Health care reform is swiftly moving providers and patients toward value-based payment and away from procedural-based, fee-for-service systems. To enable physical therapists and physical therapist assistants to be successful in this evolving environment, APTA has been actively pursuing payment alternatives as part of health care reform's triple aim of better care for individuals, lower costs, and better community health. The association's goal is to work with the federal government and payers to reform payment for outpatient physical therapist services to improve quality of care, recognize and promote the clinical judgment of the physical therapist, and provide policymakers and payers with an accurate payment system that ensures the integrity of medically necessary services. Below are areas of particular impact on PTs and PTAs.
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New Evaluation and Reevaluation CPT Codes
The 3 tiered physical therapy evaluation CPT codes recommended by AMA and supported by APTA were released in the proposed 2017 physician fee schedule, along with an updated reevaluation code. While the codes reflect 3 levels of patient presentation—low, moderate, and high complexity—the Centers for Medicare and Medicaid Services assigned the same value to all of them in the proposed rule for 2017.
Alternative Payment Models Under Medicare
Alternative payment models include the Comprehensive Care for Joint Replacement Model (CJR), a new payment system being tested for episodes of care related to total knee and total hip replacements under Medicare. The initial CJR model began in April 2016, and tentatively will expand in 2017 to include hip and femur fractures. A similar model for cardiac care also has been proposed—a mandatory bundling program for care associated with bypass surgery and heart attacks, including cardiac rehabilitation.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Enacted in April 2015, MACRA permanently repeals the flawed sustainable growth rate formula for determining Medicare payments for clinicians’ services and establishes a new framework for rewarding clinicians for value over volume. It also streamlines existing quality-reporting programs such as the Physician Quality Reporting System into a single new system, the Merit-Based Incentive Payment System (MIPS).
Medicare Postacute Care Reform
Physical therapist services represent a significant portion of Medicare Part A expenditures in postacute care settings, which include inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, and home health. APTA strongly supports reform initiatives, such as the Improving Post-Acute Care Transformation Act of 2014 (IMPACT Act), that will ensure access to and comprehensive coverage of physical therapist services that are centrally focused on the postacute care patient's unique needs.