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  • Startup of Cardiac Bundling Program, CJR Expansion, Delayed Until at Least October 1

    The introduction of a mandatory Medicare bundling program for cardiac care scheduled for a July 1 rollout is now on hold until October—and possibly until 2018, according to a new interim final rule issued by the US Department of Health and Human Services (HHS). The delay also postpones the expansion of an existing bundling program for hip and knee replacements until the same date.

    The initial 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. The 2017 rule also includes an expansion of the Comprehensive Care for Joint Replacement (CJR) model beyond hip and knee arthroplasty, to include patients undergoing care for hip and femur fractures.

    Some portions of the rule were scheduled to be implemented on February 18 of this year but were delayed when, in late January, the Trump administration froze the implementation of new rules for 60 days. HHS then moved the implementation of these rules back to March 21. Now, those portions of the rule won't be put into place until May 20.

    But those elements are what Modern Healthcare described as "minor changes." The big issue—the actual launch of the new and expanded bundling programs themselves—has been put on hold until at least October 1, with HHS now seeking comment on the "appropriateness" of not only that delay but the possibility of putting off implementation until early 2018.

    "This additional 3-month delay [from July to October] is necessary to allow time for additional review, to ensure that the agency has adequate time to undertake notice and comment rulemaking to modify the policy if modifications are warranted, and to ensure that in such a case participants have a clear understanding of the governing rules and are not required to take needless compliance steps due to the rule taking effect for a short duration before any potential modifications are effectuated," the new interim rule states.

    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.

    Foundation Announces 2017 Award Recipients

    This year’s recipients of the Foundation for Physical Therapy’s (Foundation) service awards have made significant contributions to advance physical therapy research through various fundraising initiatives, consistent support and dedication, and generous funding.

    The 2017 awards and winners are:

    • Robert C. Bartlett Trustee Recognition Service Award: Barbara H. Connolly, PT, DPT, EdD, FAPTA
    • Premier Partner in Research Award: Academy of Geriatric Physical Therapy
    • Charles M. Magistro Distinguished Service Award: Nancy E. Byl, PT, MPH, PhD, FAPTA
    • Spirit of Philanthropy Award: Patricia A. Traynor, PT

    "Winners of the 2017 service awards are proven visionaries and innovators of the profession and have long supported the Foundation in its mission to fund physical therapy research," said Foundation Board of Trustees President Edelle Field-Fote, PT, PhD, FAPTA, in a Foundation press release. "As leaders, they continue laying the groundwork for active participation in the profession through charitable work to ensure a more vibrant future for the Foundation, its funding recipients, and the clients and patients we serve, and for this we are truly grateful."

    This year’s recipients will be recognized during the Foundation’s awards luncheon on June 22, 2017, during the NEXT conference in Boston, Massachusetts.

    Interactive Map From CMS Lays Out PT and OT Market Saturation

    Physical therapists (PTs) and occupational therapists (OTs) in Polk County, Texas—county seat Livingston—must not get much sleep, because according to the Centers for Medicare and Medicaid Services (CMS), between 2015 and 2016, CMS has paid claims related to an average of 249.3 users per provider. Out in big sky country, however, things are a little different: if you happen to be a PT or OT in Broadwater County, in central Montana, PTs and OTs averaged only 26 users per provider during the same time period.

    That's just a taste of some of the data available in the latest update to the CMS "market saturation and utilization data tool," an interactive map that pulls from data used by CMS to, among other things, gauge potential fraud, waste, and abuse by getting a fairly granular sense of provider numbers and beneficiaries served. CMS says that it makes these data public "to assist health care providers in making informed decisions about their service locations and the beneficiary population they serve." Physical therapy and occupational therapy data are tied to Medicare Part B claims.

    The maps, scalable to a county-by-county level, reflect a 12-month study period, the most recent running from July 1, 2015, to June 30, 2016. Users can choose the most recent or an earlier reference period, a "health service area" (physical therapy and occupational therapy are merged; other categories include home health and skilled nursing facilities), and a specific metric: number of fee-for-service beneficiaries, number of providers, average number of users per provider, percentage of users out of fee-for-service beneficiaries, and average number of providers per county. Finally, the map can be adjusted to reflect data related to whether an area has been under a CMS provider enrollment moratorium.

    The resource also includes 2 appendices: a pdf document that describes the parameters of the data set (including the CPT codes used to define physical therapy and occupational therapy), and an interactive data set that allows users to sort the entire range of results.

    CMS Sends Out Comparative Billing Reports to PTs in Private Practice

    The Centers for Medicare and Medicaid Services (CMS) recently issued national provider Comparative Billing Reports (CBR) on physical therapy. The reports center on physical therapists (PTs) in private practice who submitted claims for physical therapy services using current procedural terminology (CPT) codes 97001, 97002, 97035, 97110, 97112, 97140, 97530, and Healthcare Common Procedure Coding System (HCPCS) code G0283 billed with the GP modifier.

    The CBRs are being faxed or mailed to approximately 15,000 providers with a specialty of physical therapist in private practice. CBRs give providers an opportunity to compare themselves with their peers both state-by-state and nationwide, check their records against data in CMS files, and review Medicare guidelines to ensure compliance. The reports are for educational and comparison purposes and do not indicate the identification of overpayments. The reports are not publicly available.

    To help PTs understand the CBR, the company that produced the reports will host a webinar on Wednesday, March 29, 2017, 3:00 pm–4:00 pm ET. During the webinar, PTs will be able to interact with content specialists and submit questions. More information is available at http://www.cbrinfo.net/cbr201702.

    PTs who receive a CBR and have questions are encouraged to call the CBR support help desk at 800/771-4430, email CBRsupport@eglobaltech.com, or visit the CBR website at www.cbrinfo.net.

    From The Atlantic: Unsupported Treatments Such as Meniscus Surgeries 'Distressingly Ordinary'

    A recent article in The Atlantic explores the idea that it's "distressingly ordinary" for patients to receive treatments whose effectiveness is not supported by evidence and uses the prevalence of meniscal surgery as a prime example.

    In "When Evidence Says No, but Doctors Say Yes," author David Epstein looks at how treatments can become disconnected from scientific support and yet continue to be used, driving up health care costs with no comparable improvement in patient outcomes.

    "Sometimes doctors simply haven't kept up with the outcomes," Epstein writes. "Other times doctors know the state of play perfectly well but continue to deliver these treatments because it's profitable—or even because they're popular and patients demand them. Some procedures are implemented based on studies that did not prove whether they really worked in the first place. Others were initially supported by evidence but then were contradicted by better evidence, and yet these procedures have remained the standards of care for years, or decades."

    Among the examples cited by Epstein: the use of arterial stents and the frequency of arthroscopic partial meniscectomies (APMs), even though for the latter "a burgeoning body of evidence says that it does not work for the most common varieties of knee pain."

    The article refers to studies that compare APM with physical therapy and found APM to be ineffective, and another that used sham surgery to compare outcomes with actual APM. "The sham surgery performed just as well as the real surgery," Epstein writes. "Except that, in the long run, the real surgery may increase the risk of knee osteoarthritis. Also, it's expensive, and, while APM is exceedingly safe, surgery plus physical therapy has a greater risk of side effects than just physical therapy."

    Part of the disconnect may be attributable to cultural changes that have tended to posit stronger belief in the curative powers of medicine than in public health or lifestyle changes—changes that can have more dramatic and long-lasting effects, according to the article. Epstein goes on to show how faulty research can feed into that belief system by making inaccurate claims about effectiveness and downplaying potential harms.

    "There's this cognitive dissonance, or almost professional depression," emergency physician Graham Walker tells The Atlantic. "You think, 'Oh my gosh, I'm a doctor, I'm going to give all these drugs because they help people.' But I've almost become more fatalistic, especially in emergency medicine. If we really wanted to make a big impact on a large number of people, we'd be doing a lot more diet and exercise and lifestyle stuff. That was by far the hardest thing for me to conceptually appreciate before I really started looking at studies critically."

    Cardiac Bundling Program Launch Still on Track After Executive Order

    Despite shifts in regulatory policy introduced by the Trump administration earlier this month, representatives from the US Department of Health and Human Services (HHS) say that the new mandatory bundling program for cardiac care—and some expansions in the existing bundling program for knee and hip replacements—will roll out as scheduled on July 1.

    Questions about implementation arose after President Donald Trump signed an executive order mandating a freeze on the implementation of all new rules for the first 60 days of the new administration. On February 15, HHS posted a notice in the Federal Register delaying some portions of the new bundling rule—but only those with a February 18 start date. The new start date for those provisions is March 21.

    According to an article in Modern Healthcare, "what will be delayed are minor changes, such as small adjustments on quality scores, and a new track … that meets the criteria to be an advanced alternative payment model under MACRA." The article cites an "HHS spokesman" as stating that "there are no plans to further change the launch of the models."

    In other words, it's still full-steam ahead for the July 1 launch date of the cardiac bundling model for Medicare beneficiaries, which will be required in 98 randomly selected metropolitan areas. The cardiac model will be applied to care associated with bypass surgery and heart attacks, and includes provisions that will incentivize the use of cardiac rehabilitation. The 2017 rule also includes an expansion of the Comprehensive Care for Joint Replacement (CJR) model beyond hip and knee arthroplasty, to include patients undergoing care for hip and femur fractures.

    Both models are based on the same approach: CMS establishes a lump payment target for a total episode of care, from admission to a set number of days postdischarge, and compares what hospitals spend in total on care with what Medicare thinks they should be spending. If the total spending is less than the Medicare target, the hospitals may be eligible to receive additional payment from Medicare—but if they spend more than the Medicare target, they could be required to pay back some portion of the difference.

    Prior to 2016, CMS offered only voluntary bundling programs to hospitals. Last year's CJR model was the first time participation was required—albeit limited to 67 metropolitan areas. The cardiac bundling model will be a required system for 98 markets (which overlap with the 67 already participating in the CJR).

    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.

    Physical Therapy Outcomes Registry Open for Business, Ready to Make History

    After several years of careful development, APTA has launched what it predicts will be a new chapter in the history of the physical therapy profession: the Physical Therapy Outcomes Registry (Registry). The project aims to build an extensive nationwide repository of patient and practice data that APTA Chief Executive Officer Justin Moore, PT, DPT, describes as "a bridge from our proud past in physical therapy to fully realizing our potential in the future."

    The Registry collects and aggregates electronic health record data from participating physical therapist (PT) practices, allowing PTs to make improved, data-informed clinical decisions, track and benchmark outcomes against industry data, and demonstrate the value of PT services. It's the most extensive resource of its kind designed specifically for use in the physical therapy profession.

    Speaking at the Registry's February 15 launch event held at the APTA 2017 Combined Sections Meeting, APTA President Sharon Dunn, PT, PhD, described the platform as "a resource that will elevate the care we provide our patients, that will better visualize our value, and that will help define our future, both as individual therapists and as a profession."

    "Ultimately, that means making a difference in people's lives," Dunn added.

    In a video dispatch on the launch, Jay Irrgang, PT, PhD, FAPTA, who heads up the scientific advisory panel that oversaw the development of the database, described the Registry as a singular source of data "from the profession, for the profession," adding that information from the Registry has the potential to impact not only practice, but quality improvement initiatives, payment, and research.

    The extent of those impacts? To a large degree, that's up to the profession itself, Moore told the audience at the launch event.

    "The Physical Therapy Outcomes Registry has the potential to become one of the most significant developments in the history of our profession, but only if we, as a profession, make use of it," Moore said. "The Registry is a bridge to our full potential. It's up to us now to walk across it."

    Visit the Registry website  to find out how it works, and learn how you can use the Registry to transform your practice—and the profession.




    Lymphedema Treatment Legislation Returns to Congress

    The possibility of Medicare paying for lymphedema treatment supplies, a longtime target of APTA advocacy efforts, is back on the table at the US House of Representatives with the reintroduction of a bill that would expand coverage.

    Last week, Reps Dave Reichert (R-WA), Earl Blumenauer (D-OR), Leonard Lance (R-NJ), and Jan Schakowsky (D-IL) introduced the Lymphedema Treatment Act (HR 930), legislation that would expand the range of compression supplies covered by Medicare for lymphedema treatment. A companion bill is expected to be filed in the Senate in the coming weeks.

    “Individuals suffering from lymphedema should have equal access to treatment," said Rep Reichert in a press release announcing the introduction. “Closing the Medicare coverage gap for compression garments is a common-sense way to give patients real hope to fight back and live with the best possible quality of life.”

    Similar legislation was introduced in 2015 but never made it to a full vote in either the House or Senate, even though the bill had 261 cosponsors in the House. During the lead-up to that push, APTA representatives participated in a congressional hearing to educate lawmakers and staff on the bill.

    APTA staff will monitor the legislation’s progress and update members with news and advocacy opportunities.

    Judge Lays Out What CMS Must Do to Correct Jimmo Education Failings

    The 2013 settlement agreement reached in theJimmo v Sibelius case was supposed to have debunked the "improvement standard" myth once and for all—provided, of course, that the Centers for Medicare and Medicaid Services (CMS) did the debunking and educated Medicare contractors and others on the importance of stopping inappropriate coverage denials. Last year, a federal judge ruled that CMS fell short on those efforts. Now that same judge has spelled out just what CMS must do to make things right—and by when.

    In a ruling released February 2, US District Court Judge Christina Reiss told the Secretary of Health and Human Services that CMS has until September 4 to complete a series of steps that would make it clear to Medicare contractors, Medicare Advantage plan administrators, and others that the so-called "improvement standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy.

    These education efforts were supposed to have taken place after the 2013 Jimmo settlement around the improvement standard—a standard that CMS claims it never explicitly supported yet somehow became common practice among contractors. In August, 2016, Reiss found that the postsettlement CMS efforts "reflect[ed] virtually no effort to educate participants" and ruled that "corrective action" should be taken at once. After CMS and plaintiffs failed to agree on the specifics of a plan, Reiss issued the most recent ruling that lays out just what CMS needs to do.

    The decision requires CMS to take the following steps:
    • Publish a new webpage specifically related to the Jimmo settlement
    • Publish a statement that disavows the improvement standard
    • Publish a list of frequently-asked-questions on the issue
    • Develop and administer trainings for providers and adjudicators
    • Conduct a national conference call to clarify the coverage policy

    In addition, Reiss sided with the opponents of CMS when it came to the exact wording of the statement that would be issued. According to the ruling, CMS will be required to use verbatim language that includes the words "the Medicare program will pay for skilled nursing care and skilled rehabilitation services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)."

    APTA actively supported efforts to press for better education by CMS and provided a declaration to the Center for Medicare Advocacy, 1 of the plaintiffs representing Medicare beneficiaries. Additionally, APTA maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.

    APTA, Canadian Physiotherapy Association Team Up in Opioid Battle

    The opioid epidemic knows no borders, and neither should the physical therapy profession's response to it: that's the concept at the heart of a new collaboration between APTA and Canadian Physiotherapy Association (CPA).

    The associations’ "shared commitment" was laid out today in a statement that describes both organizations as devoted to "helping Americans and Canadians find healthier ways to manage pain and reduce the use of prescription pain medications." 

    APTA President Sharon Dunn, PT, PhD, said she was delighted to see APTA and CPA modeling the teamwork that will be necessary to end the epidemic.

    "The tragedy and magnitude of the opioid crisis is a call to action for every physical therapist," Dunn said. "This joint effort opens up possibilities for an even more powerful response, and APTA is delighted to be working side by side with our neighbors and such an important voice in physical therapy. As a profession, we truly are better together."

    The partnership was inspired by the success of APTA's ongoing #ChoosePT public awareness campaign, launched in June 2016, which has reached millions of Americans through public service announcements, website and social media materials, paid advertising, and media coverage.

    The APTA-CPA collaboration will go beyond public education, however, and will include shared efforts to support research into the effectiveness of nonpharmacologic approaches to pain management, create practice guidelines and advisories on pain management, develop pain-management clinical practice models, and promote exercise-focused interventions. According to the statement, these combined efforts represent both associations' commitment "to put the health of our patients first.