Physical therapy received some timely, high-profile exposure in a prominent Capitol Hill news source, when APTA joined 2 other organizations to pen an opinion piece that was published in The Hill. The subject: how eliminating the in-office ancillary services (IOAS) exception for physical therapy and other services could save Medicare money in what could be troubling times ahead.
Calling the elimination of the IOAS exceptions "an alternative without a hitch, without a downside, and where both the patient and taxpayer win," APTA President Sharon Dunn, PT, PhD, OCS, joined presidents of the American Clinical Laboratory Association (ACLA) and the Board of the American Society of Radiation Oncology (ASRO) in a letter that spelled out just how the exceptions process is encouraging overutilization at a time when the Medicare program is considering significant hikes to premiums.
While writing that "on the whole," the Ethics in Patient Referrals Act—also called the Stark law—helps to decrease overutilization that can happen when physicians can self-refer beneficiaries to entities in which they have a financial interest, APTA, ACLA, and ASRO stated that the exceptions carved out for some services, including physical therapy, are costing the program dearly.
"This loophole has paved the way, according to the Government Accountability Office (GAO), for spikes in utilization of certain ancillary services and a measurable jump in Medicare payments to physicians," the letter states. "Closing the physician self-referral loophole … would realign provider incentives, which is in the best interests of Medicare beneficiaries, taxpayers, and the American health care system."
Efforts to eliminate the IOAS exception have been going on for several years and are among APTA's public policy priorities for 2015-2016. Late last year, APTA and others advocating for an end to the loophole got a boost from the American Association of Retired Persons (AARP), which threw its support behind congressional efforts to stop the practice.
In the letter published in The Hill, APTA, ACLA, and ASRO make the case that ending the exemptions not only will strengthen the quality of health care practice, but can even help to blunt "the impending jolt" that could be imminent for beneficiaries.
"The reality is Congress can protect the integrity of medicine by eliminating services from the well-intentioned IOAS, enhance patient care by minimizing overutilization of services and unnecessary procedures, and soften the blow for the Medicare beneficiaries targeted for premium sticker shock in the New Year," the letter states.
A bill that would help physical therapists (PTs) in private practice improve continuity of care received supportive comments from several members of a House subcommittee during a hearing that featured the testimony of Sandra Norby, PT.
Norby's comments were provided during a House Energy and Commerce Subcommittee on Health hearing on the Prevent Interruptions in Physical Therapy Act (HR 556) and 2 other health care-related bills. The bill, which has companion legislation in the US Senate, would extend locum tenens provisions to PTs, allowing those therapists to bring in another licensed physical therapist to treat Medicare patients and bill Medicare through their Medicare national provider identifier (NPI) during temporary absences for illness, pregnancy, vacation, or continuing medical education.
APTA and the association's Private Practice Section collaborated on pressing for the legislation, which is one of the goals of the association's public policy priorities.
In her testimony, Norby described the legislation as a change that would provide "needed regulatory relief" through "a simple technical fix."
"Physical therapy is part of the comprehensive care model, therefore it is high time that the PT receives the same protections against unavoidable absences that are available to [other health care providers]," Norby said in her statement.
Norby outlined the safeguards that would prevent fraud and abuse of the provision, and provided her own personal example of the problems now faced by private practice PTs—a time when one of her staff PTs, the only one for that particular clinic, was off for maternity leave. As the only PT certified by Medicare to continue service at that particular clinic, Norby had to make the long trip to the rural Iowa clinic, often sleeping at the facility so that she could be on hand to see patients the next day—all in addition to her regular duties.
In questions that followed witness testimony Norby explained why the continuity opportunities provided by locum tenens were of particular value for physical therapy by using rehabilitation after a total knee replacement as an example. "Any interruption…is going to be very very detrimental to the progress of their care," she explained. "If continuity is interrupted, "[Patients] are literally going to have more visits to achieve that goal we set up in the first place."
Subcommittee members included Rep Gus Biliraikis (R-FL) and Ben Ray Lujan (D-NM), who introduced the bill and are leading the House efforts for passage. At the hearing, Billiraikis described the bill as "pro-patient and pro-physical therapists," while Lujan characterized the change as "common sense legislation."
Billirakis showed the real-world effects of the current system by sharing a letter from constituent Alicia Nixon, PT, DPT, BCA, PMDB, who wrote to Billirakis telling him that it was "almost impossible to take a vacation to attend seminars because of my need to be onsite at the clinic," and that "I was recommended to have surgery 6 years ago that I still have not had because it would require me to be away from my practice for over 6 weeks for recovery." Nixon also described an instance in which, in order to respond to a court summons, she had to close her clinic for the day, resulting in lost wages for her staff.
In later remarks, Lujan spoke out in more detail about his personal connection to physical therapy and his understanding of the importance of care continuity. Describing a head-on automobile accident that left him severely injured, he said that "it was physical therapists … that really put me back together to being able to move, and to be able to just walk."
If there had been an interruption in his care, he said, "I can't imagine what would've occurred."
APTA will monitor the progress of the bills and post updates to its locum tenens webpage. Resources on the website include a podcast on the importance of this legislation and information on how PTs can get involved in advocating for its passage.
Sandra Lee Norby, seated at far right, prepares to testify on locum tenens for physical therapists before the House Energy and Commerce Subcommittee on Health.
The Centers for Medicare and Medicaid Services (CMS) rulemaking process is in full swing. This year, it's a mix of the usual subjects—changes to rules such as the physician fee schedule and prospective payment systems for home health and outpatient care—and a new initiative that's getting some wider attention: a plan to test bundled care models for hip and knee replacements that would affect more than 800 acute-care hospitals.
As the proposed rules are released, APTA analyzes, creates summaries, and submits comments to CMS on the rules that affect physical therapists (PTs) and physical therapist assistants (PTAs).
Here's a rundown of the latest set of comments submitted by APTA.
Bundled Care Model for Joint Replacement
The proposed Comprehensive Care for Joint Replacement Payment Model (CCJR) would require acute-care hospitals in 75 areas in the US—a wide range of metropolitan areas big and small—to use a bundled care model for all hip and knee replacements. The bundle would include all related services provided 90 days post-discharge from the hospital. The test period would begin January 1, 2016, and end December 31, 2020.
APTA comments (.pdf):
In its comments to CMS, APTA reiterates its support of initiatives "to improve the quality of patient care and … ensure access to high-quality care," provided the initiatives "preserve quality rehabilitation services in the right place at the right time." At the same time, the association suggests improvements to the rule, including delaying implementation for at least a year, making participation voluntary, ensuring patient choice and access to care, and allowing waivers for telehealth, outpatient therapy limits, and other care variations "that reflect a patient-centered, rather than regulation-based, approach to care."Also available from APTA: PT in Motion News article; summary and highlights
Physician Fee Schedule
The first physician fee schedule to emerge after last year's repeal of the sustainable growth rate (SGR), the rule proposed for 2016 focuses on misvalued codes, quality provisions, and self-referral—in addition to payment rates, of course. As proposed, the fee schedule for 2016 would include a .5% payment increase called for under the Medicare Access and CHIP Reauthorization Act (MACRA).
APTA comments (.pdf):
Many of APTA's comments focus on CMS’ proposal to review 10 CPT codes commonly reported by PTs to determine if they are "misvalued" and need to be updated. The association recommends a careful approach, using "objective screens" rather than relying on costs as the sole trigger to identify misvalued codes, and suggests that the CPT work group continue to develop new codes to report physical medicine and rehabilitation services. Other recommended changes include continued incentives for participation in quality reporting systems; collaboration between CMS, APTA, and other organizations to create "a core data set or finite list of measures" used to gather information on patient function; and a requirement that providers use a unique modifier on the claim form to denote who is providing services that are billed as "incident to."Also available from APTA:PT in Motion News article; summary and highlights
Home Health Prospective Payment System
The proposed rule includes an estimated $350 million payment reduction in 2016 compared with 2015—about 1.8%—based on factors that include a market basket increase offset by other downward adjustments (related to case mix growth, rebasing, and productivity) that turned the increase into a net decrease. As in other proposed rules issued this year, CMS is increasing quality reporting requirements and beta testing new value-based payment models.
APTA comments (.pdf):
In its comments, APTA voices support for value-based payment and scoring methodologies for home health agencies, but warns that evaluations should not be based entirely on functional gains. APTA suggests that CMS not apply functional improvement measures to patients whose treatment goal is to maintain function. The association also suggests a short transition period to standardize patient assessment data across postacute care facilities (PACs), and encourages more stakeholder engagement as CMS moves toward greater standardization of PAC data. Also available from APTA:PT in Motion News article; summary and highlights
Outpatient Prospective Payment System
According to CMS, the proposed rule is primarily an attempt to implement changes "arising from our continuing experience with [outpatient prospective payment and ambulatory surgical center payment] systems." But for PTs, the real issues arise from the "2-midnight rule" for short hospital stays, and the ways the rule designates a patient in the hospital as an outpatient (instead of an inpatient admission)—thus triggering the therapy cap, functional limitation reporting, and other requirements. —In the proposed rule, CMS asks for more feedback on how it's implementing the 2-midnight rule.
APTA comments (.pdf):
The association describes the 2-midnight rule as "an arbitrary time-based approach that disregards the role of clinical judgment" and encourages CMS to continue its consideration of the importance of clinical judgment in making short-stay hospital decisions. APTA also calls the application of outpatient requirements to the inpatient setting "nonsensical" and recommends that payments "are accurately aligned in tandem with setting parameters for short stays, observation stays, and the creation of an assessment and intervention stay."
The proposed rules listed above aren't the first issued by CMS this year. Earlier this summer, the association commented on proposed rules for acute care and long-term care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, and Medicaid managed care organizations.
Want more details on what CMS has in store for postacute care providers in 2016? Check out this online continuing education course from APTA.
Physical therapists (PTs) in private practice and other providers who participate in the physician quality reporting system (PQRS) are being sent notices from the Centers for Medicare and Medicaid Services (CMS) about a potential 2016 "negative payment adjustment," depending on whether they met satisfactory reporting requirements in 2014. Here's what you need to know:
Who could be affected
The notices affect individual eligible professionals (EPs) and group practices that registered for the 2014 group practice reporting option and billed under the Medicare physician fee schedule for Part B beneficiaries.
What it's about
CMS is following up on a rule that triggers payment adjustments for the affected providers who did not meet satisfactory reporting requirements in 2014. PTs who did not meet the satisfactory reporting requirements for the 2014 reporting year will be subject to a 2.0% penalty in 2016.
How to find out if you're affected
You can access your PQRS report online to find out if you're on the list of providers receiving a payment adjustment.
What you can do about it
If you think that an error was made and you shouldn't be receiving an adjustment, you can request an informal review. But do it soon—CMS says that the review window will only be open for 60 days after notices were sent, and most went out on September 11. Keep in mind that CMS is not issuing hardship exemptions—changes will be made only if CMS has made an error.
CMS issued a fact sheet (.pdf) on the PQRS adjustments that offers details on the notice and additional links to other services and portals, including one that can inform you of all payment adjustments that you may be subject to in 2016, based on your tax identification number. Providers with questions should contact the CMS QualityNet Help Desk at 866/288-8912 (TTY 877/715-6222) or via email@example.com, 7:00 am-7:00 pm Central Time Monday through Friday.
Physical therapists (PTs) and physical therapist assistants (PTAs) participating in APTA's upcoming Virtual Career Fair will have the opportunity to interact with the largest number of employers the event has featured since 2013—and there's still time to get on board.
The September 15 virtual event allows PTs and PTAs to communicate directly with employers from across the country, and in a variety of settings, all from the convenience of their own computers. Participants can check in and out of the job fair at any time during its open hours, 1:00 pm-4:00 pm ET.
And the best part: it's free to APTA members. But to participate, you need to register, and you need to do it soon.
"The Career Fair has always been a great way to help our members take advantage of some unique opportunities, but we're really excited about this particular fair because of the number of employers who will be on hand," said Julie Hilgenberg, APTA senior advertising specialist and fair organizer. "As a job seeker, it's always helpful to be able to directly communicate with a potential employer, and this fair is all about maximizing those connections."
Registration for the APTA Virtual Career Fair is still open, but will be closing soon. Learn more and register via the career fair webpage.
A proposed change in how Medicare would reimburse for lower-limb prostheses is drawing mounting criticism from patients and stakeholder organizations—including APTA. According to the association, the proposals now being considered would negatively affect patients by "restrict[ing] the ability of a therapist to provide the appropriate medically necessary care if they are providing therapy to a patient who has received an ill-fitting, or non-customized prosthetic or component based on Medicare coverage policies."
In a letter submitted to the durable medical equipment administrative contractors (DME MACs), the association takes issue with a proposal developed by the DME MACS that would impose extensive restrictions on who could receive a lower-limb prosthesis, what kind (or kinds) of prosthesis they could get, and when and under which conditions Medicare would pay for the devices. Though the DME MACs contend that the changes are necessary to counteract steep rises in prosthetics expenditures among Medicare beneficiaries, critics including APTA believe the proposal ignores the realities of rehabilitation and shortchanges the importance of clinical judgment.
"APTA understands the difficult balance of providing quality care that is medically necessary while attempting to curtail costs," the association states in its letter. "However, this [local coverage determination] has the potential to result in lower quality of care while ultimately increasing costs. In the long run, costs could be higher to Medicare due to complications associated with prosthetics that were inappropriate for the patient due to restrictive requirements, provided untimely or not provided at all."
APTA's concerns about the proposal range from what it views as overly restrictive definitions of terms in some sections to a lack of clarity in others, and addresses provisions that the association feels would minimize the importance of the expert individualized determinations made by appropriate health care professionals.
Additional problematic areas of the proposal cited by APTA and other organizations include the potential for CMS to restrict patients to older-model artificial legs if the beneficiary has any form of mobility aid (such as a walker or cane) that they would use for limited purposes, and a requirement that the prosthesis must provide "the appearance of a natural gait." In its letter, APTA points out that "'Natural gait' is a subjective term—and potentially discriminatory, particularly when dealing with individuals with disabilities."
Last week, opponents of the proposal staged a protest at the headquarters of the US Department of Health and Human Services (HHS), an event that drew coverage by CNN and other news outlets. The protest effort received a boost from former Nebraska Senator Bob Kerrey, who himself has an amputation and was quoted in a press conference as saying that "this is as stupid a rule as I've ever seen," and that the rule "completely ignores what's going on with amputees."
The comment period on the proposed changes closed on August 31. CMS has not established a timeline on when any new rules would take effect, according to an article in Modern Healthcare.
A recent Wall Street Journal (WSJ) article on the potential overuse of ultrahigh therapy hours among nursing homes prompted a response from APTA that delivers the physical therapy profession's perspective.
"Patient care decisions should be made by clinicians in accordance with their clinical judgment and ultimate professional responsibility to their patients," President Sharon L. Dunn, PT, PhD, OCS, writes in a letter to the editor published on August 26 (registration/sign in maybe required to view WSJ version; access an online copy from APTA here). "Value … should be the primary indicator of performance."
The APTA letter was written after the WSJ published an article citing "copious" use of ultrahigh therapy hours billed to Medicare by skilled nursing facilities (SNFs). That report claims that between 2001 and 2013, the use of the ultrahigh category of rehabilitative therapy reimbursement—720 minutes or more a week per patient—has increased from 7% of patient days in 2002 to 54% of patient days in 2013.
"The challenges to ensuring delivery of appropriate patient care against systems that incentivize volume-based rehabilitation services are, unfortunately, well known to those in the rehabilitation profession," Dunn writes. "It isn't uncommon for rehabilitation professionals to find themselves in situations in which they are pressured to meet goals that have less to do with the patient's needs and more to do with the volume of services provided."
The letter also describes the collaborative efforts of APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA) to push for value-based care based on clinical judgment, not productivity goals. "We are deeply committed to ensuring that the correct incentives are invoked in care delivery in a manner that earns our patients' trust," Dunn writes.
More on the value-vs-volume debate, and APTA's efforts to support practice integrity: APTA, AOTA, ASHA Consensus Statement on Clinical Judgment in Health Care Settings (.pdf); APTA Center for Integrity in Practice website (includes a free course on compliance); "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.
Patient access to physical therapy, legal protection for the term "physical therapy," and the detrimental effects of high patient copays were all part of the discussions taking place at the APTA exhibit booth at the National Conference of State Legislatures (NCSL) Annual Conference held last week in Seattle. This year's conference attracted almost 5,000 state legislators, regulators, association representatives, corporations, and public policy experts from around the country.
APTA staff and volunteers from the Physical Therapy Association of Washington helped to get the policy messages across in conversations with visitors to the booth as well as through the "APTA PT Challenge," a quiz on term protection, copays, and patient access that visitors took to be eligible to enter a drawing for a Fitbit. In addition, the association participated in the annual NCSL "Walk for Wellness," with members of the Washington Chapter leading warm-up exercises.
Also on hand at the APTA booth: a representative from the Federation of State Boards of Physical Therapy, who provided information on the proposed Interstate Licensure Compact for Physical Therapy.
Check out the Storify below to see how the #PTTransforms message is being shared.
Data, data, data. The final rules for inpatient rehabilitation facilities (IRF) payment and the inpatient prospective payment system (IPPS) continue the Centers for Medicare and Medicaid Services' (CMS) effort to put teeth into its push for more quality reporting while offering a mix of payment increases and cuts.
In rules that aren't significantly different from what they were when proposed in April (IRF, IPPS), CMS is applying more pressure to make the shift to a system it describes as being "based on the quality, rather than the quantity of care [health care providers] give patients."
CMS issued fact sheets on both the IRF and IPPS final rules. Here's a quick rundown.
Inpatient Rehabilitation Facilities
Payment: CMS has updated payments in 2016 by 1.8%--about $135 million. No changes were made to facility-level adjustments, which remain frozen at 2014 levels.
The big takeaway: After several years of evaluation, CMS has finally created a standalone market basket for IRFs, which will in turn boost payments. The trade-off: substantially increased quality reporting requirements.
The exclusive IRF market basket will allow CMS to collect outcome measures required by the IMPACT Act, a law that seeks to standardize reporting across postacute care facilities. These measures, which initially will include data on pressure ulcer incidence, falls, and changes in patient function and cognitive function, will be expanded over time. CMS expects to publicly share IRF reporting data beginning in the fall of 2016.
Inpatient Prospective Payment System
Payment: Not surprisingly, it's complicated. Acute care hospitals that successfully participate in the quality reporting program and that are "meaningful" users of electronic health records would receive a .9% payment update. Hospitals that don't successfully participate in the quality reporting program face a one-fourth reduction in that update; facilities that are not meaningful users of EHRS would have their update reduced by one-half.
CMS is also continuing its penalties on high readmission rates. According to an article in Kaiser Health News, the majority of hospitals will face reductions based on 30-day readmission rates between 2011 and 2014. Other reductions include a potential 4.6% overall reduction for long-term care hospitals (LTCHs).
The big takeaway: Data and outcomes. CMS will update the hospital inpatient quality reporting program by adding 7 new measures in 2018 and 2019, and will increase the measures required in the value-based purchasing program. LTCHs will also be required to report the same postacute care measures that will be required of SNFs through the IMPACT Act.
APTA provided comments on both the IRF (.pdf) and IPPS (.pdf) proposed rules, and will develop summary highlights on the final rules in the coming weeks.
Skilled nursing facilities (SNFs) will see a Medicare rate increase next year, although it won't be quite as much as originally proposed by the Centers for Medicare and Medicaid Services (CMS). And while news about next year's payment adjustment almost always gets attention, some of the most notable parts of the new rule are more focused on the future beyond 2016, and what SNFs will be expected to do if they want to avoid penalties—or pursue incentives.
As for payments, the rule rolled out last week by CMS includes a rate increase of 1.2% for 2016, a bump that's down about $70 million from the 1.4% increase proposed earlier this year. Overall, CMS projects aggregate payments to increase by $430 million in 2016.
But the news isn't just about payments. Other parts of the rule are worth noting because of the ways they will change reporting requirements over the next few years. These changes apply to 3 main areas:
The reporting changes are designed to comply with specific mandates in the Affordable Care Act, the Protecting Access to Medicare Act, and the IMPACT Act, but CMS believes the combined effect of the new requirements will be to move the ball closer to the goal of value-based payments. "The final rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people," CMS states in a fact sheet on the changes as proposed in April.
APTA submitted comments on the proposed rule (.pdf), and will develop a summary and highlights guide during the coming weeks.
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