Researchers at The Ohio State University have successfully engineered an electronic neural bypass system that has allowed an individual who is quadriplegic to move his hand and fingers with his thoughts alone.
The system, dubbed Neurobridge, connects a microchip implanted on the motor cortex of a patient's brain to a computer, which uses algorithms to learn and interpret the patient's brain signals and send them on to a sleeve that stimulates the muscles required to perform a certain movement. Total time from thought to movement is reported to be less than a tenth of a second.
The system debuted recently when Ian Burkhart, a 23-year-old man who was paralyzed in a swimming accident, clenched and unclenched his fingers, rotated his wrist, and picked up a spoon. Stories and videos on the trial have appeared in The Washington Post, ABC News, and Computerworld, among other media outlets.
The proposed 2015 Medicare physician fee schedule (PFS) rule released July 3 would result in an estimated 20.9% reduction in payments beginning April 1, 2015, unless congressional action is taken to avert sustainable growth rate (SGR) reductions. If those reductions are avoided, the rule’s aggregate impact on payment is a positive 1% for outpatient physical therapy services. Either way, the first quarter of 2015 would see no change in payment rate due to the Protecting Access to Medicare Act (PAMA) of 2014, provides for 0% PFS update for services furnished between January 1, 2015 and March 31, 2015.
Additional proposed policies that will impact physical therapists include updates to the Physician Quality Reporting System (PQRS) program, CMS’s proposal to review the values that determine payment for a number of CPT codes reported by physical therapists, and a proposal for a new process for establishing PFS payment rates that is more transparent.
The proposed rule will be published in the July 11, 2014, Federal Register. The public will have until September 2, 2014, to submit comments in response to this rule, and APTA will submit comments on behalf of its members. After reviewing public comments, CMS will publish a final rule on or about November 1, which will become effective for services furnished during 2015. APTA will provide a more detailed summary of the rule in the upcoming week.
The rule proposed July 3 by the Centers for Medicare and Medicaid Services (CMS) includes a 2.1% increase in payment rates for 2015 under the outpatient prospective payment system (OPPS) and changes to hospital admissions requirements.
The proposed rules affect hospital outpatient departments and ambulatory surgical centers beginning January 1, 2015. Proposals include the implementation of comprehensive payments for certain services, clarification of the requirement for an admission order for all hospital inpatient admissions, and a change that will require physician certification for hospital inpatient admissions only for long-stay cases and outlier cases, not short stays.
Informed by comments received regarding the requirements for a physician certification of hospital short stays, CMS clarifies that admission orders are a condition of payment for all inpatient hospital admissions. However, CMS will require a physician certification only for long-stay cases (20 days or more) and outlier cases. CMS states that the admission order, medical record, and progress notes must contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification for shorter stays.
The rule also proposes the implementation of the 2014 OPPS final rule policy creating 28 comprehensive ambulatory payment classifications (APCs) to handle payment for the most costly device-dependent services. The policy would treat all individually reported codes as components of a comprehensive service, resulting in a single prospective payment based on the cost of all individually reported codes. CMS will make a single payment for the comprehensive service based on all charges on the claim, and charges for services that cannot be covered separately by Medicare Part B or that are not payable under the OPPS will not be reimbursed. Further, CMS proposes to conditionally package certain ancillary services when they are integral, ancillary, supportive, dependent, or adjunctive to a primary service.
In addition, CMS proposes to change its consideration of requests the expansion of physician-owned hospitals under the physician self-referral regulations and establishes an appeal process for Medicare Advantage organizations regarding CMS-identified overpayments.
Most physical therapy services provided in the outpatient hospital department are not paid under the OPPS and are paid instead under the Medicare Physician Fee Schedule (PFS) (see related news story on the proposed PFS for 2015), though a small subset of ‘‘sometimes therapy’’ physical therapy services are paid under the OPPS when they are not furnished as therapy, meaning not under a certified therapy plan of care. CMS provides an annual update of these “sometimes therapy” services subject to direct supervision requirements. The update can be found at http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.
The proposed rule will be published in the July 11, 2014, Federal Register. Comments on the rule are due September 2, 2014. APTA will submit comments on behalf of its members. A detailed summary of the rule will be available for APTA members shortly.
Estimating a net decrease of .3% to home health agencies for next year, the Centers for Medicare and Medicaid Services (CMS) has released its proposed rule for the Home Health Prospective Payment System (HH PPS) for 2015. The rule proposes a home health market basket update of 2.2% adjusted for multifactor productivity as mandated by the Affordable Care Act (ACA), and includes a requirement that functional therapy reassessments be conducted every 14 days.
CMS will implement the second year of the ACA-mandated 4-year phase-in for rebasing adjustments to the HH PPS payment rate by decreasing home health payment by 3.5 percent. The proposed national, standardized 60-day episode payment for 2015 is $2,922.76. The proposed per-visit amount for physical therapy in 2015 is $139.73 for home health agencies (HHAs) in compliance with quality reporting requirements.
Other rules have been proposed it the following areas:
Last, CMS invites comments on a pilot value-based purchasing (VBP) model for HHAs that would begin in 2016. CMS hopes to test the model in up to 8 states.
APTA staff is conducting a complete review of the proposed rule and will provide a detailed summary in the coming days.
A new report comparing some common tests, procedures, and treatments has found that hospital outpatient departments (HOPDs) consistently charge more than community-based settings for the same services. For physical therapy, HOPDs charged on average 50% more than freestanding clinics.
The study, conducted by the former Center for Studying Health System Change and published by the National Institute for Health Care Reform, used private insurance claims data from 2011 for about 590,000 active and retired nonelderly autoworkers and their dependents to track charges for magnetic resonance imaging (MRI) of the knee, colonoscopies, common laboratory tests, and physical therapy. What researchers found was that where the service was provided made a big difference in how much was charged.
In looking at physical therapy, the study's authors limited investigations to therapeutic exercise and manual therapy—"2 common physical therapy services" that accounted for $25.9 million of the $38 million spent on physical therapy among the claims analyzed, according to the report. Their findings: in looking at 136,000 services provided, "average prices were 41 percent and 64 percent higher in HOPDs for therapeutic exercises and manual therapy, respectively, than in community settings."
While not significant enough to account for the differences, the study notes that patients receiving physical therapy in HOPDs were somewhat "sicker" than patients receiving the other procedures, treatments, and tests studied.. " The authors write, "the health status difference might be explained because patients with hospital inpatient stays—say for a knee replacement—are more likely to be referred to physical therapy in HOPDs than in community settings."
Other findings in the report pointed to some even more dramatic differences. These include:
Authors write that the findings show that there is an opportunity for private insurers to reduce spending by looking at ways to incentivize the use of lower-priced community providers through excluding higher-priced providers from networks, implementing a tiered system that requires patients to pay more when using these providers, or capping the amount of payment to in network providers for particular services.
The use of predictive analytics—the same kind of technology credit card companies use to spot questionable spending activities—has enabled the US Centers for Medicare and Medicaid Services (CMS) to recover or prevent more than $210 million in improper payments in 2013. The savings are nearly double the amount identified during the previous year using the system, according to a report issued in June (.pdf).
According to CMS, the "predictive algorithms and other sophisticated analytics" that are now run nationwide against all Medicare fee-for-service claims are doing a good job of identifying fraudulent billing before payment is made. The process, called the Fraud Prevention System (FPS), is helping to move the agency away from heavy reliance on the "pay and chase" model that has met with mixed success.
The technology is analogous to the processes used by credit card companies to identify potential fraud. CMS monitors which Medicare identification numbers are used and by who (similar to tracking credit card charges made in one location when the cardholder lives far away from the place of purchase), billing frequency that is outside the norms (similar to flagging excessive credit card charges made in a short amount of time), patterns of billing (similar to credit card charges that echo patterns of known bad actors), and links between a provider and other known bad actors (similar to monitoring certain addresses for credit card charges).
CMS adopted the technology in 2011 as required by the Small Business Jobs Act of 2010. In its first full year of operation, the system produced a 3:1 return on investment. Last year, that ratio jumped to 5:1.
"The majority of health care providers enrolled in Medicare are honest, reliable business partners," CMS states in the report. "The FPS, as currently implemented, is not designed to flag transactions from this sort of provider; rather, the FPS is geared towards discovering egregiously improper patterns of billing–often amounting to fraud."
APTA is helping physical therapists (PTs) understand regulations and payment systems through its Integrity in Practice campaign that puts them in touch with tools and resources to promote evidence-based practice, ethics, and professionalism.
Check out the latest addition to the Integrity in Practice webpage:
Preventing Fraud, Abuse, and Waste: A Primer for Physical Therapists (.pdf)
is a free guide that examines not only the laws around these issues but the ways in which PTs can avoid fraud, abuse, and waste with payers, referral sources, and patients.
America's physicians aren't educating their patients on weight, diet, and physical activity because America's physicians aren't themselves educated on weight, diet, and physical activity. That needs to change, and soon, according to a coalition of organizations calling for more coverage of these issues in medical schools.
In a recently released white paper (.pdf), titled "Training Doctors for Preventive Care," the Bipartisan Policy Center, the Alliance for a Healthier Generation, and the American College of Sports Medicine write that "America's medical education and health care delivery system does not currently provide doctors with the experience or incentives to deliver messages about weight, diet, physical activity, and chronic disease in a consistent and effective manner." The paper asserts that even while obesity rates in the US have been climbing, the average number of hours devoted to nutrition education has been dropping to the extent that now fewer than 30% of medical schools provide the minimum hours of nutrition education recommended by the National Academy of Sciences. The group also released an infographic (.pdf) highlighting the problem.
According to the coalition, physicians are aware of the gap in training: a recent survey found that only 1 in 4 doctors feel they received adequate training on how to counsel patients on diet or physical activity.
In the white paper, the organizations make 9 recommendations that they believe will begin to fix the problem, including the development of standard nutrition and physical activity curricula, increased nutrition and physical activity requirements for residencies and continuing education, reimbursement of health services "that target lifestyle factors such as nutrition and exercise," and the expansion of board-accredited training programs "to create a cadre of experts in nutrition and physical activity who can teach health professionals." The coalition's recommendations were featured recently in a Washington Post report.
"Ensuring that medical professionals have the tools and expertise to address nutrition and physical activity is only one part" of a broader agenda to reduce obesity and chronic disease nationwide, the report states. "Nonetheless, it is an area where practical improvements are within reach, if policymakers and stakeholders work together to implement changes."
APTA has long supported the promotion of physical activity and the value of physical fitness, and is involved with the National Physical Activity Plan (NPAP), where the association has a seat on the NPAP Alliance board. The association also offers several resources on obesity, including continuing education on childhood obesity, and a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity.
Is that advertised offer of a low-cost screening for stroke risk and heart disease good public health outreach or an "unethical" exercise in "fear mongering?" According to a consumer group that issued strongly worded letters to 20 hospital systems, the answer is clear—and hospitals need to do something.
Public Citizen announced last week that it is calling on hospital systems across the country to sever partnerships with companies providing the screenings, which are usually well-advertised and often provided in buses adapted for the purpose. Public Citizen asserts that administering the screening to asymptomatic, unselected individuals is an "unethical" and "exploitative" practice that "is more likely to cause harm than benefit."
The group's efforts are focused on screening packages from HealthFair that include 6 tests: echocardiogram, electrocardiogram, carotid artery ultrasound, abdominal aortic aneurysm ultrasound, hardening of the arteries test, and peripheral arterial disease test. When administered to asymptomatic individuals, the group writes, the tests can yield false-positive results that can lead to "unnecessary, risky, and costly diagnostic procedures and treatment interventions" or can result in overdiagnosis, "in which individuals are diagnosed with conditions that will never cause symptoms or death."
In its letter to hospitals, Public Citizen minces no words about the screenings. "It is exploitative to promote and provide medically nonbeneficial testing through the use of misleading and fearmongering advertisements and solicitations in order to general medically unnecessary but profitable referrals to your institution," the group writes, adding that "this screening violates the ethical principles of beneficence … and nonmaleficence."
The questions around the appropriateness of certain tests are similar to other efforts being made within the broader health care provider community. For instance, the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign is centered around lists of procedures (.pdf) that tend to be done frequently, yet whose usefulness is called into question by evidence. APTA was 1 of the first 3 nonphysician organizations invited to join the campaign, and the association has included its participation within APTA's wider "Integrity in Practice" initiative.
The newly confirmed Secretary of Health and Human Services can put another item on her "to do" list—changing Medicare payment policy to allow for accountable care organizations (ACOs) to receive payment for telehealth and remote patient monitoring, including when used as part of physical therapy. At least that's what a coalition of health care-related organizations and a tech corporation would like to see, anyway.
According to a June 11 article in Medscape (free one-time registration required), organizations including the Alliance for Connected Care, the American Telemedicine Association, and the National Association of ACOs have requested that Secretary Sylvia Matthews Burwell look at expanding Medicare's coverage of telehealth beyond beneficiaries in rural areas who must travel to "originating sites." This could be done, the letters argue, if Burwell were to waive restrictions in the Medicare Shared Savings Program.
The letter from the American Telemedicine Association, the Health Information and Management Systems Society, and 10 other nonprofit organizations and for-profit corporations argues that current Medicare regulations "place arduous restrictions on telehealth services which limit patient access to new technologies, effectively discouraging providers from utilizing advanced … solutions in their practices." The letter lists physical therapy as one of the services that could benefit from a new approach that would lower costs and improve outcomes.
The letter estimates that current Medicare restrictions disqualify 80% of Medicare beneficiaries who don't happen to live in a setting defined as "rural," and that coverage is denied for service that originates from a patient's home or other nonmedical location, such as hospice.
The news is, there's no news: once again, the United States ranks first among industrialized nations in health care spending but lands near the bottom on most health care outcomes, and winds up in last place overall.
The Commonwealth Fund has released its Mirror Mirror report on health care among 11 wealthy countries, and just as in 2010, 2007, 2006, and 2004, the US is found to have an expensive system that comes in dead last in efficiency, equity, and mortality/life expectancy—and near the bottom in most other measures.
The report compared spending and outcomes among Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the US. The report estimates per-capita health expenditures in the US at just over $8500, almost $3,000 more than the next highest rate (Switzerland), and more than $5,000 above the UK, the country with the highest-rated health care system overall.
Switzerland was ranked second to UK, with Sweden, Australia, and Germany next in line. Canada was ranked second-to-last. Although the US did do well in preventive care, waiting times, and specialist care, it lagged behind in access to services and the ability to receive prompt service from primary care physicians, according to the report.
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