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  • Study: Some Changes in Care Occurred After Jimmo Settlement

    The 2013 Jimmo v Sebelius settlement was supposed to bust the "improvement standard" myth under Medicare Part B, but has the agreement actually made a difference in care? Authors of a new study say yes—but there's more work to be done.

    Authors focused on 2 datasets from Medical Expenditure Panel Surveys—one from 2011–2012, and another from 2014–2015, for a representative sample of 1,183 patients receiving physical therapy and/or occupational therapy. The time periods selected were chosen to provide a before-and-after snapshot of care relative to a 2013 court settlement requiring the US Centers for Medicare and Medicaid Services (CMS) to clearly debunk the idea that Medicare coverage can be extended only if that care will actually improve the patient's condition. The fallacy, known as the "improvement standard," was widely used as the basis for denials of claims for individuals with chronic conditions in need of skilled maintenance therapy.

    Researchers assessed the impact of the Jimmo settlement by looking at changes to the number of physical therapy and/or occupational therapy visits per year, per patient, focusing specifically on the number of individuals who had 12 or more therapy visits during a 12-month timespan. Authors also examined variables including race, body mass index, and geographic region. APTA member Justine Dee, PT, MS, coauthored the study.

    The results, e-published ahead of print in The Archives of Physical Medicine and Rehabilitation (abstract only available for free) show that the treatment landscape did in fact change, with the post-Jimmo patients 1.41 times more likely to have 12 or more visits than those receiving care prior to the agreement. There were no significant demographic or other differences between the groups except for age, which was lower in the postsettlement group.

    Other findings from the study:

    • Overall, the median number of therapy visits pre-Jimmo was 7; that number rose to 8 in the postsettlement group.
    • The total estimated number of Medicare recipients receiving physical therapy or occupational therapy rose between the 2 time periods studied, from 6.3 million in 2011 and 2012 to 9.3 million in 2014 and 2015.
    • Prior to Jimmo, nonwhite patients were slightly more likely than white patients to receive extended therapy, with adjusted probability for nonwhite patients estimated at 0.39 compared with a 0.21 probability for whites. After Jimmo, those probabilities reversed, with a 0.30 probability for whites, and a 0.23 probability for nonwhites. Authors describe the reasons for the change as "obscure" but write that the difference did seem to diminish over the time period studied.

    "We can estimate that, at a minimum, the Jimmo settlement will increase utilization by about 12 million visits per year," authors write. "Given typical reimbursements of $80 per therapy visit, costs will increase by approximately $960 million/year. However, if outpatient therapies can help minimize functional decline, avoidable hospitalizations, and nursing home admissions, the Jimmo settlement may result in lower total costs."

    Other stakeholders, including APTA, have reason to believe that utilization numbers may continue to rise, given CMS' weak efforts at getting the word out about Jimmo to its contractors between 2013 and summer of 2017. Last year, the agency was ordered to step up its communications around Jimmo by a federal judge who found that CMS wasn't living up to its end of the settlement agreement.

    "It's likely that numbers are higher now that CMS is doing a better job of education," said Kara Gainer, director of regulatory affairs for APTA. "But now isn't the time for CMS to let up; if anything, CMS needs to be doing even more on Jimmo, particularly in relation to payment changes in the home health and skilled nursing facility settings, where maintenance therapy can play a major role." APTA offers multiple resources related to the Jimmo settlement and the broader concept of skilled maintenance at a webpage devoted to the topic.

    Authors acknowledge that other national health care policy changes also may affect the numbers they observed, but they echo Gainer's perspective that CMS shouldn't take its eye off the ball when it comes to education around Jimmo.

    "Although we do see a change in utilization, the [Center for Medicare Advocacy, one of the groups that brought the Jimmo case to court] and other organizations continue to report that many [Medicare Administrative Contractors] are still requiring that patients demonstrate improvement as a condition of continued coverage. Education and support of the Jimmo settlement guidelines need to continue to ensure that patients are not being inappropriately denied their Medicare benefits."

    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.