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  • Defense Department Makes Big Change in Tricare Vendors

    In a major shift, the Department of Defense (DOD) has selected Humana Military and Health Net Federal Services to manage its Tricare health insurance system, parting ways with UnitedHealthcare. The new contracts, worth a combined $59 billion, apply to the program that serves US military members and their families.

    The new contracts will also be built around a new condensed regional system: instead of separate contracts for North, South, and West regions, DoD has established only 2 coverage regions—East and West. Health Net Federal was assigned the $18 billion contract for the 21-state West region, while Humana now has the contract for the 32-state East region, worth $41 billion. Previously, Humana had managed the South region, UnitedHealthcare had managed the East region, and Health Net had managed the West region.

    According to an article in Military.com, DoD is describing the change as a "reorganization," rather than a rebidding process, that will "simplify the system for both government and users."

    "If the contracts are managed well and the handoff is smooth, the change should have very little impact on Tricare beneficiaries, including Tricare for Life users," according to the Military.com article. "But the relationship between beneficiary and contractor can quickly go bad when payments to providers are slow to process or the contractor kicks back to the patient bills for services that should be covered."

    Representatives from DoD say the change will make it easier for beneficiaries to move from region to region, and will facilitate the use of electronic health records (EHR). Federal News Radio reported that under the new contracts, Health Net and Humana will be required to handle all referrals to outside providers electronically and to "ensure private providers can interface" with the EHR system DoD is rolling out in its military treatment facilities.

    APTA is aware that the Tricare reorganization may create issues related to physical therapy reimbursement, and will work on behalf of the membership to address them with DoD and the managed care companies.

    In order to assist APTA in monitoring the effects of the change on physical therapists and physical therapist assistants, members are encouraged to share their experiences with the Tricare changes by emailing advocacy@apta.org with name, member ID, and contact information for staff follow-up.

    CMS Expands Mandatory Bundling Program to Cardiac Care, Including Rehab

    The Centers for Medicare and Medicaid Services (CMS) has announced the latest in its move toward value-based payment systems—this time through the introduction of a mandatory bundling program for care associated with bypass surgery and heart attacks, including provisions that would incentivize the use of cardiac rehabilitation.

    The demonstration plan announced by CMS would affect hospitals in 98 randomly selected metropolitan areas and would work much like the Comprehensive Care for Joint Replacement (CJR) model implemented this year. Similar to CJR, the new bundling plan would reimburse providers a set amount for an entire episode of care, from admission to 90 days after the patient is discharged. Medicare would create targets for spending, and if the total spending is less than the Medicare target, the hospitals may be eligible to receive additional payment from Medicare. If hospitals spend more than the Medicare target, they could be required to pay back Medicare for some portion of the difference. And like CJR, the cardiac bundling plan is mandatory for hospitals in those areas.

    Also included in the cardiac demonstration proposed rule: a proposal to extend the CJR bundling provisions beyond hip and knee arthroplasty to include patients undergoing care for hip and femur fractures. The project would launch July 1, 2017, and last for 5 years.

    "Just like CJR, the model is mandatory and extends to metropolitan statistical areas [MSAs] that include the 67 areas already covered in CJR," said Roshunda Drummond-Dye, APTA director of regulatory affairs. "If PTs want to formally collaborate with hospitals to share in incentive payments, they must negotiate contractually. But the bottom line is, if they are included in one of the identified MSAs and they treat patients within 90 days from discharge from the hospitals after a heart attack, bypass, or hip surgery, the care they provide will count toward the bundle."

    The cardiac program also includes an initiative that would promote the use of cardiac rehabilitation during the 90-day period after discharge. According to a fact sheet from CMS, the initial payment would be $25 per cardiac rehab service for each of the first 11 services paid for by Medicare. After 11 services are paid for by Medicare for a beneficiary, the payment would increase to $175 per service. "Clinical studies have found completing a rehabilitation program can lower a patient’s risk of heart attack or death," CMS writes. "Increasing the use of cardiac rehabilitation services has the potential to improve patient outcomes and help keep patients healthy and out of the hospital."

    Drummond-Dye says that the expanding use of bundling programs is part of a larger shift toward value-based payment models—and something PTs need to be tuned into.

    "One key proposal that uniquely affects PTs is the provision to make CJR and other bundled payment models qualify as alternative payment models under [the Medicare Access and CHIP Reauthorization Act, or MACRA]," Drummond-Dye said. "At first glance, this is good news for our providers, as this gives them more opportunities to participate in alternative payment models and quality programs under MACRA—it's something that APTA advocated for in our comments, and, essentially, CMS listened."

    Meanwhile, APTA advises that PTs stay on top of patient data and evidence to make the bundling models work for them.

    "It is imperative that PTs know the composition of the patient population they treat and have clinical evidence on the outcomes of their care for this patient population," Drummond-Dye said.

     APTA intends to provide comments on the cardiac bundling demonstration by the September 24 deadline, and continues to track implementation of CJR.

    The APTA CJR webpage contains extensive information on both the nuts-and-bolts of the program and the considerations physical therapists should weigh when making practice decisions. The online resource also includes links to evidence-based clinical information and community programs, as well as a free webinar on the system.

    Opioids in the News: Congress Passes Opioid Bill, Medical Marijuana for Pain, the Path From Pain to Addiction, More

    The opioid abuse epidemic, and its relationship to the US health care system's approach to pain treatment, continues to make news. Here are some of the latest reports and features.

    The good news: Congress passed a bill addressing the opioid epidemic, and Obama has promised to sign it.
    The compromise bill awaiting President Barack Obama's signature is largely focused on providing help for the addicted, including allowing more people to have access to naloxone, the drug that can reverse an opioid overdose. The legislation also establishes a grants program, administered through the Department of Health and Human Services, that helps states and community organizations improve treatment and recovery programs, and allows police to divert the addicted to treatment rather than jail.

    The bad news: the bill lacks adequate funding.
    While some legislators applauded the bill as a good first step in battling the epidemic, critics pointed out that the bill does not include funding. Members of Congress say they will take up funding in a separate bill.

    A tragic story of 1 man's journey from pain, to prescription opioid addiction, to heroin.
    Oregon National Public Radio reports on John, a carpenter who now lives in his truck and uses heroin to counter pain from an old injury. Initially treated with opioids, John's prescriptions were reduced, leaving him in pain and ready to seek out illegal drugs.

    Wearable technologies could play a role in the fight against opioid abuse.
    A company has developed a wristband equipped with biosensors that can help identify when an individual with an addiction has relapsed.

    Could the use of medical marijuana for pain treatment help to decrease opioid use rates?
    In "What Can't Medical Marijuana Do," the Atlantic looks at claims that in states with legal medical marijuana, opioid prescriptions for pain treatment are as much as 12% lower than in states that prohibit medical marijuana.

    One state's attempt to curb opioid abuse through its Medicaid program has created controversy …
    Maryland Medicaid beneficiaries with opioid addictions had been receiving suboxone film to help curb their cravings. Claiming that the drug, delivered in the form of a paper strip, is too easily diverted and winds up being itself abused, the program has switched to Zubsolv tablets. Individuals who receive the treatment say it doesn't work nearly as well. "This is taking patients who are stable, who are doing really well, and saying we're going to do something to disturb how well you're doing," 1 physician told National Public Radio.

    … While other states look at the relationship between opioid addiction and housing.
    Government and community leaders from some Northeast states gathered recently to talk about how individuals addicted to opioids often face homelessness or substandard housing, and how improvements in affordable housing could in turn decrease drug use.

    APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign, an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign will unfold throughout 2016 and include national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    ACA Anti-Discrimination Rule for Health Care Providers, Payers Takes Effect July 18

    In a combination of changes that codify longstanding guidance and expand definitions, the Department of Health and Human Services (HHS) will very soon implement an anti-discrimination rule that could alter the ways some providers and payers manage care.

    Beginning July 18, health care providers and payers that accept federal dollars will be subject to a provision of the Affordable Care Act barring discrimination in care and coverage on the basis of race, color, national origin, age, disability, and sex. As with other similar changes at the federal level, the new rules include gender identity discrimination in the definition of sex discrimination—meaning, among other things, that individuals must be allowed to enter the restrooms, hospital wards, or other gender-restricted areas that are consistent with their gender identity.

    Although the subject of media attention, the clarifications around facility use are just a small part of a rule that also codifies guidance to ensure access (including free language assistance services) to individuals with limited proficiency in English, prohibits health insurance benefit designs that discriminate against individuals who are transgender, and calls for "reasonable" accessibility changes to avoid discrimination based on disability.

    The Kaiser Family Foundation reports that the new rule does not resolve whether the definition of sex discrimination includes discrimination based on sexual orientation alone, nor does it set specific standards for medical equipment for people with disabilities.

    "The rule does not explicitly require insurers to cover gender-transition treatments such as surgery," according to an article in Modern Healthcare. "But insurers could face questions if they deny medically necessary services related to gender transition for a man who identifies as a woman, or a woman who identifies as a man."

    How can physical therapists and physical therapist assistants best respond to the needs of a patient or client who is transgender? Check out the open-access cover story on working with this population in the July issue of PT in Motion magazine.

    Proposed CMS Rule Aims to Tackle Medicare Appeals Backlog

    In response to pressure to do something about a growing backlog of Medicare appeals, the Centers for Medicare and Medicaid Services (CMS) has proposed a new rule that it hopes will make the system more functional through, among other measures, expanding ways to set precedent and extending some adjudicatory powers to attorneys.

    The proposed rule seeks 2 major changes to the Medicare appeals process: the first update would allow the US Department of Health and Human Services' Department Appeals Board to select certain cases to be "precedential," meaning that the rulings would be binding on all future decisions. The idea behind the change is to give those considering making an appeal more resources to help them decide if the effort is worth pursuing, and to provide judges with a body of cases to reference when deciding on new appeals.

    The second major proposal would allow senior attorneys to serve as "attorney adjudicators" with the power to issue decisions in circumstances in which an appeal does not require a hearing, is dismissed, or needs to be remanded for more information. In addition, parties involved in an appeal could waive their right to a hearing and allow the attorney adjudicator to review the case.

    APTA is reviewing the proposed rule and will provide comments on behalf of membership by the August 29 deadline. Those comments will be posted at the association's website.

    Proposed Physician Fee Schedule: New Evaluation Codes, Same Payment

    With the release of the 2017 proposed physician fee schedule, the Centers for Medicare and Medicaid Services (CMS) is giving physical therapists (PTs) their first glimpse of a coding system that acknowledges varying levels of complexity in evaluations—though, for now, there is no difference in payment rates among those levels, and no changes from 2016 rates. Instead, CMS is calling for educational efforts to train PTs on how to appropriately use the new system. In addition, CMS continues its review of potentially misvalued codes, which includes 10 commonly used physical therapy codes.

    The proposed rule, which covers Medicare Part B services that apply to PTs, physicians, and other providers, incorporates work done by the American Medical Association (AMA) CPT Editorial Panel to retool current procedural terminology (CPT) codes for evaluation and reevaluation. PT in Motion News will publish more information on the rule in the coming days, based on an APTA staff analysis of the entire document. In the meantime, here are some features of the new rule that affect PTs.

    Evaluation codes will be tiered—pricing won't.
    CMS’ proposal adopts much of the system created by the CPT Code Editorial Review Panel. The new evaluation code descriptors stratify evaluations by complexity—low, moderate, and high—but in a departure from recommendations from the American Medical Association's Relative Value Scale Update Committee, they will be priced as a group rather than individually. That means CMS will keep the longstanding relative value unit (RVU) of 1.20 for all 3 levels of evaluation. The proposed rule also includes 1 reevaluation code with an RVU of .60.

    Education on the new codes will be key.
    The proposed rule calls for extensive PT education on how to appropriately code using the different evaluation levels—an effort that will be led by APTA. The association will provide detailed information on how to differentiate the number of personal factors that actually affect the plan of care and how to select the number of elements from any of the body structures and functions, activity limitations, and participation restrictions to make sure there is no duplication during the PT's examination of body systems.

    Work on potentially misvalued codes will continue, but look for changes in 2017.
    CMS has identified multiple potentially misvalued codes, including 10 commonly used in physical therapy, and has acknowledged that APTA and other specialty groups are working to develop proposed coding changes through the CPT process. In the meantime, CMS is looking for input on values. The potentially misvalued codes associated with physical therapy are: electrical stimulation, ultrasound therapy, therapeutic exercises, neuromuscular reeducation, aquatic therapy/exercises, gait training therapy, manual therapy (1/regions), therapeutic activities, self-care management training, and electrical stimulation (other than wound).

    The bottom line, however, is that Congress has set a .5% target for all misvalued codes in 2017 (not just the physical therapy-related ones). CMS believes that if the total misvalued code changes can account for a .51% reduction in net expenditures, it can avoid mandating a broad overall reduction in payment for services.

    At this point, payment rates for 2017 are unclear.
    Besides the fact that CMS doesn't publish conversion rates until it issues its final rule (usually late October/early November), the Medicare Access and CHIP Reauthorization Act (and elimination of the sustainable growth rate last year), coupled with the work on misvalued codes, make this year's situation somewhat different from previous years. MACRA is targeting a .5% update, but final payment rates will also be affected by the projected .51% reduction in the misvalued codes.

    CMS thinks allowing PTs to code for telehealth would take an act of Congress—literally.
    While CMS proposes to add several codes to the list of services eligible to be provided by way of telehealth, it's not going to add any physical therapy services to that list. Why? According to CMS, PTs are not listed in statute as authorized providers of telehealth services—and changing that would require congressional action.

    The rule also proposes tightening self-referral provisions, instituting new Medicare Advantage provider requirements, and introducing a new diabetes prevention program.
    With other notable provisions in the proposed rule, CMS hopes to smooth out a wrinkle that allowed a self-referral physician to levy per-unit rental charges to use space and equipment owned by the physician and leased to the referred facility, and aims to require all Medicare Advantage providers and suppliers to first be screened and enrolled in traditional Medicare. Also proposed for 2018: the Diabetes Prevention Program (DPP), a structured program that includes dietary coaching, lifestyle intervention, and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals who are prediabetic. CMS is asking for comment on the program, including the enrollment of providers and suppliers as well as eligibility requirements for beneficiaries.

    APTA intends to comment on the proposed rule by the September 6 deadline.

    CMS Outpatient Payment Proposed Rule Addresses Opioids, Hospital-Owned Off-Campus Facilities

    The proposed outpatient prospective payment system (OPPS) rule recently released by the Centers for Medicare and Medicaid Services (CMS) includes payment increases, but the provisions getting the most attention are one designed to decrease opioid prescribing and another that will move certain off-campus hospital-owned outpatient departments out of the OPPS payment system.

    Here are a few highlights from the proposed rule.

    Patient satisfaction survey questions about pain management will be eliminated.
    In the midst of an opioid abuse epidemic that has gained national attention, CMS has announced a proposal that would eliminate questions about pain management from the patient satisfaction surveys used in its value-based purchasing programs. It's a move that CMS is taking after it received feedback that the pain management questions may "[create] pressure on hospital staff to prescribe more opioids in order to achieve higher scores on this dimension," according to a fact sheet from CMS.

    "Although CMS is not aware of any scientific studies that support an association between scores on the pain management dimension questions and opioid prescribing practices, we are proposing to remove [the questions] in an abundance of caution," CMS states, adding that alternate questions are being developed for future use.

    Hospital-owned off-campus outpatient departments won't be getting paid through OPPS.
    The second notable change in the proposed rule—the removal of hospital-owned, off-campus outpatient departments from the OPPS—was less of a surprise, given that Congress mandated CMS to do something about the issue when it passed the budget in 2015. The proposal will have minimal effect on physical therapists (PTs).

    The change is intended to curb what Medicare sees as a pattern of hospitals buying up off-campus physician offices to receive the higher rates associated with OPPS. Congress picked up on the issue when it approved the Bipartisan Budget Act of 2015 and directed CMS to place these facilities "under the applicable payment system." For now, that payment system would be the Medicare physician fee schedule, a "transitional policy" that CMS intends to use in 2017 while it explores other options for payment. CMS estimates that the change will reduce OPPS spending by about $500 million in 2017. Because PT services already are billed under the physician fee schedule, PTs will not feel the change directly.

    While the proposal was met with criticism from the American Hospital Association and other hospital trade groups that claim the change would be a disincentive for hospitals to create new outpatient facilities, CMS sees the change as one that will help to ensure that the program and its beneficiaries "do not pay more for care simply because of the setting in which that care was received," according to a CMS press release. Exceptions to the change would be made for certain services, including those delivered in a dedicated emergency department.

    EHR reporting requirements are changing, and PTs should start paying attention.
    Another important consideration: CMS plans to update electronic health records (EHR) reporting requirements to give hospitals greater flexibility in participating in the EHR incentive program. Under the proposed rule, CMS will implement a 90-day EHR reporting period to reduce administrative burdens on hospitals. The change is worth noting, because even though PTs have been exempt from meaningful use requirements in the past, these requirements will come into play once PTs begin participation in the Merit-Based Incentive Payment System in upcoming years.

    Payment is up for hospitals and ambulatory surgical care.
    As for payment, the proposed rule contains an anticipated 1.6% payment increase for hospitals paid under OPPS in 2017, with ambulatory surgical care centers slated for a 1.2% increase. The proposal also includes refinements to packaging of ancillary services, new policies for device-intensive procedures, and changes to partial hospitalization rate-setting.

    APTA will submit comments to the proposed rule, which are due by September 6.

    Oregon Insurer Makes It Easier to #ChoosePT

    A small insurer has taken a big first step in changing a dynamic that can lead to opioid abuse and addiction: Corvallis, Oregon-based Samaritan Health has announced that it has removed its prior authorization requirements and session limits for patients seeking physical therapy to treat pain.

    According to the Lund Report, Samaritan will lift the requirement for members of its Choice plan as well as for beneficiaries in its Intercommunity Health Network, Samaritan's Medicaid coordinated care organization. The change is intended to help decrease the use of opioids in the treatment of pain, particularly among patients with low back pain. The changes also apply to occupational therapy.

    "Many studies now point toward movement therapy and exercise with body conditioning to help improve back pain," explained Kevin Ewanchyna, MD, Samaritan Health Plan's chief medical officer, to the Lund Report. "Physical therapists can provide the training and skill set to help the individual achieve their goals in exercise and movement therapy."

    The Samaritan change comes at a time of national focus on an epidemic of opioid abuse and heroin use. A big part of that focus involves a discussion on how to move the country's health care system away from models that use opioids as a first-line treatment for pain and toward nonopioid approaches that include physical therapy. APTA is taking an active role in advocating for a shift away from opioids, both through its involvement with a White House initiative to battle the epidemic and by way of its national #ChoosePT campaign.

    Oregon has been more proactive on this issue than many other states. Last year, the state changed its Medicaid plan to allow beneficiaries to access physical therapy and other nonsurgical and nondrug approaches to back pain as the priority treatment; more recently, the Oregon Medical Association made opioid abuse a central focus of its state advocacy agenda.

    APTA's #ChoosePT campaign is a national initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign will unfold throughout 2016 and include national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach.

    The Latest News on Zika

    June brought new findings to light on the effects of Zika and talk of potential vaccines. Meanwhile, state governors are frustrated as Congress continues to squabble over Zika funding.

    WHO: Zika May Cause Neurological Problems in Thousands of Babies
    According to Reuters, the World Health Organization warned that nations with Zika infections should be on the lookout for infants with health problems other than microcephaly. Health issues could range widely and include “spasticity, seizures, irritability, feeding difficulties, eyesight problems, and severe brain abnormalities.”

    Baby Born in Florida With Zika-Related Microcephaly
    Florida’s health department announced the state’s first case of microcephaly related to Zika infection. The mother, originally from Haiti, contracted the virus in Haiti, and traveled to Florida to give birth. Florida Governor Rick Scott expressed sympathy for the mother and frustration with federal lawmakers, challenging Congress to “do their part” to fund Zika prevention and response.

    NYC: Over Half of Individuals With Zika Traveled to Dominican Republic
    According to New York City Health Commissioner Mary T. Bassett, MD, more than half of residents testing positive for Zika—140 out of 233—had recently returned from the Dominican Republic. In addition, 20 cases originated in Puerto Rico, and Guyana was visited by 14 of the patients. Bassett noted that the “results should not be used to stigmatize any group, but to raise awareness.” Twenty-four of those infected were pregnant, and 2 individuals also were diagnosed with Guillain-Barré syndrome, but have recovered.

    Zika Vaccine Optimism ...
    Three vaccines are planned to begin clinical trial in humans in 2016. Inovio Pharmaceuticals, partnered with Korea-based GeneOne Life Science Inc, received approval to begin phase I trials in 40 participants for a genetically engineered vaccine, GLS-5700. Two other vaccines were developed by researchers at Beth Israel Deaconess Medical Center, in collaboration with scientists at Walter Reed Institute of Research and the University of Sao Paulo. Trials are expected to begin as early as this fall. The Department of Health & Human Services Center for Innovation in Advanced Development and Manufacturing also will begin working on a vaccine.

    … And Zika Vaccine Concerns
    Scientists are expressing concern that Zika vaccines in development may inadvertently lead to an increase in the number of cases of the autoimmune disease Guillain-Barré syndrome. Others say the DNA-based vaccines may also increase the risk of Dengue fever.

    Congress Continues to Delay Funding for Zika Response Efforts
    Members of Congress have yet to pass a bill to adequately fund Zika-related public health preparedness and research efforts. In the most recent squabble, senators from both parties, who had agreed on $1.1 billion in funding, came to a stalemate when Republican members inserted provisions in the final bill that were a dealbreaker for Democrats. The provisions would cut $540 million from the Affordable Care Act, restrict funding for Planned Parenthood and other clinics “providing contraceptive services related to fighting the Zika virus,” and reallocate an additional $107 million from Ebola virus programs. The inaction by Congress has frustrated some lawmakers and officials, particularly in southern states, who say that state funds alone can't meet the challenges of battling the spread of the virus.

    First-Ever Tests of Deep Brain Stimulation on Humans Poststroke Ready to Begin

    Researchers at the Cleveland Clinic are ready to begin human testing on the use of deep brain stimulation (DBS) for individuals poststroke, in hopes that the technology will help to "jump start" damaged areas of the brain and aid in physical rehabilitation.

    According to an article in TIME magazine, the clinic has been federally approved to begin a human trial of a DBS technique that previously has been tested only on rats. The procedure involves sending electrical pulses from a power source implanted in the subject's chest to electrodes implanted in the brain, a technology that has been successfully used for some time on individuals with Parkinson disease (PD).

    But the intent of using DBS poststroke is not the same as its use for PD, according to Andre Machado, who heads up the project.

    "The big difference is that when we are treating the motor symptoms of [PD], we’re trying to make the symptom, like a tremor, go away," Machado told TIME. "When we are treating stroke, we are really trying to make movement come back. There is something inherently different about that."

    Animal testing revealed that DBS "appears to promote the growth of new neurons in the brain," according to a 2015 article in the Wall Street Journal (WSJ), though Machado told WSJ that researchers have no expectation that the procedure will cure stroke. Instead, he said, "the expectation is that by applying stimulation, [DBS] will augment or boost the effects of physical rehabilitation."

    "The goal of this therapy is not to replace physical training, but rather to boost the effects," Machado told TIME.

    The human study is set to begin as soon as researchers identify a subject poststroke who is severely disabled and "has exhausted all other options without improvement," according to the TIME article. The focus of the initial work will be on individuals who have suffered an ischemic stroke.