and yoga pulled her toward the PTA path
    • Lisa Zemaitis, PTA, BS, former cosmetologist and stay-at-home mom who fulfilled a promise she made to a physical therapist who helped her overcome a rotator cuff tear
    • Chris Garland, PTA, BS, who worked as a graphic designer but had been intrigued by physical therapy after seeing how it helped her mother recover from dual anterior cruciate ligament repair
    • Doug Slick, PTA, BM, a working musician whose transition to PTA allowed him to pursue a career he loves while rediscovering the joy of music—this time as a hobby, not a job

    "First Choice for a Second Career" is featured in the July 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.

    APTA Comments on SNFs, IRFs, and Inpatient Payment – And on Medicare as a Whole

    'Tis the season: the time of year when the US Centers for Medicare and Medicaid Services (CMS) accepts public comment on next year's batch of proposed rules. This time around, CMS changed things up a little, asking that in addition to feedback on specific rules, commenters also weigh in on how the entire system could be more transparent, flexible, simple, and innovative. APTA obliged.

    APTA's overarching comments were provided in the association's responses to proposed rules for the 2018 prospective payment systems for acute care facilities, skilled nursing facilities (SNFs) prospective payment system, and inpatient rehabilitation facilities (IRFs) prospective payment system. While each comment letter addressed specific provisions of the individual rules, APTA included general comments advocating for changes to some Medicare policies related to the therapy cap, direct access provisions, and physical therapist (PT) use of telehealth, among other areas.

    Although CMS can't end the therapy cap—APTA is advocating for a bill in Congress proposing just that—the association does suggest that CMS address problems that arise when patient hospital stays are reclassified by auditors after the fact as "observation status" stays. That reclassification means that therapy cap limits, designed for use in outpatient settings, inappropriately kick in at hospital admission. APTA is encouraging CMS to develop an exception policy for these patients.

    APTA also pressed for CMS to look for ways to facilitate greater PT involvement in telehealth. As with the therapy cap, the actual addition of physical therapy to the list of telehealth services included for coverage is something that requires a change in law; however, ATPA believes that new alternative payment models increasingly being introduced by CMS open up opportunities for coverage.

    "As CMS continues to develop new and innovative models, we encourage the agency to maximize the ability of multiple types of providers, including physical therapists, to have the flexibility to use telehealth services to effectively manage patient care," APTA wrote in its comments.

    Direct access was another topic covered in APTA's letters, with the association arguing that "CMS should adopt a broad policy that eliminates physician referral requirements for physical therapy services to improve patients' access to … medically necessary care."

    APTA argued that "physician authorization requirements inadvertently create significant delays in the provision of physical therapy services to individuals who would benefit from treatment by a [PT]. These delays often lead to higher costs, decreased functional outcomes, and frustration to patients."

    All 3 comment letters are available on the APTA website as downloadable pdf files. Here's a quick recap of each.

    Inpatient Prospective Payment System (PPS) proposed rule comments (PT in Motion News summary here)
    The proposed rule would increase payments to acute care hospitals by 2.9%, but long-term care hospitals could see a 3.75% cut. APTA's letter supports a CMS proposal to include dual-eligibility status as a component in calculating penalties, as well as a plan to scrap the current "patient safety for selected indicators" measure in favor of a “patient safety and adverse events composite” measure by 2023, and changes to the priority level of certification requirements for critical access hospitals to reduce administrative burdens.

    IRF PPS proposed rule comments (PT in Motion News summary here)
    IRFs and SNFs would each see a 1% payment increase in FY 2018. CMS also proposes changes to some reporting requirements and value-based purchasing, among other areas. In comments to CMS, APTA stated its support for revamping the existing “pressure ulcer quality” measure and removing the "all-cause unplanned readmission" measures. Additionally, the association agreed with CMS on its plan to update the list of codes on the "presumptive compliance list," a list used to calculate a facility's compliance with the so-called "60% rule" that links payment to treatment of 1 or more of 13 conditions. Also backed by APTA: a proposal to implement survey-based experience-of-care measures.

    SNF PPS proposed rule comments (PT in Motion News summary here)
    The proposed SNF rule contains many of the same elements as the proposed rule for IRFs. APTA was consistent in its support for the quality measure, 60% rule, and patient survey changes proposed by CMS.

    2017 NEXT: Revisit a Great Conference (or See Why You Should Attend in 2018)

    The 2017 NEXT Conference and Exposition held in Boston last month was exciting, inspirational, thought-provoking—and a really good time. If you went, you may feel like reliving it; if you didn't attend you owe to yourself to see what you missed.

    APTA offers 2 ways to check out this year's NEXT event: a storify page packed with videos, photos, and social media posts, as well as an exclusive "PT in Motion News @NEXT" page that collects news stories and videos from the event.