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  • Survey Reveals Differences in Readiness for Payment Reform Among Large Health Care Organizations

    The march toward value-based payment models may be on, but that doesn't mean everyone's moving in lockstep—or even moving at all.

    A new report from EY (formerly Ernst and Young), an accounting and management consulting firm, points out some significant differences in the ways larger health care providers are preparing—or not preparing—for value-driven care. According to the results of a survey of 700 health care executives, 67% of organizations with annual revenue between $100 million and $499 million have not implemented any value-based initiatives in their organizations. Nearly the reverse is true among the highest-earning organizations, where about 62% of the companies earning $5 billion or more a year have implemented value-based payment models, and 47% have started up bundled care models.

    "With market forces pushing for a new care delivery model, many organizations will undoubtedly be dragged into the realm of value," write authors of the report. "Relying on a series of disjointed initiatives to get there is not an effective strategy."

    APTA is working to ensure that physical therapists (PTs) have a solid understanding of what payment reform means by way of resources offered on its Payment Reform webpage. The latest addition to those resources is a short online quiz that can help members assess their readiness for payment reform.

    New Version of Senate Health Care Bill Remains Problematic for APTA

    The latest version of the US Senate's health care legislation may include tweaks intended to please critics of the earlier draft, but the changes aren't enough to alter APTA's position that the bill would decrease access to care for millions of Americans.

    The revised Better Care Reconciliation Act (BCRA) is the Senate's second attempt to rollout a bill that would repeal and replace many provisions of the Affordable Care Act (ACA). The original version of the legislation was withdrawn just before the Senate's July 4th recess, when it became evident that the bill didn't have enough support to reach the floor for debate.

    The new version attempts to woo conservative opponents of the bill by weakening the ACA's requirements around health insurance and mandated essential health benefits (EHBs) that include habilitation and rehabilitation services. In a nod opponents concerned about the BCRA's effect on Medicaid, drafters of the bill also backed off proposals to eliminate some of the taxes associated with the ACA, slowed the phase-out of Medicaid expansion, and included more money for opioid addiction treatment and research.

    Technically, the provisions around EHBs—one of APTA's major areas of concern—are different from the first version of the bill. Rather than allowing states to opt for waivers of requirements that insurance policies contain the EHBs, the new version of the BCRA would allow insurance companies to offer stripped-down policies that don't include EHBs, so long as they offer at least 1 policy option that includes the required benefits. Individuals could choose cheaper low-cost, low-coverage options or more expensive policies with full EHB coverage.

    In practice, however, the results would be the same, according to Justin Elliott, APTA's vice president of governmental affairs.

    "Even with these changes, our concern remains," Elliott said. "Under this legislation, many Americans would find themselves with health care insurance that limits access to needed care, including physical therapist services. However we will continue our discussions with Capitol Hill as the legislative language evolves.”

    The bill's Medicaid provisions include a phase-out of federal funding for Medicaid expansions by 2024, and ties any later increases to inflation rates. APTA and many other organizations remain opposed to phase-out plans as presented so far, given that the changes have the potential to leave millions of Americans uninsured. The Congressional Budget Office will evaluate the entire bill and is anticipated to have estimates on uninsured rates and overall costs early next week.

    For APTA, the central concerns it voiced in its statement on the House of Representatives health care bill haven't changed. During the House debate on the bill, called the American Health Care Act, the association wrote that the 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 association reiterated its position in a May letter to senators as they began their own work on health care legislation.

    Throughout both the House and Senate drafting and debate, APTA has continued to advocate for patient access to appropriate care and participated in a recent briefing on Capitol Hill educating lawmakers on the importance of habilitation and rehabilitation.

    Late this week, it remained unclear whether the Senate bill would be brought to the floor for debate.

    Payment Cuts Avoided in Proposed 2018 Physician Fee Schedule

    The proposed 2018 Medicare physician fee schedule (PFS) released today by the US Centers for Medicare and Medicaid Services (CMS) includes some positive news for physical therapists (PTs)—a proposal to maintain the values of some current procedural terminology (CPT) codes commonly used by PTs, and even increase values for a few.

    The proposed rule is a win for the profession and its ability to serve patients. CMS had been reviewing many of the CPT codes as potentially misvalued, putting them at risk for sizable reductions. The proposal includes no such reductions, a reflection of several years of work by APTA and its partners to maintain code values. Proposed increases in a few of the codes further underscore the effectiveness of those efforts.

    APTA will be advocating to maintain these proposed payment values in the final rule which will be released in November, and will submit comments to CMS by the September 11 deadline.

    CMS has also published a fact sheet summarizing the proposed rule.

    In addition to the fee schedule, CMS also released its proposed rule for the 2018 outpatient prospective payment system.

    APTA regulatory affairs staff are reviewing the proposed rules, and PT in Motion News will publish a follow-up report with more detailed information early next week.

    Senate Recesses Without Health Care Vote: Keep These 3 Things in Mind

    The US Senate will be entering its July 4th weeklong recess without voting on a bill to repeal and replace major provisions of the Affordable Care Act (ACA). The bill as it now stands contains several elements that APTA finds troubling, including the elimination of requirements for coverage of "essential health benefits" (EHBs) including rehabilitation, and changes to Medicaid that would likely reduce patient access to care.

    With the next opportunity for a Senate vote at least a week away, here are few things to keep in mind during the recess:

    1. It's an evolving process.
    The bill originally presented in the Senate is already beginning to morph in an effort to garner support, and it likely will change even more before all is said and done. Will EHBs and better Medicaid coverage become part of the mix? Hard to say, so stay tuned.

    2. Recess is a great time to make a few calls.
    Concerned about what you're seeing in the Senate bill? Contact your legislators—or better yet, attend a town hall if your lawmaker holds one. APTA offers this handy app that makes it easy to take action.

    3. Your association is engaged.
    APTA does not oppose the idea of improving the ACA—something APTA has made clear in its statements on the Senate bill and on the American Health Care Act approved by the US House of Representatives—but the association does oppose any provisions that would create unneeded barriers to care for Americans. And APTA has been at work on Capitol Hill educating lawmakers on the importance of habilitation and rehabilitation.

    So, go ahead. Relax. Light a sparkler. Eat a burger. Watch a parade. But don't forget that there's work to be done.

    PTAs Included in TRICARE? House Committee Takes First Steps

    TRICARE, a major part of the US Department of Defense health care system, has long insisted that physical therapist assistants (PTAs) aren't payable under the program—and for just as long, APTA has advocated that there's no reasonable basis for the exclusion. Now it looks as if APTA's position may be gaining some ground.

    On June 28, the US House of Representatives' Committee on Armed Services approved changes to the 2018 National Defense Authorization Act (NDAA) that gives the US Secretary of Defense marching orders: conduct a review to figure out how to bring PTAs, occupational therapy assistants, and other support personnel in the TRICARE payment system. The changes, brought forward by Reps Ralph Abraham (R-LA) and Ruben Gallego (D-AZ), were incorporated as part of the committee's mark-up of the NDAA.

    The NDAA will move on to a vote by the entire House and, if approved, will be taken up by the Senate. Current language calls for the report from the Secretary of Defense to be completed by April 1, 2018.

    "The amendment in committee is only a first step but an important one," said Michael Hurlbut, APTA senior congressional affairs specialist. "It's a change that we hope will ultimately lead to coverage of PTAs under TRICARE."

    APTA will continue to monitor progress of the legislation and provide updates.

    Coalitions Bring Rehab Message, Powerful Stories to Capitol Hill

    Talk about timing: less than a week after the US Senate unveiled a health care reform bill that threatens to weaken required essential health benefits (EHBs) that include habilitation and rehabilitation, and just days before the Senate's 4th of July recess, a trio of coalitions brought its powerful message to Capitol Hill: don't make changes that would limit access to these areas of care. APTA is a member of all 3 coalitions.

    The briefing, sponsored by the Habilitation Benefits Coalition, the Coalition to Preserve Rehabilitation, and the Independence Through Enhancement of Medicare and Medicaid Coalition, not only highlighted the value of rehabilitation and habilitation services and devices, it included compelling firsthand accounts of how access to these services and devices made all the difference in people’s lives.

    Sen Tammy Duckworth (D-IL) was on hand to tell the story of her care and rehabilitation after losing both legs while serving in the Army in Iraq. She described the "excellent" care at Walter Reed Medical Hospital, and how, through taxpayer support of Veterans Affairs, she was able to receive rehabilitation and needed prostheses. She said that in subsequent conversations with nonmilitary people, she often was told how they were saving up so that one day they would be able to afford the care and devices Duckworth received.

    "I realized how different the world was for people who have access to the care they need from those, who are the majority of Americans, who don't," Duckworth said. "And that's not right."

    Roseann Sdoia, a survivor of the 2014 Boston Marathon bombing, echoed Duckworth's opinion on the importance of accessible rehabilitation and devices. She described not only the costs associated with prostheses, but the considerable time that must be spent in physical therapy and occupational therapy to learn how to live with the devices. "I wouldn't be able to use those devices if I didn't have the rehab that taught me how to use them," she said.

    In addition to the briefing, coalition representatives, including APTA staff, visited 50 Senate offices.

    "The briefing was an effective way to highlight the importance of habilitation and rehabilitation in health care, particularly in light of the debate now taking place over health care reform," said Michael Matlack, APTA director of congressional affairs. "But we aren't stopping there. APTA will be working with these coalitions to continue to deliver that message while Congress is in recess and after it returns."

    2017 - 0629 - Rehab Hill Briefing

    News at NEXT: Sparking an 'Industrial Revolution' in Primary Care

    Sure, physical therapists (PTs) can explain the important role they could play in primary care. But is anyone listening? And what will it take to get physicians, facilities, and payers to take notice and act?

    From there, the questions get even more complex. Even if PTs manage to win over primary care stakeholders, is the current health care system prepared to make widespread PT involvement the rule and not the exception? And are PT education programs ready to provide the necessary training to support this new world of care?

    This seeming Gordian knot was the feature of this year's Rothstein Roundtable, part of APTA's NEXT Conference and Exposition. The title of the session—"Does Primary Care Need an Industrial Revolution?"—hinted at the panelists' consensus that some big changes need to happen, and it isn't going to be easy.

    Moderator Anthony Delitto, PT, PhD, began the discussion by noting a disconnect between patients' perceptions of primary and alternative care versus the realities of the health care environment. It's a disconnect that can leave PTs in a kind of limbo: when it comes to musculoskeletal pain and dysfunction, "the people who want alternative care … go to a chiropractor," he said, because they don't consider physical therapy an "alternative" treatment. And yet, PTs are not well-integrated into primary care settings, making it harder for the primary care patient to get the effective treatment they need quickly.

    "We need to figure out ways to better manage patients," Delitto said.

    The challenges to better patient management are fundamental, beginning with the primary care physicians themselves, according to Robert Saper, MD, who is working with Delitto on a PCORI-funded pragmatic trial examining whether or not prompt referral to psychologically informed physical therapy for patients with acute low back pain can reduce the risk of developing chronic back pain.

    "Primary care physicians do not know anything about physical therapy," Saper told the audience. " They don't know about the different [physical therapist] interventions. They don't understand your notes." The lack of understanding isn't necessarily surprising given the limited opportunities for physicians and PTs to interact, Saper said, adding that "the only reason I know [what PTs bring to the table in primary care settings] is because I crossed the bridge."

    Addressing that gap will require changes to physician education, and could be helped by simply getting PTs and primary care docs to physically work closer to each other. But as panelist Adam Goode, PT, DPT, PhD, pointed out, "co-location" alone isn't enough, because even when PTs and physicians share space, "we're still not seeing [a significant increase in] referrals."

    Panelists agreed that PTs need to become fully integrated into the primary care team. According to Saper, this means including PTs in rounds, case review meetings, and informal, regular conversations about care. "We have to get off our computers … and talk to each other."

    Saper and others provided examples of how this true integration has led to more effective primary care. All agreed that it takes more than an enlightened physician to make it happen, with panelist Jason Beneciuk, PT, DPT, PhD, MPH, noting that "executive support of systems like this is needed in order for [integration] to happen." Saper added that there were also logistical issues to be considered—things like scheduling, billing, and charting.

    Panelist Jay Irrgang, PT, PhD, scientific director of APTA's Physical Therapy Outcomes Registry, commented that "the physical therapist has got to be involved in triage of the patient." This could require a shared classification-based treatment system, he said, but the bottom line is "to realize what you can do quickly."

    "When a patient comes to a physician, they want something then," Irrgang said. "They want to fix the problem immediately." PTs may be the best option for doing just that, but referrals to physical therapist services often involve waits for the first appointment—and the first appointment usually is an evaluation, not a treatment session—representing a missed opportunity.

    Delitto proposed that the true proving grounds for more integrative systems could be in primary care facilities that operate on a "shoestring" budget, such as free clinics, which are more willing to take what bigger facilities would view as a risk. Panelists considered various possibilities, but seemed to agree that as long as volume-based payment systems rule the roost in health care, PT integration into primary care won't grow at the rate needed by patients.

    Beneciuk called the payment issue "the elephant in the room," saying that some providers might resist PTs in primary care, thinking "'you're not going to take that patient away from me.'"

    But making the case for an industrial revolution in primary care faces a catch-22: more outcomes data are needed to substantiate the effectiveness of an integrated PT role, but without wide integration of PTs, data can't be generated quickly enough.

    Delitto and Irrgang are Catherine Worthingham Fellows of APTA. Beneciuk is a Fellow of the American Academy of Orthopaedic Manual Physical Therapy, and Goode is a Fellow of the Center on Health Services Training and Research (CoHSTAR).

     

     

    CMS Proposes 2018 Quality Payment Program Rule: Here's What PTs Need to Know

    The US Centers for Medicare and Medicaid Services (CMS) may have slowed down the pace at which it is implementing the move toward quality-based payment, but that doesn't mean physical therapists (PTs) should be taking a business-as-usual attitude.

    With the release of its 2018 proposed rule for quality payment, CMS is taking some of the pressure off clinicians and groups with smaller practices or low numbers of Medicare patients to meet Merit-Based Incentive Payment System (MIPS) requirements. Still, the shift away from fee-for-service models continues, and even though PT participation in MIPS is still voluntary next year, it's almost a given that PTs will be mandatorily included as early as 2019.

    Details on the proposed rule are available from CMS, but here are a PT's 4 most important takeaways:

    1. Get involved in alternative payment models (APMs) now.
      Participating in an advanced APM could give you a 5% incentive payment with every year of successful participation. CMS offers a webpage specifically devoted to learning more about participating in APMs.
    2. APMs: They aren't just about Medicare.
      Don't limit your participation in APMs to only Medicare-based programs. According to CMS, beginning in 2019—the year PTs could be required to participate in MIPS—becoming a qualified provider through the "all payer combination option" will require the provider to participate in APMs with both CMS as well as an "other payer."
    3. Take MIPS for a test drive.
      PTs aren't formally included in MIPS, meaning reporting scores won't yet affect future payment adjustments. But you can report under MIPs voluntarily, which will help prepare you for future years when PTs are likely to be required to participate.
    4. Get with the technology.
      As health care moves to outcomes-based payment, it will be critical for PTs to have access to real-time clinical data to understand how they perform, identify areas to improve quality, and manage patient populations. Without data physical therapists will be unable to receive future incentive payments. APTA's Physical Therapy Outcomes Registry will have the ability to extract information from electronic health records, allowing your clinical data to be readily usable and actionable.

    New at PTJ: Open-Access 'Best of the Best' Collection Focuses on LBP and Neck Pain

    As far as APTA's science journal Physical Therapy (PTJ) is concerned, "greatest hits" collections aren't just for musicians—and it's proving that point by issuing a special collection of PTJ articles on low back pain (LBP) and neck pain, all free to the public.

    Now available from PTJ: a new online-only "best of the best" issue that gathers PTJ articles from the past 2 years focused on conditions that loom large in both health care costs and clinician time. Articles reflect a range of themes and approaches, and include opinion pieces, cohort studies, and randomized controlled trials.

    Some of the hits include:

    Treatment-based classification systems for low back pain should include triage and consider psychosocial comorbidities. In this "Perspective" article, authors present a new and improved version of the treatment-based classification system included in the APTA clinical practice guidelines for LBP. Authors advocate for a 2-level triage process as well as the need to evaluate a patient’s psychosocial status.

    Taping isn’t shown to be effective for managing spinal pain . Based on the limited research available, authors find no real support for any type of taping for a variety of spinal pain diagnoses.

    Global postural re-education (GPR) can reduce pain and disability for neck pain .The randomized controlled trial found that GPR was more effective than manual therapy for patients with chronic, nonspecific neck pain.

    Cognitive functional therapy is a "promising" intervention for nonspecific chronic low back pain . In a cohort study, researchers found significant reductions in pain, functional disability, and a number of psychosocial outcomes.

    Trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain are "red flags" for vertebral fracture in older adults . In patients over 75 years of age, trauma had the highest predictive value for a vertebral fracture diagnosis by their general practitioner.

    The Godelieve Denys-Struyf (GDS) method was better than standard interventions for low back pain . Researchers in Spain found that this motor control intervention improved disability scores more than a control group receiving transcutaneous electrical nerve stimulation, microwave treatment, and standardized exercises.

    APTA 2017 House of Delegates Election Results Announced

    The following members were elected to APTA's Board of Directors and Nominating Committee on Monday, June 19, at the 2017 House of Delegates in Boston, Massachusetts.

    Jeanine Gunn, PT, DPT, was elected treasurer.

    Susan Griffin, PT, DPT, MS, was reelected speaker.

    Matthew Hyland, PT, PhD, MPA, and Sheila Nicholson, PT, DPT, JD, MBA, MA, were reelected directors, and Anthony DiFilippo, PT, DPT, MEd, and Cynthia Armstrong, PT, DPT, were elected director. Armstrong will serve the 1-year remainder of Gunn's unexpired term as director.

    Michael Eisenhart, PT, and Rupal Patel, PT, PhD, were elected to the Nominating Committee.

    These terms become effective at the close of the House of Delegates on Wednesday.