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  • Proposed Home Health Rule Moves Ahead With New Payment System, Allows Therapist Assistants to Furnish Maintenance Therapy

    The US Centers for Medicare and Medicaid Services (CMS) intends to go full steam ahead with its plans to shift to a new payment system for home health beginning in 2020. The plans are accompanied by other changes that include allowing maintenance therapy to be furnished by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), providing a payment "add on" for rural home health care, and adopting an APTA-supported "notice of admission" requirement to avoid duplicate billing. The new provisions, which include a 1.3% payment increase, are included in CMS’ proposed rule released on July 11.

    The biggest shift has been more than a year in the making: a transition to a new payment system known as the Patient-Driven Groupings Model (PDGM). The PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. Instead, the system classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. APTA offers extensive information on the new system and will participate in a live August 5 webinar on the model jointly hosted by APTA, CMS, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. APTA members can participate in this webinar (free to APTA members, login required APTA members can participate in this webinar).

    But that's not all in the proposed rule (.pdf). CMS also plans to allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the therapist assistant, the qualified therapist still would be responsible for the initial assessment; plan of care; maintenance program development and modifications; and reassessment every 30 days. CMS believes the change would bring home health in line with other care settings and give home health agencies (HHAs) more latitude in how they allocate resources.

    The rule also would phase out the split payment approach that requires HHAs to submit a Request for Anticipated Payment (RAP) at the beginning of the initial episode for 60% of the anticipated final claim payment amount. A final bill for the remaining 40% is submitted at the end of the 60-day episode. RAP submissions are operationally significant, as they establish the beneficiary’s primary HHA by alerting the claims processing system that the beneficiary is under a home health plan of care and home health services are subject to consolidated billing, meaning Medicare makes payment for all home health items and services to the single HHA overseeing the plan of care.

    Instead, CMS proposes requiring HHAs to submit a notice of admission to alert the claims processing arm of CMS that a beneficiary is under a home health episode of care. The new system is a direct result of APTA advocacy, which was fueled by members in private practice settings who shared data with the association to help APTA make its case. The change will be phased in next year and fully implemented in 2021.

    APTA and its members successfully argued that the split percentage approach is fraught with logistical inefficiencies that often result in confusion for CMS and therapy providers in outpatient settings. The proposal to replace the RAP with the notice of admission, to be submitted within 5 days of the start of care, would be needed to establish the primary HHA so the claims processing system would be alerted to a home health period of care, helping to eliminate the possibility of any lag time between a beneficiary's admission in home health and the HHA's notice of the admission to CMS. This too-common delay trips up outpatient providers who begin treatment (and billing) before CMS knows that the beneficiary has transitioned to home health. CMS describes the change as "an important step in paying responsibly and appropriately for home health services," according to an agency fact sheet on the proposed rule.

    As for payment, home health would see an overall 1.3% boost—about $250 million. The increase, initially targeted at 1.5% to comply with the Bipartisan Budget Act of 2018, was decreased by .2% to accommodate a rural add-on policy.

    Among other elements of the proposed rule:

    SPADE requirements are expanding. CMS is continuing its efforts to increase the range of standardized patient assessment data (SPADE) reported by HHAs. The use of SPADE in home health was instituted to bring HHAs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care settings. The proposed rule would follow through with the expansions, but it also includes requirements for reporting on cognitive function and mental status, comorbidities, and social determinants of health, among other categories. HHAs would be required to report these additional elements beginning in 2022 for admissions and discharges that occur between January 1 and June 30, 2021.

    A pain measure would be discontinued. Partially in response to concerns about the potential for overprescription of opioids, CMS is proposing to remove the Improvement in Pain Interfering with Activity Measure (NQF #0177) from the Home Health Quality Reporting Program (HH QRP) beginning in 2022. Under this proposal, HHAs would no longer be required to submit OASIS Item M1242, "Frequency of Pain Interfering with Patient’s Activity or Movement" for quality reporting purposes beginning in 2021.

    A pain-related question would be deleted from patient surveys. CMS proposes to remove a patient survey question that asks whether the patient and provider talked about pain in the past 2 months. The question, currently in the "Special Care Issues" composite measure, would be dropped beginning July 1, 2020. Similar to the pain measure being proposed for deletion, the survey question is being eliminated due to concerns about the ways it might influence unnecessary drug prescriptions. The changes are consistent with an earlier CMS decision to eliminate pain-related items from hospital patient surveys.

    APTA continues to review the proposed rule and will provide comments to CMS by the September 9 deadline. In the coming weeks, APTA also will post a unique template letter on its Regulatory Take Action webpage for individuals to use to submit their own comments on the proposed rule.

    From PT in Motion Magazine: Social Determinants of Health

    Health care is one thing. But the context of that care, the constellation of factors that can affect health for individuals and entire communities? That's something else entirely—and physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy education programs are engaged.

    Now available in the July issue of PT in Motion magazine: "Addressing Social Determinants of Health," an exploration of the ways the physical therapy profession is responding to the concept that improving the health of society demands providers, researchers, educators, and policymakers get involved with the economic, environmental, and behavioral factors that can shape health. These factors, broadly referred to as social determinants of health (SDOH), can seem overwhelmingly systemic, but that isn't stopping some APTA members from taking them on in a variety of creative, impactful ways.

    The article shares the work of several PT-led organizations, including Move Together, which works to provide physical therapy infrastructure to areas in need (among other programs); Mama LLC, a physical therapy consulting service focused on improving women’s health domestically and internationally; and the Arlington, Virginia, Free Clinic, led by Nancy White, PT, DPT, which has embraced SDOH-conscious practices in its programs. Author Christine Lehmann also looks at SDOH-related research being performed by PTs, as well as the ways physical therapy education is responding to the concept.

    As the article explains, SDOH can include cultural and economic variables, but other factors such as the built environment and climate change can even come into play. At the same time, the concept also calls for PTs and PTAs to change their day-to-day approach to working with patients by considering—and acknowledging—the realities of a patient's environment, from micro to macro.

    "Addressing Social Determinants of Health," featured in the July issue of PT in Motion magazine, 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: "Looking at Physical Therapy Holistically," an article on how PTs are addressing both the body and mind in treatment, and "Providing Onsite Physical Therapist Services," a look at PTs who bring their services to patients.

    APTA, AOTA, ASHA Create Guide to Assess Habilitative, Rehabilitative Insurance Benefits

    Insurers' habilitation and rehabilitation benefits come in all shapes and sizes—which is exactly the problem, according to APTA, the American Occupational Therapy Association (AOTA), and the American-Speech-Language-Hearing Association (ASHA). That's why the 3 organizations collaborated on a guide to assessing benefit adequacy that emphasizes transparency, access, and affordability throughout benefit plans that can be all over the map.

    The guide, available on APTA's Essential Health Benefits webpage, forgoes offering a laundry list of specific benefits in favor of establishing a set of principles that the associations believe lead to appropriate coverage of habilitative and rehabilitative services. Those principles are rooted in the idea that the benefits are necessary not just to improve function but also to maintain it, and that physical therapy, occupational therapy, and speech-language pathology are the "key" services in any habilitation/rehabilitation benefit package. The collaborative document echoes many of the themes included in APTA's public policy priorities, which emphasize increased patient access, cost and coverage transparency, and use of telehealth in service delivery.

    The resource addresses how best to ensure adequate scope of coverage and access, appropriate provider qualifications, and essential benefit information needed for consumers to determine if a plan meets their needs. It also provides tips and recommendations for consumers as well as plan providers and policymakers.

    However, the guide isn't just a collection of broad statements—APTA, AOTA, and ASHA also dig into some specifics when it comes to adequate habilitation and rehabilitation coverage, including:

    • Using the definition of habilitative and rehabilitative services adopted by the US Department of Health and Human Services
    • Creating separate rather than combined visit limits for physical therapy, occupational therapy, and speech-language pathology
    • Ensuring direct access to all 3 therapies
    • Providing clear information to consumers on whether benefits can be delayed due to utilization management practices, whether telehealth is permitted, and if same-day physical therapy, occupational therapy, and speech-language pathology services are allowed

    As for recommendations for plan improvements, the 3 organizations offer 14 ideas they believe would advance "optimum value" and increase patient access to therapy services. Those suggestions include wider use of telehealth, recognition of the role of therapy providers in population and preventive health, ending policies that limit coverage of each therapy discipline to 1 condition, and stronger acknowledgement that "rehabilitative maintenance therapy and habilitative services are allowed for individuals with chronic, progressive conditions…to prevent further deterioration of function."

    Expanded Health Reimbursement Arrangement Rule May Widen Use of the Employer Offering

    A final rule from the US Department of Health and Human Services (HHS) will expand small employers' ability to offer Health Reimbursement Arrangements (HRAs), a change that may make it easier for more Americans to purchase health insurance that they don't receive from their jobs. While it's still too early to tell if the change will significantly impact patients seen by physical therapists (PTs), APTA's advice is to keep an eye open, and be aware of the nuances of HRA payment.

    The new rule, set to go into effect January 1, 2020, will allow qualified small employers to offer what's being called an "Individual Coverage HRA" as an alternative to traditional group coverage plans. The idea behind HRAs is that employers provide a monthly tax-free allowance to employees, who can be reimbursed for health care-related expenses up to the allowance limit. The changes set to go into effect next year would permit HRAs to be used to pay for health insurance purchased on the individual market, and allow employers to offer "excepted benefit" HRAs to supplement employer-sponsored insurance—even if the employee isn't enrolled in the group plan.

    HHS believes that the change will open up coverage options for more than 11 million employees and family members and increase insurance portability, according to an HHS press release. APTA submitted comments to the proposed rule that largely supported the changes, but recommended that any individual health insurance paid via an HRA must be a policy deemed compliant with the Affordable Care Act. The final rule supports APTA's position.

    Those numbers are just estimates, however, and there's no way of knowing just how the use of HRAs will shake out next year, said Kate Gilliard, APTA regulatory affairs senior specialist.

    "PTs need to understand that these HRAs will be out there, and that whether the patient can use the HRA for copays depends on how it's set up with the employer," Gilliard said. "Some HRAs are only good for premium payments, so we're advising our members to verify the details of a patient's HRA. If it's found appropriate for use, the HRA can be processed just like a health savings account or flexible spending account."

    APTA regulatory affairs staff will monitor rollout of the rule and share new information in PT in Motion News and elsewhere.

    UnitedHealthcare Announces New Pilot Program to Increase Access to Physical Therapist Services as Result of Collaboration With APTA

    This week, UnitedHealthcare (UHC) announced a pilot program in 5 states that will waive the cost of copays and deductibles for 3 physical therapy sessions for patients with low back pain (LBP) living in Connecticut, Florida, Georgia, North Carolina, and New York. The pilot, which could affect as many as 1 million enrollees, goes into effect July 1, 2019. Other states will join the program in 2020 and 2021.

    Specifically, the pilot will be available to UHC enrollees with new onset of LBP when receiving care from an outpatient in-network provider. This benefit change will not extend the enrollee’s physical therapy or chiropractic benefit maximum, and will apply only to services related to treating back pain. Enrollees must have physical therapy or chiropractic benefits remaining in order to use this benefit.

    UHC will send emails about the benefit change on a quarterly basis to enrollees in the 5 states as they gain access to the benefit. Information also will be included on myuhc.com in the enrollee’s benefit information under Rehabilitation Services - Outpatient Therapy and Chiropractic (Manipulative) Treatment.

    This pilot follows a multiyear collaboration between APTA, OptumLabs, and UHC that included publication of a study in the American Journal of Managed Care (subscription required). This study affirms that higher copays and payer restrictions on provider access may steer patients away from more conservative treatments for LBP, including physical therapy and chiropractic services. "Innovative modifications to insurance benefits," authors write, "offer an opportunity for increased alignment with clinical practice guidelines and greater value."

    "This type of collaboration between a professional association and a private insurer is key to advancing the essential role of the physical therapy profession in improving outcomes for patients," says Carmen Elliott, MS, APTA's vice president of payment and practice management. "APTA continues to advocate for benefit design that is validated by data and meets the needs of patients, providers, and payers.”

    The study's authors, which include APTA member Christine M. McDonough, PT, PhD, hypothesized that patients with LBP who had easier access to a wider array of providers and lower out-of-pocket costs would be more likely to first seek out conservative approaches such as physical therapist (PT) or chiropractic services.

    Researchers looked at 5 years of claims data from OptumLabs Data Warehouse for 117,448 adult patients to determine the relationship between health plan benefit design and patient choice of primary care physician (PCP) versus a physical therapist or chiropractor as the first-line provider for new-onset LBP.

    Patients were excluded if they were not enrolled 2 years before and after the onset of LBP with no prior diagnosis of LBP or back procedures, or if they had filled opioid prescriptions within a year of LBP onset. Included patients could not have had any neoplasm diagnosis in the previous year or recent LBP-related diagnoses, such as spinal fractures, that would require more intensive treatment.

    For the analysis, authors divided the patients into 2 groups: those who first sought treatment from either a PCP or a PT, and those who first sought treatment from either a PCP or chiropractor.

    Their findings include:

    Only 2.8% of the 82,052 patients in the PCP-versus-physical therapist group chose to see a PT first, while 31% of the 115,144 patients in the PCP-versus-chiropractor group chose to see a chiropractor first. The majority of patients had a point-of-service (POS) health plan, and approximately 30% had no copayment or deductible to meet.

    Fewer restrictions on provider access was associated with higher likelihood of seeking out physical therapy or chiropractic treatment. Compared with patients with a POS plan, patients enrolled in a preferred provider organization (PPO) plan—the least restrictive option—were 32% more likely to see a physical therapist first. Patients in exclusive provider organization (EPO) plans were 16% less likely than POS patients to see a physical therapist first. These findings were similar for choosing a chiropractor versus a PCP.

    Higher copayments decreased the likelihood of a patient seeing a physical therapist as first provider. Patients with a copayment over $30 were 29% less likely to see a physical therapist first than were patients with no copayment. This association was not evident for chiropractic.

    As deductibles increased, the odds of a patient seeing a PT first declined; this association was not consistent for chiropractic. Patients with a deductible between $1,001 and $1,500 were 19% less likely to see a PT first (as opposed to seeing a PCP) than were those who had no deductible, while patients in this level were more likely to see a chiropractor first. Patients with a deductible of $1,500 or more were 11% less likely to see a PT first and 7% less likely to see a chiropractor first.

    There were mixed results for consumer-driven health plans (CDHPs) such as health reimbursement accounts (HRAs) and health savings accounts (HSAs). Patients with HRAs were 16% less likely to see a PT first compared with patients without CDHPs, but they were slightly more likely to see a chiropractor first. Patients with HSAs were 25% more likely to see a PT first compared with patients without CDHPs. HSAs had no effect on the chiropractic group.

    "Our study has demonstrated that patients experiencing LBP are moderately responsive to network restrictions and cost sharing in their choice of entry-point provider," authors write. "Reductions in spending are not necessarily accompanied by improvement in value, particularly if patients bypass routine care that would prevent higher downstream costs."

    [Editor's note: McDonough is also the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant as well as a recipient of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    VA Rolls Out New Community Care Program

    The US Department of Veterans Affairs (VA) released final rules related to a completely retooled program that allows veterans more choice in health care providers, but some of the provisions will apply only to certain regions (for now), and other interpretations of the new rule—including whether physical therapists (PTs) will be considered primary care providers—will be made as needs arise.

    The final rules released this week are related to implementation of the VA Mission Act of 2018, which consolidates VA’s community care programs into a new community care program known as the Veterans Community Care Program. Among programs being consolidated is VA Choice, the program created in 2014 to increase access and reduce wait times for VA patients by allowing greater use of non-VA providers. The VA Choice Program will continue to provide care to veterans until the new program is fully operational.

    Community Care Eligibility Criteria
    The Veterans Community Care Program final rule provides the nuts-and-bolts guidance on the operation of the new Community Care Network, the centerpiece of the Mission Act, and specifically on 2 of the central features of the Mission Act: how and when veterans might qualify for receiving covered non-VA care, and who can provide it. The new community care provisions will apply only to certain regions of the country upon rollout and will expand incrementally.

    When it comes to which veterans would qualify for non-VA care, the rule includes a long list of criteria, including the inability of a VA facility to provide the type of care the veteran requires, as well as factors including treatment frequency, geographical proximity of an appropriate VA facility, the veteran's ability to travel, and a "compelling reason" for the veteran to receive non-VA services, among others.

    Entities who want to be included as eligible non-VA providers will need to enter into a contract with VA, and either not be a part of (or employee of) VA or not provide the same services provided within the VA. The provider must also be accessible to the veteran, which includes a reasonable wait time to receive services. The rule also states that VA will announce quality standards through a separate document but predicts that "quality comparisons will generally be based on care that is locally available and not on national averages." In its comments on the proposed rule, APTA asked VA to clarify how it would define types of care, including primary and specialty care, and whether physical therapy would be considered primary care. The VA responded by taking a wait-and-see approach, writing that "we believe in a majority of cases that it will be clear what standard should be applied to what care."

    For now, the new system is being rolled out in states in Regions 1, 2, and 3 of VA’s new Community Care Network, which includes mid-Atlantic, southern, and Midwestern states: Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Iowa, Kansas Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, US Virgin Islands, Vermont, Virginia, Washington DC, West Virginia, and Wisconsin. The program isn’t expected to be operational everywhere until the end of 2019 at the earliest.

    Urgent care
    In another rule, VA clarified policies and procedures around covering veteran access to urgent care from non-VA providers without prior approval from VA. Qualifying facilities would include urgent care and walk-in retail health clinics.

    As in the community care rule, qualifying non-VA providers would need to enter into a contract or agreement with VA. Veterans could in turn go to those facilities to seek a range of urgent care, including flu shots, vaccines, certain screenings, and other services, so long as the care isn't emergent or based on care over an extended period of time. In the rule, VA states it will provide veterans with information on participating urgent care providers.

    In its comments on the proposed rule, APTA asked VA about whether follow-up care related to a covered urgent care visit would need separate VA authorization. VA responded by stating that follow-up care must be coordinated by VA.

    APTA regulatory affairs staff continues to monitor the implementation of the Mission Act and will post resources and information on its Veterans Affairs and TRICARE webpage.

    Final HHS Report on Pain Management Adds to Drumbeat for Better Access to Nondrug Approaches

    The final report from a US Department Health and Human Services (HHS) inter-agency task force on pain management best practices is out, and its call for greater collaborative care and improved access to physical therapy comes through loud and clear. It's a report that in many ways echoes APTA's white paper on opioids and pain management published nearly 1 year ago.

    The "Report on Pain Management Best Practices" changed little from its draft version released in January [Editor's note: this PT in Motion News article covered the draft in depth]. Like its predecessor, the report identifies gaps and inconsistencies in pain management that can contribute to opioid misuse.

    While the task force acknowledges that opioids may be appropriate when carefully prescribed in some instances, it also argues that other approaches—including "restorative therapies" furnished by physical therapists and other health care professionals—should be on equal footing with pharmacological alternatives, particularly when it comes to reimbursement and patient access.

    "Restorative therapies play a significant role in acute and chronic pain management, and positive clinical outcomes are more likely if restorative therapy is part of a multidisciplinary treatment plan following a comprehensive assessment," the report states, while pointing out that "use of restorative therapies is often challenged by incomplete or inconsistent reimbursement policies."

    APTA submitted comments on the draft report, and offered members a chance to contribute to the report's development through a customizable template letter. Association staff members also met in person with Vanila M. Singh, MD, task force chair, and provided public commentary to the task force on 2 occasions.

    The HHS report is consistent with a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches.

    "This report from HHS adds to an overwhelming body of knowledge that spells out the need for patient-centered, collaborative care that makes nonpharmacological approaches to pain management more accessible to public," said Katy Neas, APTA executive vice president of public affairs. "But the question is, what will the public, federal agencies, and other stakeholders do with the information in this report and so many others like it? Will payers actually change their reimbursement guidelines to align with best practices, or should more regulatory changes be brought to bear? The path forward is clear, and some positive changes are happening, but as this report makes clear, it's time to pick up the pace."

    APTA continues to build on its successful #ChoosePT campaign to educate the public on safe, effective alternatives to opioids for pain management. The most recent addition: a downloadable pain profile chart that makes it easy for patients to assess the severity and impact of the pain they're experiencing.

    Legislation to Include PTs in Student Loan Relief Program Now in House and Senate

    A little more than 1 month after its companion bill was introduced in the US Senate, legislation that could open up student loan repayment opportunities for physical therapists (PTs) has been introduced in the House of Representatives. The proposed change, strongly supported by APTA, would allow PTs to participate in the National Health Services Corps (NHSC), a federal initiative that provides greater patient access to health care in rural and underserved areas—and incentivizes health care provider participation through a student loan forgiveness program.

    Like the Senate version (S 970), the House version, titled the "Physical Therapist Workforce and Patient Access Act" (HR 2802), would allow PTs to participate in the NHSC loan repayment program. The initiative serves an estimated 11.4 million Americans who live in designated Health Professional Shortage Areas (HPSA) and repays up to $50,000 in outstanding student loans to certain health care professionals who agree to work in an HPSA for at least 2 years. The House bill is cosponsored by Reps Diane DeGette (D-CO) and John Shimkus (R-IL).

    "If enacted, this legislation would be very good news for PTs, and even better news for patients who need increased access to care," said Katy Neas, APTA's executive vice president of public affairs. "Legislators on both sides of the aisle are recognizing that access to physical therapist services can be a useful tool in the fight against the opioid crisis, which has been especially devastating in rural and underserved areas. Physical therapists are expert in musculoskeletal systems and can provide invaluable services to patients with acute and chronic pain, and this bill will make it easier for patients in rural and underserved areas to access those services."

    In addition to its positive impact on health care access, the legislation could also provide some relief for the rising level of student debt being experienced by graduates of physical therapist education programs. It's a challenge that APTA is working to address, according to APTA Vice President of Government Affairs Justin Elliott

    "APTA's strategic plan envisions a physical therapy profession that's as diverse as the patient population it serves, and that means we must take a hard look at barriers to pursuing a career in physical therapy," said Elliott. "Clearly one of those barriers is the cost of physical therapist education. While this bill doesn't solve the problem, it could provide at least some relief for PTs facing significant student debt."

    APTA encourages members to join the push for the bills by contacting their legislators to urge them to become cosponsors by way of a prewritten letter, available at the APTA Legislative Action Center, that helps to deliver a unified message (member login required).

    APTA staff will closely track the progress of this legislation—be on the lookout for more opportunities to advocate for this important change.

    Study: 54% of Middle-Income Seniors Won't be Able to Afford Assisted Living Costs, Medical Expenses in 10 Years

    Authors of a new study say that as the wave of aging baby boomers advances, the middle-income elderly population could find itself in a particularly problematic situation—at least when it comes to finding housing that can accommodate declining mobility and increased care needs. By researchers' estimates, in as few as 10 years, over half of middle-income adults 75 and older, too affluent to qualify for Medicaid assistance, won't be able to afford many of the private seniors' housing options available today.

    The study, appearing in Health Affairs, looked at the current population of adults 75 and older in terms of population, demographics, and income status, and compared those data with projections for 2029. Authors then extended trends for health and mobility limitations to create a glimpse into what the housing landscape could be like in a decade. The results aren't encouraging for middle-class seniors, defined as those 75 and older with annuitized financial resources of between $25,000 and $74,298 in 2014 dollars.

    Among the findings:

    The senior population will increase dramatically, with middle-income seniors outpacing the high- and low-income group.
    The population of individuals 75 and older is expected to balloon from an estimated 20 million in 2014 to 33.5 million in 2029—a 68% increase. Of those 33.5 million, 43% will be seniors at the middle-income level, approximately 14.4 million people. The number of middle-income seniors ages 75-84 will nearly double, from 5.57 million in 2014 to 10.81 million in 2029. By that point, middle-income seniors will constitute the largest segment of the 75-and-older population.

    1 in 5 middle-income seniors will have 3 or more chronic conditions and 1 or more limitations in activities of daily living (ADL) by 2029—and 60% will have mobility limitations that could prevent them from living independently.
    If current prevalence levels continue, 20% of middle-income seniors will classify as "high needs," and 3 in 5 will have significant mobility limitations—factors that increase the chances that they will require more assistance in living arrangements. Additionally, an estimated 6% of middle-income seniors 75-84, and 15% of those 85 and older, are expected to have cognitive impairments.

    An estimated 54% of middle-income seniors won't have enough annual financial resources to pay for average assisted living costs and medical expenses—and that's a best-case scenario.
    Researchers say that in 2014 dollars, the annual average cost for assisted living rent and "estimated medical out-of-pocket spending" is about $62,000. Only 46% of the middle-income population will have that much available to them. The percentage drops even further among middle-income seniors who lack equity in housing, where only 19% are anticipated to have enough money to pay for average costs.

    "This confluence of factors creates a significant unmet future need, which demands new housing and care solutions to support the emerging generation of America's seniors," authors write, suggesting that responses need to come from both the public and private sectors. And those responses need to take a 2-pronged approach, by lowering the cost of assisted living and making it easier for seniors to continue living in their own homes for as long as possible.

    Researchers say that in the private sector, technology improvements could make a difference by increasing staff efficiency and thereby reducing costs, as could systems that "more formally involve family caregivers, outside volunteers, and healthier residents" in providing care, and those that offer "a la carte" care models. Authors also suggest that the private sector could respond to the coming gap by dialing back expectations for return on investments by, among other things, "charging less rent and reducing profit margins." Some of that sacrifice, they add, could be buffered through tax incentives

    In the public sector, authors suggest raising eligibility limits for housing assistance, providing subsidies and voucher programs, and encouraging "housing communities with sufficient capacity to establish their own Medicare Advantage plan." They also contemplate wider use of a 2019 change to Medicare Advantage that allows administrators to offer supplemental benefits to cover nonmedical services, including in-home modifications.

    Authors add that Medicaid could also play a role by "broadening eligibility and expanding coverage to home and community-based services for beneficiaries with higher incomes and less acute health needs." Doing so, they write, may "forestall health and functional deterioration and keep seniors in noninstitutional settings longer, when preferred."

    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.

    APTA, Other Organizations, Will Share Anti-Opioid Efforts

    There may be just about as many approaches to battling the opioid crisis as there are organizations committed to the fight—but now APTA and more than 100 other groups will be sharing experiences and learning from each other by way of a collaborative effort led by the National Academy of Medicine (NAM).

    The exchange of information is being managed through NAM's Action Collaborative on Countering the US Opioid Epidemic. The group includes community organizations, hospitals, nonprofit organizations, health professional societies, private insurers, and academia, all of which have committed to sharing their work and goals to counter the opioid epidemic through efforts that address prescribing guidelines, prevention, treatment, research, policies,and data, among other areas. Along with APTA, the more than 100 participants include the American Association of Colleges of Nursing, the American Pharmacists Association, Kaiser Permanente, and the Mayo Clinic.

    APTA has plenty to share. In addition to its award-winning #ChoosePT opioid awareness campaign, the association produced a white paper, hosted a Facebook Live event, sponsored a media tour, established an opioid and pain management resource on PTNow, and helped to develop a crossdisciplinary "playbook" on opioid stewardship—and that was just in 2018. APTA's efforts date back to 2016, when it unveiled #ChoosePT as the official campaign to educate the public on physical therapy as an effective nonopioid and nondrug option in the treatment of chronic pain.

    In APTA's statement of commitment to the collaborative, the association writes that "physical therapy providers intimately know that physical activity reduces risk of chronic conditions, many of which include pain," adding that "pain is personal, and treating it takes teamwork, including the membership and empowerment of the person being treated."

    "It is imperative in the fight against the opioid epidemic that everyone plays a role in not only the successful treatment of pain but the culture of pain," said Hadiya Green Guerrero, PT, DPT, APTA senior practice specialist. "Care providers must commit to utilizing each other’s expertise, including in the areas of educational and interprofessional training. APTA is eager to bring its perspective on preventing and treating pain to the table, and to learn from so many other organizations that share our commitment to ending the devastation of opioid misuse and addiction."

    NAM President Victor Dzau agrees that collaboration is the key to making a real difference.

    "Reversing the opioid epidemic requires a multi-sectoral response—no organization, agency, or sector can solve this problem on its own," Dzau said in an NAM press release. "We are thrilled to see such a robust commitment from organizations across the country in joining us to be part of the solution."

    This isn't APTA's only connection with NAM—the association is also a member of the Academy's Action Collaborative on Clinician Well-Being and Resilience.