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  • Time to Act: CMS Proposes Significant 8% Cut to Physical Therapy in 2021

    In this review: APTA's response to a CMS plan to cut Medicare physician fee schedule (PFS) reimbursement for physical therapy providers by 8% beginning in 2021. The reduction for 2021 is included in the proposed 2020 PFS.
    Proposed 2020 Physician Fee Schedule (see table 111, p 1187)
    CMS Fact Sheet
    CMS press release

    The big picture: a proposed 8% cut in Medicare reimbursement for physical therapy providers in 2021
    Deep within the proposed 2020 PFS, CMS reveals a plan that puts Medicare beneficiary access to physical therapy at risk by way of an estimated 8% cut to fee schedule reimbursement in 2021. CMS says the reductions, which affect multiple providers to different extents, are driven by changes to reimbursement formulas for evaluation and management (E/M) services furnished by physicians and some other providers.

    APTA's message to CMS: significant cuts to fee schedule reimbursement for physical therapy providers will put challenging and likely unsustainable financial pressures on physical therapists (PTs), particularly in rural and underserved areas where access is already limited. As more PTs feel this pressure and opt out of treating Medicare beneficiaries—or close their doors altogether—patient access to care will suffer.

    "The changes to reimbursement for office/outpatient E/M codes itself are positive ones and we fully support access to primary care services, but the idea that these changes must be accompanied by deep cuts to other crucial services is outrageous," said Kara Gainer, APTA's director of regulatory affairs. "At a time when our aging population is in need of greater access to physical therapy, with its proven benefits and track record for reducing overall costs, CMS has instead decided to turn its back on the facts and put patients at risk."

    What we're doing—and what you can do (before September 27)
    We're preparing a formal comment letter to CMS, but that's just a part of APTA's efforts. Because the proposal affects multiple providers, from PTs and occupational therapists to clinical social workers, clinical psychologists, ophthalmologists, optometrists, and chiropractors, we're circulating a provider organization sign-on letter objecting to the cuts, and we're working with the American Occupational Therapy Association to develop an additional sign-on letter to be circulated among members of Congress.

    Even more important, we're urging APTA members to bring their individual voices to bear on this issue. We've created a customizable template letter that makes it easy to let CMS know how these proposed cuts will pose a real danger to Medicare beneficiaries and negatively impact PTs' ability to practice under Medicare. Make sure you get your comments to CMS by the September 27 deadline (the template letter includes instructions on how to submit to CMS).

    Tip: this letter is the second template letter we've created in response to the 2020 PFS. The first addresses the problematic physical therapist assistant/occupational therapy assistant coding modifier plan, and is still available for download. If you haven't yet completed and submitted that letter, you can combine it with the letter on the reimbursement cuts.

    What's next
    Deadline for comments is September 27, and the final rule will likely be issued by November 1. In addition to the sign-on letters described above, APTA and several other provider associations will meet with CMS officials in mid-September to share concerns and provide recommendations on a range of issues related to the PFS.

    APTA Launches New ‘Find a PT’ and ‘ChoosePT.com’ Website to Support Consumer Awareness

    Every day, people choose physical therapy for a multitude of reasons, from managing pain to building healthy lifestyle habits. Now APTA's consumer-focused website has a new name—and a new look—to support that reality and help connect patients with physical therapists (PTs) through an enhanced "Find a PT" feature.

    This week, APTA unveiled ChoosePT.com, a consumer website that replaces MoveForwardPT.com, now retired after 10 years. The new site is a best-of-both-worlds combination of 2 of the association's most high-profile and far-reaching initiatives—APTA's popular online source for consumer-oriented health information, now operating under a name that leverages the power of the association's award-winning opioid awareness campaign. The ChoosePT site is expected to receive more than 4 million visitors in 2019, with anticipated increases in the coming years.

    The transition to ChoosePT does not significantly change the content on the former MoveForwardPT site, which still includes information on symptoms and conditions, prevention, and pain management, as well as access to podcasts and videos that deliver powerful messages about the difference physical therapy can make in people’s lives.

    But not everything's the same: The changeover has allowed APTA to make improvements to the site's "Find a PT" directory, an APTA member benefit for physical therapists, that makes it easier for consumers and other providers to filter results by practice focus or specialization.

    The upgraded feature is an opportunity that members shouldn't miss, according to Jason Bellamy, APTA's executive vice president of strategic communications.

    “Millions of people will visit ChoosePT.com this year, and one of their most common destinations will be Find a PT," Bellamy said. "APTA members should ensure their information is up-to-date, and add a headshot to make their profile more appealing. Our message to members is, 'do everything you can to help consumers choose you.'"

    ChoosePT.com is also enhanced by geolocation technologies that, with a user's permission, create an online experience customized to the user's physical location. APTA state chapters that have an active geolocation page—49 to date—can add state-specific information to the ChoosePT site, providing visitors with an additional depth of relevant information.

    Bellamy believes the change to ChoosePT.com is the right move at the right time, with more exciting changes coming around the corner.

    “When we launched our opioid awareness campaign we knew our #ChoosePT message was dynamic enough to extend beyond the safe management of chronic pain,” Bellamy said. “With APTA’s centennial approaching in 2021, and the public awareness opportunities that will provide, this was the perfect time to make that our primary call to action.”

    Want t-shirts with the new ChoosePT logo? They're available here.

    New Rule Allows CMS to Deny Enrollment to Providers 'Affiliated' With Sanctioned Entities

    In this review: US Centers for Medicare & Medicaid Services (CMS) Medicare, Medicaid, and Children's Health Insurance programs; Program Integrity Enhancements to the Provider Process (final rule)
    Effective date: November 4, 2019
    CMS Press Release

    The big picture: a new level of authority for CMS
    CMS has released a final rule that gives it the power to revoke Medicare, Medicaid, and Children's Health Insurance Program (CHIP) enrollments of providers or suppliers who have an "affiliation" with previously sanctioned entities, even if those providers and suppliers aren't directly violating any existing rules themselves. CMS says the new authority will help to "stop fraud before it happens."

    While APTA supports efforts to reduce waste, fraud, and abuse in all areas of health care, we believe this rule may create more problems than it solves, particularly given an overly broad definition of what constitutes an "affiliation." The likely result: undue administrative burden for providers and suppliers who have been compliant from the start.

    The rule goes into effect November 4.

    Notable in the final rule

    • "Affiliations" authority. Under the new rule, all Medicare, Medicaid, and CHIP providers must disclose current or past affiliations with any organization that has uncollected debt, has had a payment suspension under a federal health care program, has been excluded from a federal health care program, or has had billing privileges denied or rescinded. If they don't disclose, CMS reserves the right to prevent them from participating in Medicare, Medicaid, and CHIP. These affiliations must be reported even if the other organization was not enrolled in Medicare, Medicaid, or CHIP at the time of the relationship.

    What's an "affiliation"? CMS provides 5 definitions:

    1. Direct or indirect ownership of 5% or more in another organization
    2. A general or limited partnership interest, regardless of the percentage
    3. An interest in which an individual or entity "exercises operational or managerial control over, or directly conducts" the daily operations of another organization, "either under direct contract or through some other arrangement"
    4. When an individual is acting as an officer or director of a corporation
    5. Any reassignment relationship
    • Expanded authority to revoke Medicare enrollment for other reasons. The final rule also gives CMS more power to revoke or deny Medicare participation for providers or suppliers who do any of the following:
    • Try to come back into the Medicare program under a different name.
    • Bill for services or items from noncompliant locations
    • "Exhibit a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs."
    • Owe CMS money from an overpayment referred to the US Treasury Department.

    Concerns
    When the rule was first proposed in 2016, we voiced our concerns in a comment letter that characterized the plan as an overly burdensome one that would prove costly for providers and, ultimately, decrease patient access to care as providers downscaled or ended their participation in Medicare. Not much has changed since then

    Between the extremely low 5% ownership threshold that triggers disclosure (APTA proposed a 25% bar), the requirements that providers disclose relationships with affiliates who weren't enrolled in Medicare at the time, and a poorly defined "lookback" requirement that puts a 5-year limit on how far back a provider must scour its records for bad-actor affiliates but no similar timeframe on how long ago that affiliate's violations may have occurred, the new rule is burdensome to say the least.

    Under the rule, we wrote, "providers and suppliers will be forced to become private investigators to determine whether an affiliate ever had its enrollment denied, revoked, or terminated. We believe this is simply not feasible and will divert time that physical therapists could spend on improving the quality of patient care rather than on regulatory requirements that will not make the Medicare program appreciably safer."

    Where things stand
    According to Kate Gilliard, APTA senior regulatory affairs specialist, now that the rule is final, the emphasis should be on monitoring for impacts and reporting problems to strengthen APTA's advocacy for changes in future versions.

    "It's clearly important for CMS and the physical therapy profession to make every reasonable effort to eliminate fraud in health care, and APTA will continue to work toward that goal," Gilliard said. "But this rule threatens to sacrifice patient access to care for the sake of a shotgun approach to the problem, adding further unnecessary burden to providers who already follow the rules. That's the message we will continue to bring to CMS."

    The new rule goes into effect November 4. APTA will provide information on how to comply with the new requirements as it becomes available.

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    Posture and Movement Coordination, Sensorimotor Integration May Affect Motor Skills in Children With Autism

    In this review: Postural Control and Interceptive Skills in Children With Autism Spectrum Disorder
    (PTJ, August 2019)

    The message

    In children with autism spectrum disorder (ASD), problems with sensorimotor integration and difficulty in coordinating posture and arm motions may result in impaired motor planning and control. These children also exhibited fewer anticipatory postural adjustments and demonstrated more corrective control during arm movements. Compared with typically developing peers, children with ASD were less likely to use visual cues to plan for motions required to catch an item, such as a ball.

    The study

    To examine the interplay of sensory cues, postural demands, and arm movement during ball-catching, researchers in Taiwan asked children with and without ASD to catch a ball rolling down a ramp toward them. Of the children, 15 had ASD and 15 were typically developing age- and sex-matched peers.

    During the task, each child was asked to catch a foam ball rolling down 3 stationary tubular ramps inclined at 4 degrees. The first ramp was placed directly in front of the child, while 2 others each were placed 35 degrees to the left and right. The first 59-centimeter section of each ramp was enclosed so that the child could not see the ball. A sensor within the tube activated a beep as the ball passed through, and, to test catching with and without visual cues, a second sensor lit up an arrow sign during half of the catching attempts.

    A real-time motion-capture system measured the children's arm movements while catching the ball. The authors measured center of pressure (COP) displacements using a computerized pressure plate and recorded ball-catching on video, both synchronized with the motion capture system.

    Findings

    • Children who were typically developing had a significantly higher success rate for all 3 ramps than did their peers with ASD.
    • Children with ASD were more successful in catching on the left side and right side ramps than they were in catching on the center ramp.
    • Visual pre-cues had no effect on rates of ball catching. However, children with ASD used visual information to plan their arm movements significantly less often than did their typically developing peers.
    • Overall, children adjusted their posture before moving their arms in nearly half of catching attempts. While children with ASD had a lower rate of postural adjustment for lateral ramps compared with their peers, all of the children were more likely to adjust their posture for lateral directions than they were for the middle ramp. Children with ASD made anticipatory postural adjustments later than did children who were typically developing, and all children adjusted their posture earlier when presented with visual pre-cues.
    • Amplitude of shoulder excursion was greater in children with ASD, and was higher overall when visual pre-cues occurred. In contrast, elbow displacements were larger when no visual pre-cues were present. Visual pre-cues were associated with slower arm movements for lateral catches. In general, children with ASD moved their arms faster than did their peers.
    • During lateral catches, both groups demonstrated larger COP displacements and greater COP velocity, but visual pre-cues resulted in slower COP velocity.
    • Children with ASD demonstrated more corrective control during arm movements than did their typically developing peers.

    Why it matters

    Physical therapist interventions for children with ASD, the researchers write, "could focus on the integration between perception and motor components as well as motor adaptability of the motor skills."

    Related APTA resources

    The association offers a Cochrane systematic review and several clinical practice guidelines through the PTNow resource area. Individuals who want to learn more about physical therapist treatment for autism spectrum disorder can visit APTA's consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association's consumer website.

    Keep in mind…

    The study excluded children with intellectual disability and attention deficit and hyperactivity disorders, which might reduce generalizability to the entire ASD population. Also, the small sample size limited the authors' ability to analyze the effect of any comorbidities.

    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, where's you'll also find a clinical summary on Autism Spectrum Disorder in Children.

    New Clinical Guidelines Find Strong Evidence Supporting Exercise Therapy for Knee Pain

    In this review: Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association
    (The Journal of Orthopaedic and Sports Physical Therapy, September 2019)

    The message    
    It's all about movement: In its first-ever comprehensive clinical practice guideline (CPG) on patellofemoral pain (PFP), APTA's Academy of Orthopaedic Physical Therapy (Academy) lays out a set of recommendations that stress exercise therapy as the best approach to improve functional performance in the short, medium, and long term. But that's just 1 facet of the guidelines, which also include recommendations on diagnosis, classification, and examination.

    The study
    A panel of content experts from the Academy conducted an extensive review of scientific articles associated with PFP from 1960 to 2018, evaluating each for its evidence related to physical therapist (PT) clinical decision-making around the condition. From an initial field of 4,691 articles, reviewers winnowed the studies down to 271 that addressed diagnosis and classification (120), examination (56), and interventions (95). The panel then analyzed the overall strength of evidence, and shared a draft of its recommendations with members of the Academy and, later, with a panel of consumer representatives and other stakeholders that included claims reviewers, coding experts, researchers, and academic and clinical educators.

    Recommendations were assigned letters according to the strength of the evidence evaluated: A-"strong," B-"moderate," C-"weak," D-"conflicting," E-"theroretical/foundational," and F-"expert opinion."  

    Among the Recommendations
    Recommendations within the following CPG categories include:

    • Interventions. CPG authors found strong evidence supporting exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve outcomes, stressing that a combination of hip and knee exercises is better than a focus on knee exercises alone.
      The guidelines also find strong evidence that dry needling shouldn't be used for PFP, and moderate evidence that clinicians should stay away from the use of "biophysical agents" including ultrasound, cryotherapy, electrical stimulation, and laser treatments.
      Taping was supported by moderate-level evidence. The guidelines state that clinicians should combine physical therapist interventions such as foot orthoses, taping, mobilizations, and stretching when appropriate, but that "exercise therapy is the critical component and should be the focus in any combined intervention approach."
    • Diagnosis. Use of diagnostic tests that reproduce retropatellar or peripatellar pain during squatting received an A-level recommendation as a diagnostic tool, as did "performance or other function activities that load the patellofemoral joint in a flexed position, such as stair climbing or descent."
    • Examination. Strong evidence supports the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub¬scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-PF), and the visual analog scale (VAS) for activity or the Eng and Pierrynowski Questionnaire (EPQ) as ways to measure pain and function. Moderate-level evidence supports the use of "clinical or field tests" that reproduce pain and allow for assessment of movement. Authors write that "these tests can assess a patient's baseline status relative to pain, function, and disability; global knee function; and changes in status throughout the course of treatment."
    • Classification. The guideline panel found no "previously established valid classification system" for PFP, so it developed one. The system is based on impairment and function-based categories that include overuse/overload, muscle performance deficits, movement coordination deficits, and mobility impairments.


    Why the CPG Matters
    PFP is estimated to affect 1 in 4 adults every year, with women reporting knee pain twice as often as men do. Authors of the CPG write that while the recommendations shouldn't be considered a standard of care that guarantees a successful outcome for every patient, they are a reflection of the best-available evidence around the condition. They add that "significant departures" from the CPG "should be documented in the patient's medical records."

    APTA's Role
    The association provided funding and technical support during development of the CPG. This support is part of an ongoing APTA initiative to work with its sections and academies to produce a range of guidelines that highlight the evidence base for physical therapy in treatment of a variety of conditions. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    3D Technology: All That's Fit to Print?

    When it comes to 3D printing and physical therapy, the future is now—well, almost now.

    In the September issue of PT in Motion magazine: "A New Dimension to Physical Therapy," a feature article that explores the current use of 3D as well as its challenges and possibilities, as seen through the eyes of physical therapists (PTs), a physical therapist assistant (PTA), and a professor of visual arts who heads the University of North Georgia's 3D printing efforts.

    The APTA members interviewed for the story say that in many ways 3D printing has arrived in physical therapy—and already is allowing for the creation of customized equipment and devices, many of which can be produced relatively quickly, and some at a fraction of the cost of their non-3D printed counterparts. The possibilities for orthotics and adaptive equipment for pediatric patients are just some of the reasons the interviewees are excited about the technology's future.

    "Future," however, is the key word: While 3D technology has improved dramatically since its debut in the 1990s, refinements still are needed. And the cost of the devices—particularly those capable of manufacturing with multiple materials—must come down before they become standard equipment in a physical therapy clinic.

    The challenges aren't just technological—a clinic has legal and regulatory considerations should it decide to go all-in on 3D printing now or in the future. Patient safety is an issue, of course, but so is the line between a clinic that produces the occasional customized orthotic and an equipment manufacturer, and the attendant regulatory oversight that entails.

    Still, those challenges shouldn't overshadow 3D printing's potential in physical therapy, and they certainly shouldn't cause physical therapy education programs to shy away from incorporating 3D printing concepts into their curricula.

    Robert Latz, PT, DPT, who was interviewed for the article, says there's good reason for practicing PTs and physical therapy students to keep up with the technology and not wait until it's perfected.

    "We need to learn the technology and apply the development process to this new technology," Latz says in the article. "If we do not do this, someone else will. I guarantee that the technology of 3D printing is only going to continue to improve and that the cost to create with this technology will continue to decrease."

    "A New Dimension to Physical Therapy" is featured in the September issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Also open to all: highlights from the 2019 APTA NEXT Conference and Exhibition.