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  • Major Health Industry Groups Look to Streamline Prior Authorization

    While prior insurance authorization may be right up there with death and taxes when it comes to life's certainties, 6 major health industry groups believe the process could be much improved.

    The American Hospital Association, America's Health Insurance Plans, the American Medical Association, the American Pharmacists Association, BlueCross/BlueShield, and the Medical Group Management Association issued a consensus statement outlining 5 ways the health care system could "improve the [prior authorization] process, promote quality and affordable health care, and reduce unnecessary burdens." Those 5 areas are:

    Selective application of prior authorization. The consensus letter argues for basing application of prior authorization on "provider performance on quality measures and adherence to evidence-based medicine or other contractual agreements."

    Regular reviews of prior authorization and adjustments for volume. "Regular review of the list of medical services and prescription drugs that are subject to prior authorization requirements can help identify therapies that no longer warrant prior authorization due to, for example, low variation in utilization or low prior authorization denial rates," according to the statement.

    Better communication and transparency. The group calls for improved communication between health plans, providers, and patients "to minimize care delays and clearly articulate prior authorization requirements, criteria, rationale, and program changes."

    Attention to continuity of care. The statement identifies continuity of care as "vitally important" and urges "additional efforts to minimize the burdens and patient care disruptions associated with prior authorization."

    More automation. "Moving toward industry-wide adoption of electronic prior authorization transactions based on existing national standards has the potential to streamline and improve the process for all stakeholders," the group states in the letter.

    "This consensus statement is a step in the right direction," said Elise Latawiec, PT, MPH, APTA staff lead for practice management. "The areas noted in the statement align very closely with APTA's positions on relieving administrative burdens and its efforts to explore potential solutions, and we are looking at ways to support and collaborate on this important effort."

    Ohio Workers' Comp Program Requires Nonsurgical, Nonopioid Treatment of LBP as a First Step

    In what the Associated Press (AP) describes as "a groundbreaking guideline," the Ohio agency that oversees that state's workers' compensation program has rejected spinal fusion surgery and opioid prescriptions as an early response to back pain. Instead, the state now requires that all workers with work-related back injuries undergo at least 60 days of nonsurgical care, including physical therapy, while avoiding opioids, before pursuing other treatments.

    According to an AP article published in The New York Times, Ohio isn't the first state to restrict payments for surgery, but its approach includes a new twist: including a warning on the use of opioids. The Ohio rule stipulates that the 60 days of "alternative" treatment must be accomplished while avoiding opioid use if possible, an approach that NYT says is "more aggressive than other states that also decline to pay right away for the surgery."

    In the report, the Ohio Bureau of Workers' Compensation defended the move by citing research showing that spinal fusion surgery is "often ineffective," can lead to complications, and may result in increased opioid use postsurgery. The policy went into effect on January 1.

    APTA Physical Therapy Outcomes Registry Again Receives CMS Designation for MIPS Reporting

    APTA's Physical Therapy Outcomes Registry (Registry) has been approved again by the US Centers for Medicare and Medicaid Services (CMS) as a qualified clinical data registry (QCDR). The designation for 2018 means that physical therapists (PTs) who participate in the Merit-based Incentive Payment System (MIPS) program can submit their data directly from the Registry, but the CMS approval is also an acknowledgment that APTA offers a robust, reliable system for tracking and benchmarking patient outcomes.

    Although voluntary for now, PT participation in MIPS could be mandatory as early as 2019, making it important to become familiar with the system (APTA encourages eligible PTs to voluntarily participate in MIPS now).The Registry’s QCDR status will be particularly helpful for practices whose electronic health records (EHRs) do not have the capability to report directly to MIPS.

    According to Heather Smith, PT, MPH, APTA's director of quality, the value of the Registry goes well beyond MIPS data submission.

    "Registry data will allow physical therapists to understand their treatment patterns, interventions, and outcomes for specific patient populations," Smith said in an APTA news release. "In everyday practice, PTs then use the information objectively to evaluate how a patient, a group of patients, or a population of patients are cared for."

    Registry users can access nonproprietary outcomes measures supported by CMS, as well as measures specific to particular EHR systems. In addition, APTA has begun the process of developing its own quality measures. The Registry also will include region/disease-specific treatment and outcome modules to help PTs treat patients according to established clinical practice guidelines. The first such module, focused on congenital muscular torticollis, is now under development through a partnership between APTA and the Academy of Pediatric Physical Therapy.

    The Registry enables PTs to make improved, data-informed clinical decisions, track and benchmark outcomes against industry data, and demonstrate the value of physical therapist services to payers and fellow providers. It directly integrates with multiple third-party EHR systems. For more information about the Registry, visit www.ptoutcomes.com.

    Headed to the APTA Combined Sections Meeting in February? Check out the Registry booth at the APTA Pavilion, the Registry poster session on February 23, and 2 related presentations: "A Multi-Dimensional Data Collection System (#2145)" and "Balancing Inclusion and Use of Outcomes Instruments in the Registry (#2144)."

    APTA Board Recommends Further Exploration of Education Reform Through Education Leadership Partnership

    Mandatory residency that integrates specialty certification? Staged licensure? Someday, physical therapist (PT) education could include any or all of those things, as education inevitably evolves to meet the needs of society, the profession, and the health care system.

    But APTA will not be pursuing any of those paradigm-changing options right now.

    That much is clear after APTA’s Board of Directors (Board) adopted multiple motions related to the pursuit of best practice in clinical education at their November meeting. The motions were the result of recommendations from a task force appointed to respond to a 2014 charge from APTA’s House of Delegates (House) to investigate the future of physical therapist education (RC 12-14 and RC 13-14).

    The Board’s actions in November, which included amendments to the task force’s original recommendations, were the byproduct of months of extensive stakeholder engagement opportunities designed to generate feedback, including multiple in-person and virtual town halls, an online survey, and a collection of resources at APTA.org about the task force recommendations.

    “What we heard loud and clear from our stakeholder engagement is that the profession isn’t convinced that a highly integrated system of staged licensure and clinical-and-residency education, as originally recommended by the task force, is in the profession’s and ultimately our patients’ best interest right now, and we responded to that feedback,” said APTA President Sharon Dunn, PT, PhD, board-certified orthopaedic clinical specialist.

    “The task force recognized that some of their recommendations would mean massive changes that would take many years to implement, and it was always a priority to ensure that student debt wouldn’t increase as a result," Dunn explained. "Even so, there are too many unknowns in need of further investigation, and too many factors beyond APTA’s direct control, to commit right now to that kind of massive reform. But these conversations on advancing practice and education must continue in order to continue to meet our professional obligations to society.”

    So what happens now?

    Several things, but most simply and most significantly: the Board recommended that the Education Leadership Partnership (ELP) continue to explore the issues and concepts that were proposed as part of this multiyear exploration of PT education.

    The ELP comprises representatives from APTA, the Education Section of APTA, and the American Council of Academic Physical Therapy (ACAPT). It was formed in 2016 to help reduce unwarranted variation in practice by focusing on best practices in education.

    The Board recognized that the ELP is best positioned to pursue concepts identified by the task force, including:

    • Inclusion of clinical education inquiry into the profession’s data management plan and prioritized education research agenda
    • Development of a framework for formal partnerships between academic programs and clinical sites to include defined accountabilities for all parties
    • Development of a structured PT clinical education curriculum that could include elements such as universal definitions for entry-level competencies, the enhancement of the residency and certification process to better complement the standard clinical education experience, and the development of standardized measurement tools to evaluate student competencies at all phases of education
    • Creation of a long-term strategic plan for professional and postprofessional education informed by engagement with relevant stakeholders

    The Board does not have authority over the ELP and thus cannot formally charge the ELP to take specific actions. But by adopting motions to forward various recommendations to the ELP, the Board is demonstrating its trust in that partnership.

    “This whole process is a wonderful illustration of APTA’s ability to bring stakeholders together to examine our present and imagine our future,” Dunn said. “From the original member-generated motions in the House to the outstanding engagement around the task force recommendations, thousands of APTA members and nonmembers provided input that will inform the ELP’s ongoing efforts to achieve best practice in physical therapist education.”

    Final CMS Bundling Rule Reduces Number of Mandated Participants, Expands Possibilities for PTs

    The US Centers for Medicare and Medicaid Services (CMS) has issued a final rule on bundled care that largely mirrors what the agency proposed in August: a scaled back knee and hip joint replacement bundled care model—albeit with more opportunities for participation by individual providers—and cancellation of a plan to expand bundled care models to cardiac care and hip and femur fractures.

    Known as the Comprehensive Care for Joint Replacement (CJR) model, the hip and knee bundle program launched in 2016 was the first-ever attempt by CMS to mandate bundled care. The rule as it now stands applies to 67 different geographic areas covering some 800 hospitals: beginning in 2018, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas. CMS estimates that 430-450 facilities will participate in the CJR next year, a number that includes facilities participating voluntarily.

    In addition to reducing the number of geographic areas required to participate in the CJR, the final rule also follows through on a CMS proposal to switch low-volume and rural hospitals in the remaining 34 areas from mandatory to voluntary participation. A CMS fact sheet summarizes the changes in store for 2018.

    At the same time CMS pulls back on the reach of the CJR, it is making it easier for clinicians, including physical therapists (PTs), to be included as qualifying alternative payment model (APM) participants (QPs) under the Quality Payment Program’s Advanced APM track. By expanding the ways providers can make it onto a CMS "affiliated practitioner list" to include clinicians whose contractual relationship with a facility supports a hospital's CJR goals, the new rule would deepen the pool of providers eligible to receive the Advanced APM 5% incentive payment. CMS will continue to maintain ultimate authority for who does and doesn't qualify as a QP, based on Medicare Part B claims data, but says it won't establish a specific threshold a clinician must meet to be considered supportive of a facility's CJR goals.

    The expansion of the requirements to be considered a QP is good news for physical therapists but is tempered by other factors. The reduction of the number of hospitals in the mandatory program will dampen the effects of the change, as will the fact that the increased participation options apply only to facilities participating in "Track 1" of the CJR program—a version with more stringent requirements that also puts facilities at more financial risk.

    As for expansion of mandatory bundling programs into other areas, that's no longer in the works. Just as proposed, the final rule halts a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to begin in February of this year but were delayed until October 1, and then pushed back again to a January 2018 startup date. The rule effectively cancels those programs altogether.

    CNN Money Looks at Challenges Faced by PTs, Other Providers, Whose Jobs Require Touch in the Workplace

    A recent article in CNN Money looks at the issue of touching in the workplace from the perspective of professions that typically involve physical contact—including physical therapy.

    "No Touching in the workplace. But what if your job requires it?" includes interviews with long-term care workers, a nurse, and Jill Boissonnault, PT, PhD, co-author of a recent study on inappropriate patient sexual behavior (IPSB) involving physical therapists, physical therapist assistants, and students. That study, which appears in Physical Therapy (PTJ), found that 84% of respondents had experienced IPSB at some point during their careers or training, and that 47% had experienced IPSB within the past year. The study is also the subject of a recent PTJ podcast.

    In the CNN article, Boissonnault points out that PTs and other health care workers experiencing IPSB are in a complicated situation that can pit the unacceptability of the patient's actions against the provider's ethical commitment to patient care. "That doesn't mean we would tolerate a client jeopardizing our safety…but the clients' best interests need to be forefront in our minds," she tells CNN.

    'Hollywood' High Tech May See Wide Release in Physical Therapy, but PTs Will Remain Feature Attraction

    Tech site CNET is making the case that technologies such as motion-capture interfaces may be the next big thing in physical therapy, but representatives from APTA are tempering that enthusiasm for virtual reality with a dose of actual reality: there needs to be a real, live physical therapist (PT) involved to evaluate patients and help them get the most benefit from any technology.

    In a recent article titled "Hollywood tech lands a leading role in health care," CNET writer Abrar Al-Heeti writes that cutting-edge video technology is "starting to find its way into physical therapy" in what proponents believe are promising ways. The article focuses on the use of motion-capture technology—the same video-based tracking interface that animated the indigenous characters in Avatar—and virtual reality headsets but also touches on simpler technologies including motion-tracking and video games.

    The CNET article quotes developers touting the ways in which the new technologies could help patients adhere to and properly perform postoperative home exercise programs. "The patient becomes more engaged in their therapy," one analyst tells CNET. "The patient is able to perform therapy at their convenience, at their own time, and their own location."

    Maybe, say Matt Elrod, PT, DPT, MEd, and Hadiya Green-Guerrero, PT, DPT, but not without a PT. Both Elrod and Green-Guerrero are practice specialists at APTA.

    "If somebody has a shoulder problem, just to say 'Go do this technology' is really not the best bet," Elrod tells CNET. "What you need is a thorough evaluation…[and] examination to determine where the dysfunction really is."

    Green-Guerrero points out that at the end of the day, any technology is a tool—and tools require someone who knows how to use them. "Technology can definitely augment what we do as physical therapists [but] those who use it know that it's not a replacement for a physical therapist," she says in the article.

    Washington Post: Female PTs Will Spend Last 4 Weeks of 2017 Working 'For Free'

    Guess what the majority of physical therapists (PTs) will be doing beginning December 2? According to a recent article in The Washington Post, that's when female PTs start working for free for the rest of the year while their male counterparts continue to get paid. And that disparity is actually a bit smaller than the one faced by most women in the workforce.

    The Post article, published on October 26, examines the issue of gender pay gaps by way of establishing "work-for-free" dates in multiple professions—the date after which average wage disparities equate to the lower earning group (almost always women) working without pay for the remainder of the year. On a national level, according to the article, women's salaries are approximately 80% of what men receive, a gap that translates into 10 weeks of work without pay for women. Put into calendar form, that means that when averaged across professions, women began working for free on October 14.

    The physical therapy profession fares better than the national average, with an estimated work-for-free date of December 2 for women. That correlates with an average hourly pay difference of $37.23 an hour for male PTs versus $34.33 per hour for female PTs, according to the article. Data for the report were derived from a study by IPUMS, a census and survey research organization that specializes in microdata.

    The December 2 disparity date for physical therapists is the same as for elementary and middle school teachers. That date is better than the work-for-free date for physicians and surgeons (September 8) and dentists (October 19) but slightly worse than for registered nurses (December 6) and social workers (December 19).

    The article includes graphics, potential causes, and an exploration of various theories that attempt to explain the gap. Those theories include the idea that women tend to choose lower paying jobs ("sort of," the article states), that they choose to work part-time (that's not always by choice, according to the Post), and that younger, more educated women don't experience a wage gap (they do).

    "What this all hints to is that the causes of the gender gap are many and more nuanced than just individual choices or corporate discrimination," writes author Xaquin G.V. "However you slice the data, the gap is there."

    From PT in Motion: The Power and Potential of Clinical Registries

    To succeed in a value-based care environment, all health care providers—including physical therapists—must embrace accountability in the form of standardized patient outcomes data. Clinical outcomes registries are one way many health care professional societies and large health systems are doing so.

    This month’s issue of PT in Motion magazine includes a feature article on clinical outcomes registries such as APTA’s Physical Therapy Outcomes Registry, including a look at how they work, and how practices can increase the power of their electronic health record (EHR) data to inform and improve patient care.

    "Strength in Numbers: The Power and Potential of Clinical Data Registries" explores how other medical professional societies are using registries to collect and analyze outcomes to improve patient care. Nicholas A. Vaganos, MD, a cardiologist whose employer participates in a clinical registry, tells PT in Motion, "When you pay attention to the data…it helps improve your treatment and your documentation."

    The registry directors interviewed for the article share examples of how the findings from large amounts of clinical data can revolutionize the way providers practice by providing real-time insights to supplement clinical practice guidelines. The article includes practical insights from physicians, quality experts, and an EHR software vendor on the nuts-and-bolts of participating in a registry.

    To find out more about APTA's Physical Therapy Outcomes Registry, visit the registry website or email registry@apta.org.

    "Strength in Numbers: The Power and Potential of Clinical Data Registries" is featured in the November 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.

    Final Fee Schedule Rule a Mixed Bag; Outpatient Rule More Positive

    The US Centers for Medicare and Medicaid Services (CMS) has issued final rules for the 2018 Medicare physician fee schedule (PFS) and outpatient prospective payment system (OPPS) that don't vary significantly from the proposed rules released earlier in the year—except when it comes to 1 element involving the current procedural terminology (CPT) codes.

    As in the initial proposal, work relative value units (RVUs) for CPT codes will be maintained under the PFS as per recommendations from an American Medical Association review panel. However, CMS has changed its approach to practice expense RVUs: instead of maintaining those RVUs at 2017 levels as proposed, the agency will adopt the panel's recommendation for some reductions. APTA staff are analyzing the entire rule and will issue a detailed summary in the coming days that will clarify the impact those reductions might have. CMS has issued a fact sheet on the final rule.

    Taken as a whole the final PFS rule contains more good news than bad in the wake of a lengthy review of multiple CPT codes—many of which commonly are used in physical therapy—as potentially "misvalued." The review had put those codes at risk of sizable reductions for both work and practice expense RVUs. While some practice expense RVUs may drop, the final rule includes no cuts to the work RVUs and actually increases values for a few. Initial analysis indicates that overall, the increases and cuts likely balance out.

    More positive news related to the fee schedule: CMS will increase the therapy cap from $1,980 to $2,010 beginning in 2018. The therapy cap landscape could be seeing further changes, however, pending the outcome of an effort in Congress to repeal some elements of the therapy cap process.

    The PFS announcement comes on the heels of a final OPPS rule that also includes provisions supported by APTA—particularly moves toward reimbursement for outpatient-based total knee arthroplasty (TKA) and "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical access hospitals and rural hospitals with fewer than 100 beds. The final rule also mirrors the proposed rule's overall 2% payment increase for outpatient hospitals and a 1.9% boost for ambulatory surgical centers. A detailed APTA summary of the OPPS rule also is in the works. CMS has issued a fact sheet on the final rule.