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  • Senate Health Care Reform Bill Contains Provisions Opposed by APTA

    Despite some changes designed to appeal to a wider range of US senators, the newly released Senate version of health care reform still contains provisions that concern APTA: namely, a loosening of required "essential health benefits" (EHBs) that include rehabilitation services, and changes to Medicaid that could reduce the range of available benefits. Changes are still possible, however, and APTA has plans to reemphasize its positions as the Senate considers the bill.

    The bill, technically a substitute for the American Health Care Act (AHCA) approved by the House of Representatives in May, is characterized as less extensive in its effort to repeal and replace the Affordable Care Act (ACA), but it contains several of the same features as the House legislation, including plans to cap and then reduce Medicaid appropriations, transition Medicaid to a block grant system, and change EHB requirements-features that APTA has publicly opposed.

    Like the AHCA, the Senate substitute bill weakens the power of federally mandated EHBs—which include physical therapy—by allowing states to apply for waivers to reduce the requirements or eliminate them entirely. The result, according to APTA, is a likely reduction in access to habilitative and rehabilitative services for millions of Americans that could have lasting societal effects. In a statement on the AHCA, APTA President Sharon Dunn, PT, PhD, wrote that the EHB change and other provisions set the stage for a health care system that would create "unneeded barriers to care and reduce the access to care for millions of Americans."

    The bill has yet to undergo review by the Congressional Budget Office (CBO) and could be altered based on the CBO analysis or compromise efforts within the Senate.

    Meanwhile, APTA is not sitting still. On June 27, association representatives will participate in a congressional briefing on Capitol Hill aimed at educating lawmakers and staff on the value of rehabilitation and habilitation services and devices in American's health care system. The event is sponsored by the Independence Through Enhancement of Medicare and Medicaid, the Habilitation Benefits Coalition, and the Coalition to Preserve Rehabilitation. APTA is a member of all 3 groups.

    APTA will continue to analyze and monitor the bill and report on potential effects.

    Bill in House Aims to Hold Feds to Special Education Funding Obligations

    Think that the US government should live up to its promises when it comes to funding educational needs of students with disabilities? So does a bipartisan group of legislators who have introduced a bill that would obligate the government to pay what it promised to pay according to the Individuals with Disabilities Education Act (IDEA). APTA is among the many organizations supporting the legislation.

    Called the IDEA Full Funding Act (HR 2902), the bill seeks to ensure that the federal government pay 40% of the average per-pupil expenditure for special education, the percentage establish in the IDEA, signed into law in 1975. Federal contributions have consistently fallen short of the 40% mark, with the most recent federal funding only representing about 15.7% of expenditures.

    The legislation was introduced in the US House of Representatives by Reps Jared Huffman (D-CA), David McKinley (R-WV), Tim Walz (D-MN), Dave Reichert (R-WA), Kurt Schrader (D-OR), and John Katko (R-NY). Similar legislation will be introduced in the US Senate by Sen Van Hollen (D-MD).

    "The law guarantees every student the right to a free and appropriate public education, but Congress needs to provide the resources to make that guarantee meaningful." said Huffman in a press release. "That’s why I’m joining with my colleagues from across the aisle to introduce the IDEA Full Funding Act, because we know that providing our children with a first-class education should not be a partisan issue. The bottom line is this: no child should ever be denied a quality education, or be kept from reaching their full potential, because they have a disability."

    APTA is among the long list of organizations advocating for full funding of IDEA. That list includes the American Federation of Teachers, American Music Therapy Association, American Occupational Therapy Association, American Psychological Association, American Speech-Language-Hearing-Association, National Association of Social Workers, National Down Syndrome Congress, and National Education Association.

    APTA will monitor the bill's progress and report on developments as they happen.

    CMS: Start Preparing for New Medicare Beneficiary ID Numbers

    Although the official rollout won't occur until 2018, it's not too soon for health care providers to prepare their practice management systems for a new Medicare beneficiary ID system that no longer uses Social Security numbers (SSNs).

    Details on the change are available in a guidance resource from the US Centers for Medicare and Medicaid Services (CMS). The shift will move the Medicare system away from Health Insurance Claim Numbers (HICNs) that contain the beneficiary's SSN, and toward a CMS-generated Medicare Beneficiary Identifier (MBI). The change, intended to thwart fraud, was required by provisions in the Affordable Care Act and the Small Business Jobs Act.

    According to CMS, new cards with MBIs will be mailed to beneficiaries beginning in April 2018, with official startup of the use of MBIs in claims beginning in October of the same year. Providers can start using the MBI as soon as their patients receive the new cards and should have systems in place to accept the new number by April 2018.

    The changeover includes a transition period from October 2018 through December 2019, during which time CMS will accept claims using either the HICN or MBI.

    JAMA Viewpoint: The 'False Dichotomy' of Hospital Falls Prevention vs Mobility Promotion

    Hospitals that keep patients immobile as a way of preventing falls are engaging in a "false dichotomy" that can be damaging in the long-term, argue authors of a "Viewpoint" article published recently in JAMA Internal Medicine (preview only available for free). In fact, they write, programs that promote mobility with supervision "may actually help to prevent injurious falls" more effectively than those that encourage patients to stay in bed.

    Current federal payment policies penalize hospitals for certain hospital-acquired conditions, including falls resulting in injuries. While well-intended, these policies have had "unintended consequences" for patient mobility, function, and quality of life, according to authors Matthew E. Growdon, MD, MPH; Ronald I. Shorr, MD, MS; and Sharon K. Inouye, MD, MPH. Patient immobility contributes greatly to "post-hospital syndrome," in which patients are at risk for functional decline, adverse events, and readmission to the hospital.

    Instead, the authors advocate for the Centers for Medicare and Medicaid Services (CMS) to "develop quality measures that promote mobility as part of routine clinical care"—including early mobilization protocols, documenting how often patients are out of bed, and use of patient accelerometers instead of bed or chair alarms to monitor patient movement.

    Despite widespread implementation of hospital falls-prevention efforts over the past 20 years, authors write, evidence shows the rate of "injurious falls" has not declined significantly in the United States. Research has found this to be true in Australia, as well.

    According to the authors, the problem with current falls prevention efforts lies in their "troubling assumption that keeping patients from moving can stop such falls." "Falls prevention teams could be transformed into mobility teams" to enhance patient outcomes, they write.

    Authors cite recent studies of combined assisted walking and mobility initiatives, such as the Hospital Elder Life Program (HELP), designed by coauthor Inouye, that may be more effective at preventing falls than current falls prevention programs that result in keeping patients immobile much of the time. Other promising programs included supervised walking combined with a balance assessment or a behavioral intervention to promote mobility after leaving the hospital.

    While noting that data collection will be the key to assessing effectiveness of such efforts, the authors argue that making changes now will "shine a bright light on the false dichotomy between fall prevention and the promotion of mobility."

    APTA offers a variety of resources on falls prevention, including a  practice guideline on the assessment and prevention of falls tests and measures related to falls , a Physical Therapy-published  clinical guidance statement from the Academy of Geriatric Physical Therapy , an  online community  for PTs and physical therapist assistants interested in falls prevention, and a  balance and falls webpage .

    Unintended Origins, New Directions, Dark Reality: Latest News on the Opioid Epidemic

    Although awareness of the severity of the nation's opioid crisis is growing and the number of practice guidelines recommending nondrug approaches to pain treatment is increasing, the problem itself continues to take its toll on Americans across the country. That toll is well-documented by the media, with an increasing amount of attention also being paid to how the country found itself in this situation and what we do to make our way out of it.

    Here's a brief roundup of recent reports.

    Despite guidelines, Americans are still receiving lots of opioids for low back pain.
    A National Public Radio – Truven survey reveals that more than half of respondents experienced low back pain in the last year; among those who sought help from a physician, a surprisingly high number received prescriptions for painkillers. "We have a serious problem with our health care delivery system where physicians are highly incentivized to prescribe pills and perform procedures because that's what pays," Stanford University psychiatrist Anna Lembke tells NPR. "They're also motivated to please patients but don't have much time to manage complex medical conditions."

    Did this 1980 letter help to spark the opioid epidemic?
    The New York Times reports on "how a one-paragraph letter with no supporting information helped seed a nationwide epidemic of misuse of drugs like Vicodin and OxyContin by convincing doctors that opioids were safer than we now know them to be." The letter, which appeared in a 1980 issue of the New England Journal of Medicine, has been cited more than 600 times as evidence that addiction was a rare occurrence; the letter's author, Hershel Jick, MD, tells the Associated Press that "I'm essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did."

    Fentanyl use is spreading at a harrowing rate.
    According to the US Drug Enforcement Administration (DEA), the amount of DEA seizures of drugs that include fentanyl more than doubled from 2015 to 2016. "Drug use today has become a game of Russian roulette. There's no such thing as a safe batch; this is the opioid crisis at its worst," DEA spokesman Rusty Payne tells CNN.

    Ohio is suing 5 drug companies for their role in the opioid crisis.
    Ohio Attorney General Mike DeWine announced that the state has sued 5 drug companies, alleging misconduct by intentionally lying about the dangers of painkillers and making false claims about the benefits of the drugs. In 2016, overdose deaths rose to more than 4,000—a 36% increase from 2015. "This lawsuit is about justice, it's about fairness, it's about what is right," DeWine said. "These drug companies knew that what they were doing was wrong and they did it anyway."

    One businessman is shining a light on evidence as the path out of the opioid epidemic.
    From Forbes magazine: Former hotel entrepreneur Gary Mendell founded Shatterproof to battle the opioid crisis, and has formed a task force that, instead of being led by high-profile business or health care industry leaders, puts "science front and center" by turning over leadership to experts in the science behind pain and addiction. The task force aims to "find evidence-based ways for employers and state governments … to incentivize healthcare providers to use more evidenced-based quality measures and approaches to treat patients with pain or addiction," according to the article.

    APTA's #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach.

    CMS Will Cover Supervised Exercise Therapy for Peripheral Artery Disease

    Calling the supporting evidence "at least equivalent to already covered therapies" for intermittent claudication (IC), the US Centers for Medicare and Medicaid Services (CMS) announced that it will extend Medicare coverage for supervised exercise therapy (SET) to treat peripheral artery disease (PAD).

    The expansion, announced in a May 25 coverage decision, will cover physician-referred SET for up to 36 30 to 60-minute sessions over a 12-week period. The sessions must be conducted in a physician's office or outpatient facility, and must be delivered by "qualified auxiliary personnel" that includes physical therapists (PTs), nurses, and exercise physiologists. Supervision will be conducted by a physician or "non-physician practitioner"—a physician assistant, or nurse practitioner/clinical nurse specialist.

    "Trials showed that SET decreases mortality, reduces cardiovascular risk factors, increases exercise capacity, and increases quality of life in older adults," CMS states. "While in general exercise capacity alone, which was an endpoint in a number of studies, would not be an appropriate outcome, it is a meaningful outcome for IC due to symptomatic PAD since there is a well-established evidence link to all-cause mortality."

    To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit must also include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.

    CDC: 1 in 3 Rural Residents Has Arthritis; Over 50% of Those Experience Activity Limitations

    In brief:

    • Survey of 426,361 adults across US asked about arthritis and arthritis-attributable activity limitations (AAALs); responses were divided according to 6 categories of population descriptors, from rural to urban
    • Nearly 1 in 3 rural residents reported arthritis; rate was 1 in 5 for urban residents, 22.7% for the US overall
    • More than half (55.3%) of rural residents with arthritis reported AAAL; rate was 49.7% in urban areas
    • Higher incidence among rural residents applied to all age groups studies
    • Researchers believe interventions in rural areas may be hampered by lack of activity-friendly infrastructure

    America has an arthritis problem, and rural America is being hit especially hard—that's the finding of a report from the US Centers for Disease Control and Prevention (CDC) that estimates nearly 1 in 3 rural residents in the US has some form of arthritis, with more than half of those with arthritis experiencing activity limitations.

    The latest study, which appears in CDC's May 25 Morbidity and Mortality Weekly Report, describes the results of a detailed study of the 2015 Behavioral Risk Factor Surveillance System (BRFSS), a survey of 426,361 noninstitutionalized adults across the 50 states and the District of Columbia. Researchers asked respondents, "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" If the answer was "yes," respondents were then asked, "Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?"

    Once data were collected, researchers organized responses according to where respondents lived, assigning them to 1 of 6 categories developed by the National Center for Health Statistics: city, large fringe metropolitan, medium metropolitan, small metropolitan, micro metropolitan, and rural. Here's what they found:

    • Overall, more than 1 in 5 respondents reported arthritis (22.7%), with 43% of those reporting arthritis-attributable activity limitation (AAAL).
    • Major differences were discovered in arthritis and AAAL rates between urban and rural residents, with the rate of arthritis among rural residents at 31.8%, compared with a 20.5% rate among urban residents. AAAL prevalence was also worse in rural areas, where 55.3% of respondents with arthritis reported limitations, compared with 49.7% in the most urban areas.
    • Arthritis prevalence was higher among rural residents for nearly all age groups studied.
    • Although rates tended to increase as population density decreased, the overall correlations to demographic, health, and behavioral patterns were similar for each population area, with women, older adults, smokers, adults with less education, adults who are less physically active, and adults with higher body mass index reporting higher rates of arthritis within each population grouping.
    • AAAL rates were particularly high for rural residents who also reported a functional or work disability, with 56.7% reporting activity limitations. That rate was 42.3% among urban residents.
    • Authors speculate that the higher rates may be due to a higher prevalence of recognized risk factors in rural areas—particularly older age, obesity, and lower socioeconomic status.

    While they write that "wider use of evidence-based interventions including physical activity and self-management education in rural areas might help reduce the impact of arthritis and AAAL," authors also acknowledge that may be easier said than done. Using walking as an example of a "low impact, accessible activity proven to reduce pain and improve quality of life," they describe how lower-density environments make this more difficult through limited pedestrian infrastructure, lack of sidewalks, long distances between destinations, and sometimes even a lack of a destination itself.

    But even without plentiful pedestrian-friendly environments, the physical activity levels of rural residents could be increased if health care providers would simply suggest self-management programs and recommend that their patients be more active, they assert.

    "The higher prevalence of arthritis and AAAL among rural US residents highlights the need for evidence-based intervention approaches such as physical activity, self-management education, and vocational rehabilitation programs," authors write. "Health care providers and community organizations can help residents participate in these helpful interventions."

    APTA offers multiple resources on arthritis management through community-based programs, including an overview of evidence-based programs, and a decision aid to help physical therapists choose an appropriate program for the patient. Additionally, the US Bone and Joint Initiative (USBJI) offers a series of free public education programs aimed at helping providers increase community awareness of osteoarthritis treatment. APTA is a founding member of USBJI.

    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.

    Cardiac Bundling Program, CJR Expansion, Won't Happen Until January 2018

    The introduction of a mandatory Medicare bundling program for cardiac care that had been delayed until October has now been pushed back further to January 2018, according to a final rule by the Centers for Medicare and Medicaid Services (CMS). That delay also applies to plans to expand the comprehensive joint replacement model (CJR) already in place.

    The final rule requires 98 randomly selected metropolitan areas to participate in bundling programs for care associated with bypass surgery and heart attacks under Medicare parts A and B, and includes provisions that will incentivize the use of cardiac rehabilitation. It also includes an expansion of the CJR model beyond hip and knee arthroplasty, to include patients undergoing care for hip and femur fractures.

    However, these changes will not be implemented before January of next year. CMS says the delay “will ensure that CMS has adequate time to undertake notice and comment rulemaking, if modifications are warranted.” APTA has developed a fact sheet on the rule, and CMS offers general information and presentation slides on the topic, plus an overview of what it calls "episodic payment models."

    APTA's education efforts on bundling began well before the April 1, 2016, startup of CJR and include 2 webinars (1 on the basics of the CJR program and 1 that includes insights from PTs participating in bundled care programs), an article in PT in Motion magazine, and a webpage that contains background information as well as links to evidence-based clinical information and community programs.

    New Canadian Guidelines Seek to Move Physicians Toward Nondrug Treatments for Pain

    Add the Canadian Medical Association to the list of organizations shifting guidelines away from opioids in the treatment of chronic noncancer pain. In a set of updated recommendations that authors describe as consistent with US Centers for Disease Control and Prevention (CDC) guidelines, Canadian physicians are being urged to pursue nonopioid and nondrug treatments as a firstline approach.

    The guidelines, published in the May 8 edition of CMAJ, are an update to opioid prescription guidelines released in 2010, in which "almost all supported the prescribing of opioids," according to the new guidelines' authors. The new recommendations take a markedly different position, advocating not just for nondrug approaches but also for lower dosages when opioids must be used, as well as for tapering programs for patients receiving high-dosage therapy of 90 milligrams or more daily.

    Researchers conducted a systematic review of literature that included analysis of multiple prescription and pain treatment guidelines, including the CDC resource. Guideline development also included meetings with stakeholders from law enforcement, medical regulation, pharmacy patient advocacy, addiction medicine, pain medicine, and several Canadian government agencies.

    In the end, 10 guidelines were developed and tagged as being either a "strong recommendation," meaning that the recommendation is appropriate for almost everyone, or a "weak recommendation," meaning that the guidance is applicable to a majority of patients but may not be appropriate for an "appreciable minority." The strong recommendations include use of nonopioid approaches, particularly with patients with substance-use disorder, as well as prescriptions for fewer than 90 milligrams per day when opioids are indicated. Authors also strongly recommend "a formal multidisciplinary program" that may include physical therapists to assist patients attempting to taper down opioid use.

    Authors describe the guidelines as "consistent" the CDC guidelines, which have been endorsed by some provincial regulatory agencies. The new recommendations are also in sync with APTA's #ChoosePT campaign, which has been adopted by the Canadian Physiotherapy Association in a collaborative effort to educate the public about physical therapy as a safe alternative to opioids for the management of pain.

    APTA Physical Therapy Outcomes Registry Is Qualified by CMS to Submit Quality Data

    Physical therapists (PTs) now have another avenue to submit quality-reporting data under the Merit-Based Incentive Payment System (MIPS) program: APTA's Physical Therapy Outcomes Registry (Registry). The Centers for Medicare and Medicaid Services (CMS) has approved the resource as a qualified clinical data registry (QCDR).

    This means that Registry users who participate in MIPS—a voluntary program for now—can submit their data directly from the Registry. Because MIPS participation could be mandatory as early as 2019, the Registry’s QCDR status will be particularly helpful for practices whose electronic health records (EHRs) do not have that capability. APTA encourages eligible PTs to voluntarily participate in MIPS now, in order to be familiar with the program if and when participation becomes mandatory.

    “As a qualified clinical data registry, the Physical Therapy Outcomes Registry aligns with APTA’s commitment to demonstrating outcomes to advance quality and payment,” said APTA President Sharon Dunn, PT, PhD, in a news release. “The Registry will help us elevate the care we provide our patients, better understand our value, and define our future, both as individual physical therapists and as a profession.”

    The Registry includes 8 quality measures, meeting stringent CMS criteria. Registry users can access nonproprietary outcomes measures supported by CMS, as well as measures specific to particular electronic health record (EHR) systems. In addition, planned body region/disease-specific treatment and outcome modules will help PTs treat patients according to established clinical practice guidelines.

    "Patient registries will be crucial for improving and establishing best practices for future patient care, and MIPS participation is another aspect of that," said James Irrgang, PT, PhD, ATC, FAPTA, scientific director of the Registry’s Scientific Advisory Panel. “The Registry will continue to align its quality measures with CMS to support our patient’s and clients’ current and future needs.”

    The Physical Therapy Outcomes 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.

    Coming to NEXT? Learn firsthand about what the Physical Therapy Outcomes Registry can do: check out Value-Based Care: Where Alternative Payment Systems Clinical Practice Guidelines and the PT Outcomes Registry Come Together, Thursday, June 22, 8:00 am–9:30 am, and "The Physical Therapy Outcomes Registry: A Multidimensional Data Collection System," Thursday, June 22, 11:00 am–1:00 pm in the Exhibit Hall.