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  • Updated MedPAC 'Payment Basics' Series Provides Medicare Payment System Overview

    Given some of the major shifts in the Medicare payment landscape over the past few years, gaining an understanding of even the big-picture workings of the system can be a tall order. The Medicare Payment Advisory Commission (MedPAC) offers an updated resource that can help.

    Now available for free download: MedPAC's latest version of "Payment Basics," a series of informational sheets that describe the need-to-know elements of 20 different Medicare payment systems. Areas covered include outpatient therapy, skilled nursing facilities, home health services, hospital acute inpatient services, and more. The newest version of the resource updates the 2015 edition.

    Most information sheets provide background on how the system is organized and flowcharts for a visual representation of how that particular payment system works.

    Quick facts from MedPAC Payment Basics: According to the MedPAC report on outpatient therapy, in 2016 Medicare spent $7.6 billion on outpatient therapy services, a 6% increase from 2015. Physical therapy services accounted for 72% of all spending in this area. In terms of settings, nursing facilities and physical therapy private practice clinics accounted for 71% of the spending, at 37% and 33%, respectively. Hospitals were next, at 16%.

    New Report Looks at Link Between Surgery-Related Opioid Prescriptions, Later Opioid Abuse

    Calling surgery "a long-ignored gateway to persistent opioid use, dependence, and addiction," the Plan Against Pain (PAP) has issued a new report that focuses on the relationship between opioid prescriptions for surgical procedures and later opioid dependence and abuse. The bottom line: though there are glimmers of hope, the overall outlook remains bleak, with 12% of patients who had a soft tissue or orthopedic operation in the past year reporting that they had become addicted or dependent on opioids after surgery. APTA's #ChoosePT opioid awareness campaign is a Selected Partner of PAP.

    The report, which tracks surgery-related prescribing rates overall and as linked to 7 common surgical procedures—including total knee arthroplasty (TKA), total hip arthroplasty (THA), and rotator cuff repair—also breaks down statistics by demographic and geographic variables. Researchers relied on data from the National Prescription Audit, the PharMetrics Plus Database, and surveys of 500 US adults who had soft tissue or orthopedic surgery in the past 12 months. In addition, 200 surgeons were surveyed to assess, among other issues, their motivations for prescribing opioids. The study results were released on October 10 in conjunction with the "Summit for Solutions" event In Washington, D.C., attended by APTA.

    Among the findings:

    Overall opioid prescription numbers are declining, but state rates vary dramatically.
    Nationally, in 2017, there were enough opioids prescribed to supply every person in the US with 32 pills, only a slight decrease from the 36-pill rate reported in 2016. And while every state in the country reported a drop in opioid use in 2017, those reductions varied widely, and the improvements for some states, while significant, only made a dire situation slightly better. Example: Alabama, the nation's top opioid-prescribing state, recorded a 10% decrease in opioid prescriptions between 2016 and 2017, but that only brought its opioid pills-per-resident ratio down to 65 pills for every resident—more than twice the national average.

    Progress has been slow in reducing opioid prescription rates related to surgery.
    Researchers found that among the 7 surgeries studied—TKA, THA, rotator cuff surgery, hysterectomy, hernia surgery, colectomy, and sleeve gastrectomy—the average number of opioid pills prescribed dropped, but only slightly, from 85 pills per patient to 82. Authors of the report speculate that the slow progress could be due in part to the level of pressure surgeons feel to prescribe more opioids then they feel are necessary—a pressure reported by 66% of surgeons surveyed.

    The number of pills prescribed doesn't tell the whole story. The use of fewer pills at a higher potency also poses a risk—especially for orthopedic patients.
    The study found that more than half of patients undergoing TKA, THA, and rotator cuff surgery were prescribed opioids of 50 or more morphine milligram equivalents (MMEs), more than double the 20 MME dosage recommended by the US Centers for Disease Control and Prevention (CDC). Nearly 1 in 4 orthopedic patients received prescriptions in excess of 90 MMEs per day, an amount that the CDC says poses a serious overdose risk.

    Average rate of later opioid dependence and addiction among surgical patients hovered at 12%, but was higher for TKA patients.
    Patients who received colectomy reported the highest incidence of later dependence, at 17%, but TKA patients weren't far behind, with a 15.2% rate of later misuse. Rotator cuff surgery and THA patients reported lower rates of later dependence, at 9.5% and 9.3% respectively. The 12% overall average is an increase from the 2017 study, which estimated the later dependence rate at 9%.

    Women—and Millennial women in particular—are the most at-risk for becoming "newly persistent" opioid users after surgery.
    Women were found to be 40% more likely than men to become "newly persistent" users—individuals who received opioid prescriptions 90 to 180 days post-discharge. Millennial women were found to be particularly at-risk, with more than 10% reporting persistent use, compared with 6% or Millennial men. The persistent use rate for Millennial women in the 2018 PAP study represents a 17% jump from the previous survey.

    Authors of the report believe that until better guidelines are developed it's unlikely gains can be made in more careful use of opioids related to postsurgical pain. Although there has been some progress in this area, they write, more needs to be done to "relieve the pressure surgeons often feel to prescribe more opioids than patients actually need and help set patient expectations on the amount of opioids they'll be prescribed."

    "[The lack of clear guidelines] has left surgeons mainly on their own in determining the appropriate quantity and strength of opioids needed to address their patients' pain," authors write. "As this report reveals, the absence of clear guidelines has led to tremendous variation in prescribing patterns and a great deal of overprescribing that can lead to persistent opioid use, addiction and dependence among patients, as well as unused pills that can be misused or abused by others."

    APTA has been heavily engaged in the fight against opioid misuse on several fronts. In addition to its flagship #ChoosePT opioid awareness campaign, the association also hosted a Facebook Live panel discussion and satellite media tour to highlight the effectiveness of nonopioid approaches to pain management. In addition, APTA produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship.

    Massive APTA-Supported Opioid Bill Ready for President's Signature

    Expansive legislation aimed at battling the opioid crisis will soon become law, complete with provisions that echo APTA's recommendations for education on—and patient access to—nonopioid approaches to pain management.

    On October 3 the US Senate passed the final version of the legislation by a 98-1 margin after the US House of Representatives passed the measure, 393-8. The bill is headed to the White House, where President Donald Trump is expected to sign it into law.

    The legislation is wide-ranging, covering treatment for opioid addiction and use disorder, initiatives to help promote nonopioid alternatives to pain management, and stepped-up efforts to prevent foreign shipments of illegal opioids such as fentanyl, among other provisions. Changes included in the bill affect "almost every federal agency," according to a report in The Washington Post.

    APTA strongly supported passage of the bill and worked with legislators and staff to advocate for policies that emphasize patient education and clinical research on pain and how it can be effectively managed without the overuse of opioids. The final version of the legislation echoes many of the recommendations included in an APTA white paper on the opioid crisis. Titled "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health," the document advocates for better public awareness efforts and improved benefit design for both public and private health plans.

    "The bill now on its way to the White House represents a significant step in the right direction," said Kristina Weger, APTA congressional affairs senior specialist. "But there's much more work to be done—there are many provisions that direct agencies to begin reviews and studies on potential changes that we may not see for years. We need to continue our advocacy and outreach to help fight this crisis."

    Among the components of the legislation:

    • Clarification of states' abilities under Medicaid to provide care for infants with neonatal abstinence syndrome in neonatal residential pediatric recovery centers
    • Increased screening for opioid use disorder and other substance use disorders during Medicare wellness and preventive care visits
    • Better education for Medicare beneficiaries on opioid use and pain management, including more information on nonopioid approaches and advice to discuss opioid use and pain management with their physicians
    • Direction that the US Department of Health and Human Services (HHS) submit a report to Congress on how to improve reimbursement and coverage for multidisciplinary, evidence-based nonopioid treatment for chronic pain, due within a year after the legislation is signed into law
    • Stepped-up guidance from HHS to Medicare-participating hospitals for reducing opioid use, developed in consultation with health care organizations, consumers, and other stakeholders
    • Establishment of an HHS technical expert panel to provide recommendations for best practices in surgical settings, including limits on the use of opioids in perioperative settings, with a report due within 1 year of the law's enactment
    • More information on the risks of opioid use and better coverage for nonopioid alternatives to pain management in Medicare Advantage plans and Medicare Part D prescription drug plans beginning in 2021
    • Expanded research overseen by the Interagency Pain Research Coordinating Committee to include investigations into best practices for the use of nonpharmacological pain treatments
    • Development of a demonstration program to test alternative pain management protocols in hospital emergency departments

    APTA's involvement in addressing the opioid crisis dates back to late 2015 and includes the award-winning #ChoosePT public awareness campaign. The association is urging members to promote the profession's role in effective pain management during October as part of National Physical Therapy Month, and recently a physical therapy student-led "flash action strategy" focused on nonopioid pain management for an intensive 48-hour advocacy campaign with legislators on Capitol Hill. APTA also hosted a satellite media tour on the issue that resulted in more than 200 television and radio interviews across the country to an audience of more than 13.1 million, and in February hosted a Facebook Live event, "Beyond Opioids: Transforming Pain Management to Improve Health."

    New Pediatric mTBI Guidelines from CDC Take Comprehensive Approach

    In light of what it describes as a "significant public health concern," the US Centers for Disease Control and Prevention (CDC) has issued what it says are the first-ever comprehensive clinical guidelines for the diagnosis and management of mild traumatic brain injury (mTBI) in children. The 19 sets of recommendations address the condition from diagnosis through management and treatment, and cover settings including primary care, outpatient settings, inpatient care, schools, and emergency departments.

    The resource, published in JAMA Pediatrics and available for free, is organized into 3 main areas—diagnostic recommendations, prognostic recommendations, and recommendations related to management and treatment—with each area containing several recommendations based on extensive literature reviews. The 46 discrete recommendations are organized into 19 topic areas, and include do's and don'ts that cover the gamut from the use of serum testing to diagnose mTBI to the best approaches for talking with families about the injury.

    APTA members John DeWitt, PT, DPT, ATC; and Anne Mucha, PT, DPT, MS, were members of the CDC Pediatric Mild Traumatic Brain Injury Workgroup responsible for development of the recommendations, which are published in JAMA Pediatrics. Additionally, APTA submitted extensive comments on the guidelines during the public comment period during fall of 2017. A number of issues highlighted by APTA were included or addressed in the final version.

    Among the highlights from each broad area:

    Diagnostic recommendations: imaging is (mostly) not necessary, but rating scales and testing are crucial.
    Authors of the guidelines acknowledge that while assessing for intracranial injury (ICI) is important, the use of head computed tomography (CT) should not be routine and that providers should rely more heavily on clinical decision rules including those related to the Glasgow Coma Scale (GCS). The guidelines also caution against the routine use of magnetic resonance imaging (MRI), single photon emission CT, and skull radiographs, but they stress the importance of age-appropriate rating scales and cognitive testing. Authors warn, however, that clinicians shouldn't rely solely on the Standardized Assessment of Concussion to diagnose mTBI in children ages 6 to 18. Also not recommended: the use of "biomarkers" to establish the presence of mTBI "outside of a research setting."

    Prognostic recommendations: providers need to be sensitive to factors that can lead to variation in recovery.
    The guidelines support the idea that providers should help patients and families understand that for 70%-80% of children with mTBI, significant difficulties don't persist past 1 to 3 months after the injury and that "recovery from mTBI is unique and will follow its own trajectory." However, authors also advise providers to evaluate any factors that were present in a child before the mTBI that are linked to delayed recovery, such as learning difficulties, the presence of a neurologic disorder, or a history of previous mTBI. Providers should also assess for any risk factors not related to premorbid health or functional conditions, including socioeconomic factors and the severity of the presenting injury.

    Management and treatment recommendations: the keys are education, continued assessment of progress, and understanding when to refer for specialized care.
    The authors stress the importance of patient and family education around what to look for during recovery from mTBI, including warning signs of more serious injury and management of physical and cognitive activity. The guidelines also provide detailed recommendations on returning to activity and school, and stress the importance of careful monitoring in the classroom and provision of educational supports if necessary. Also included in this section are guidelines around headache management and treatment, and the importance of providers' understanding of when to refer a patient for additional treatment, particularly in the areas of vestibule-oculomotor dysfunction, disordered sleep, and cognitive impairment.

    The CDC is accompanying release of the guidelines with an educational push to promote consistent implementation. In addition to the guidelines themselves, providers can also download resources that include screening tools, online trainings, and fact sheets in support of the recommendations.

    According to authors, the guidelines arrive at a time when pediatric mTBI is on the rise, with more than 2 million outpatient visits and just under 3 million emergency department visits for mTBI in children taking place between 2005 and 2009. The CDC believes its resource is the first comprehensive set of mTBI guidelines focused exclusively on children in the US.

    Physical therapists (PTs) play an important role in the treatment of individuals who have suffered concussions. Get the latest information on these injuries and what’s being done to reduce them at the APTA traumatic brain injury webpage (look under the "Concussion or mTBI" header). Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Short-Term Insurance Rule Adds More Uncertainty to Care

    As APTA continues to advocate for the maintenance of essential health benefits (EHBs) in insurance offered through Affordable Care Act (ACA) marketplaces, the association and other stakeholders are facing another potential challenge to patient access to care: private insurer short-term, temporary health plans that can skirt many ACA requirements around EHBs, preexisting conditions, and continued coverage.

    Earlier this month, the Department of Health and Human Services (HHS) adopted a final rule on the short-term plans, allowing the policies to provide 1 year of coverage, renewable for up to 3 years. Previously, the plans could only be used for a maximum of 3 months.

    The plans are intended to offer a cheaper insurance alternative than plans available through the ACA (although most individuals who purchase insurance through the ACA marketplaces receive subsidies that lower the out-of-pocket costs). But they are not required to comply with many of the consumer protections included in ACA plans. Instead, the plans are able to deny coverage of a preexisting condition, drop coverage should a customer's health status change, and refuse coverage for services such as mental health, prescription drugs—and, possibly, physical therapy.

    "These plans create more options, but they also create more uncertainty for patients and physical therapists," said Kate Gilliard, APTA regulatory affairs senior specialist. "We're concerned that, perhaps unknowingly, patients who purchase these plans may be moving onto plans that don't cover physical therapy or that offer very limited physical therapy benefits."

    Gilliard said the short-term plans were a hot topic at a recent National Association of Insurance Commissioners (NAIC) conference she attended as a representative of APTA.

    "The plans received mixed reviews from the commissioners," Gilliard said. "Some states openly thanked HHS for allowing more consumer options and for giving states more control over their own markets, but other states criticized the plans for the weaker consumer protections and predicted that the plans will cause prices in the ACA marketplace to rise." According to Gilliard, NAIC attendees described a variety of approaches being taken by states in reaction to the HHS rule, from accepting the provisions as written, to placing shorter time limits on coverage, to banning the plans completely.

    "Many of these states are trying to frame these plans as options that should only be used when consumers are in between major medical plans—like when they are between jobs or waiting for ACA marketplace open enrollment—and not to be relied upon as real, full health insurance," Gilliard said.

    APTA regulatory affairs staff are reviewing the rule to better understand potential impacts to patients and the physical therapy profession. However, the association has already gone on record in support of consistent EHBs and has voiced its opposition to an HHS rule change that allows states to lower the bar on required EHB coverage provisions in so-called "benchmark" plans that set the floor for coverage offered in a state marketplace. Many of the short-term plans are even skimpier than what's being offered through the ACA exchanges, even with the recent benchmark changes.

    "While APTA has always supported the importance of patient choice in health care, we are also committed to advocating for access to needed care and consumer certainty that the care patients receive today will be there tomorrow," said Kara Gainer, APTA's director of regulatory affairs. "Short-term plans offer choice but run the risk of decreasing access and creating uncertainty, and the recent final rule from HHS would appear to make matters worse."

    SNF, IRF Final Rules Follow Through on Proposed Shifts in SNF Payment Systems, IRF Reporting Requirements

    The final 2019 rules for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are substantially similar to what the Centers for Medicare and Medicaid (CMS) proposed in the spring, but that's not to say physical therapists (PTs) should assume it's a "same rule, different year" situation.

    In fact, the situation is far from a "same as usual" scenario—at least for PTs in SNF settings, who will be facing a dramatic change in how payment is determined.

    The new rules, set to go into effect in October of this year, include increases in payment of 2.4% for SNFS and 0.9% for IRFs, but the heart of the changes have less to do with payment increases and more to do with how payment will be determined and what needs to be reported. For PTs in IRFs, the reporting process could become a bit less burdensome, while PTs in SNFS will need to get up to speed with an entirely new payment system that does away with the Resource Utilization Groups Version IV (RUG-IV) process.

    SNFs: Hello Patient-Driven Payment Model (PDPM)
    The biggest takeaway from the proposed SNF payment rule was the adoption of the PDPM, and the same is true of the final rule. In doing away with the RUG-IV process, CMS adopted a model that bases payments on a resident's classification among 5 components, including physical therapy. Final payment is then calculated by multiplying the patient's case-mix group with each component (both base payment rate and days of service received) and then adding those up to establish a per diem rate. (Editor's note: more detail on the proposed rule appears in a PT in Motion News story published in April.)

    Between its release of the proposed rule and publication of the final version, CMS tweaked a few details—one around clinical categorization in the PDPM having to do with identifying surgical procedures that occurred during the patient's preceding hospital stay, and another related to a new assessment known as the Interim Payment Assessment (IPA), intended to accommodate reclassification of some residents from the initial 5-day classification. In the case of the IPA, CMS decided to make the assessment optional.

    IRFs: Goodbye Functional Independence Measure (FIM)
    As in the proposed rule, the final rule for IRFs drops the FIM and 2 quality-reporting measures related to methicillin resistant staph aureus (MRSA) infection and flu vaccine rates. According to CMS, data associated with FIM are being captured through other parts of assessment, while the costs of gathering data on MRSA and flu vaccines outweigh the benefits. (Editor's note: more detail on the proposed rule appears in a PT in Motion News story published in May.)

    The rule also allows for postadmission physician evaluation to count as one of the required face-to face physician visits and removes requirements for admission order documentation (but not the orders themselves). Additionally, under the new rule physicians will be allowed to lead team meetings remotely—a change that, when proposed, prompted APTA and others to ask CMS to extend that allowance to all team members. CMS stated in the final rule that it will evaluate how the new policy is working out and consider expanding flexibility.

    APTA comments on the proposed rules are available online (for SNF comments, visit APTA's Medicare Payment and Policies for Skilled Nursing Facilities webpage and look under APTA Comments; for IRF comments, look for the same header on the association Medicare Payment and Policies for Hospital Settings webpage). APTA summaries of the rules will be posted in the coming weeks.

    Proposed CMS Outpatient Rule Would Adopt Further 'Site Neutral' Payment Policies

    Should Medicare be reimbursing outpatient facilities owned by hospitals at higher rates than it does independent providers' facilities? The US Centers for Medicare and Medicaid (CMS) doesn't think so.

    In its 2019 outpatient prospective payment system (OPPS) rule, CMS proposes to expand its use of a "site-neutral" payment model in its reimbursements, meaning that it will do away with the current system that pays so-called "off-campus" hospital-owned facilities an estimated $75 to $85 more than it does independent counterparts. The proposal is expected to meet with opposition from hospital groups.

    If adopted, CMS estimates the change will save Medicare around $760 million in 2019, according to a CMS fact sheet on the proposed rule. Those savings would help to offset an overall payment increase of 1.25%, or about $4.9 billion.

    "This proposal indicates that CMS is aware of, and taking action against, the potential for rising costs due to the consolidation of health care systems," said Kate Gilliard, APTA's senior regulatory affairs specialist. "By implementing site-neutral payments, major health systems will be less incentivized to buy up smaller practices, because they won't be receiving a higher reimbursement rate for the mere fact that they are owned by a hospital system."

    Also included in the proposed OPPS:

    • Ambulatory surgical center (ASC) payment would increase by 2% and would be updated based on the hospital market basket update instead of the "consumer price index-urban all item" (CPI-U) system through at least 2023.
    • Nonopioid pain-management drugs that function as a supply when used in an ASC surgical procedure would be paid for separately.
    • CMS is soliciting comments on regulatory changes that might help prevent opioid use disorders and improve access to treatment in the Medicare program, as well as identify any barriers that may inhibit access to non-opioid alternatives for pain treatment and management.

    APTA is analyzing the proposed rule and will provide comments to CMS by the September 24 deadline.

    The 2019 Fee Schedule, Part 1: 5 Things You Need to Know About What MIPS Might Look Like for PTs Next Year

    Part 1 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment: how the Merit-based Incentive Payment System (MIPS) would play out for PTs and PTAs under the proposal.

    Beginning in 2019, physical therapists (PTs) and physical therapist assistants (PTAs) could be facing one of the most dramatic shifts toward value-based payment in Medicare, all courtesy of the US Centers for Medicare and Medicaid Services (CMS) and its proposed 2019 physician fee schedule. The biggest change: a requirement that eligible PTs participate in the CMS Quality Payment Program, where MIPS looms large.

    What is MIPS? Basically it's a reporting system that tracks 4 provider performance categories and awards performance points to produce a total annual MIPS score. That score in turn determines whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Physicians and a few other providers have been participating in MIPS for the past 3 years at better-than-expected rates—now PTs, occupational therapists, social workers, and clinical psychologists may be added to the list of MIPS reporters. (Editor's note: this article from a 2017 issue of PT in Motion magazine lays out the fundamentals of the program; in addition, earlier this year the association produced a podcast series on value-based care that covers MIPS and other issues.)

    With the publication of its proposed 2019 physician fee schedule, CMS provided the first glimpse at how the system would be rolled out and applied to PTs. Here are 5 things to know about what CMS is proposing:

    1. Initially, PTs will be assessed on only 2 of the 4 MIPS categories.
    Although physicians participating in MIPS must report on all 4 MIPS categories—quality, promoting interoperability, clinical improvement activities, and cost—PTs will be assessed only on quality and clinical improvement activities, at least in 2019. The cost and interoperability categories will be "zero-weighted," according to the proposed rule.

    2. There are criteria for mandatory participation, and not all PTs or practices will qualify.
    MIPS has a so-called "low-volume threshold" that essentially exempts providers from reporting unless they meet 3 annual criteria: allowed charges under Medicare Part B for professional services of $90,000 or more; more than 200 Medicare Part B-enrolled individuals provided covered professional services; and more than 200 covered professional services provided to Part B enrollees. Remember, all 3 elements must be met: given that most PTs in private practice provide more than 200 covered professional services in a year, mandatory participation in MIPS will probably boil down to the total charges and patient numbers criteria.

    3. MIPS applies to PTs in private practice only—and group practices are assessed as a whole.
    For now, MIPS will be limited to PTs in a private practice, but it's important to understand that, unlike the physician quality reporting system (PQRS) that MIPS replaces, group practices will also be assessed for reporting as a whole. That means even PTs in group practices who do not exceed the low-volume threshold level as an individual provider will be required to participate at the group level if the group itself is participating in MIPS and, combined, exceeds the low-volume threshold.

    4. You could still participate in MIPS voluntarily (and it may be a good way to understand the system before you're required to report).
    Beginning in 2019, PTs will have 2 ways to participate in MIPS by choice. First, those who meet 1 or 2 of the 3 participation criteria listed in tip 2 will be allowed to opt in to MIPS. Providers who choose to opt in would do so on an annual basis, and once they make that election they would be treated like a MIPS participant, with the ability to earn a payment incentive, remain neutral in payment, or receive a penalty based on their performance. Second, as in previous years, voluntary participation in MIPS by PTs who aren't required to do so would remain an option, with no payment adjustments associated with participation. APTA encourages voluntary participation in MIPS as a good way to get familiar with a system that seems likely to grow in its reach.

    5. Practices of more than 15 eligible clinicians would need to report to MIPS electronically beginning in 2019.
    Claims-based reporting would be limited under MIPS. Instead, electronic reporting via certified electronic health records (EHRs) or registries would be mandated for practices of 15 or more clinicians (not 15 or more PTs, but all MIPS-eligible providers in the practice). Claims-based reporting would still be an option for solo practitioners and smaller practices, but, again, it's important to understand that mandated electronic reporting is likely to be extended to ever-smaller practices in the coming years, so any providers not yet required to report electronically would be well-advised to start learning about and investing in technology now. APTA is helping to make MIPS reporting easier through its Physical Therapy Outcomes Registry, which has been recognized by CMS as a qualified path for electronic reporting.

    Up next in the series: it's not just about MIPS—a look at other ways PTs could participate in the CMS Quality Payment Program.

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care in general and MIPS in particular, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    The 2019 Fee Schedule, Part 2: Quality Reporting Options Other Than MIPS

    Part 2 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment looks at alternatives to participation in the Merit-based Incentive Payment System (MIPS).

    For physical therapists (PTs), required participation in MIPS seems like the big news in the US Centers for Medicare and Medicaid Services (CMS's) proposed 2019 physician fee schedule. And it is big news—but it's just a part of an even bigger picture known as the Quality Payment Program (QPP), the real heavyweight in the proposed rule.

    It's actually QPP that PTs, occupational therapists, social workers, and clinical psychologists would be required to participate in beginning in 2019. MIPS is just 1 way of doing it (part 1 of this series covered some of the must-knows about how that system works). But CMS also proposes other ways that PTs might participate, mostly by way of Advanced Alternative Payment Models (AAPMs) or through an option that involves a Medicare Advantage demonstration.

    So what should you consider when weighing the non-MIPS alternatives for participating in QPP? Here are a few basic concepts to keep in mind.

    Don't get overwhelmed. AAPMs are complicated—but they're not impossible to understand.
    First, about AAPMS: they are a subset of alternative payment models (APMs). To quality as an AAPM, according to the proposed fee schedule, the model must meet the following 3 criteria:

    • Require at least 75% of all eligible clinicians to use certified electronic health record technology (CEHRT) in 2019 for all CMS-created APMs, and by 2020 for so-called "other payer" APMs
    • Use quality measures that are comparable to those used in MIPS
    • Put some skin in the game by bearing financial risk for underachieving—CMS is proposing that the risk would need to be equal to 8% of the average estimated total Medicare Parts A and B revenues of providers and suppliers in the APM, or 3% of the expected expenditures that an APM entity is responsible for under the APM

    Under the proposed rule, PTs who fully participate in an AAPM—that is, PTs who meet or exceed the relevant payment amount or patient count threshold for the year based on participation in an AAPM to become Qualifying APM Participants (QPs)—would not be required to comply with MIPS and would be eligible for payment adjustments (depending on the AAPM’s payment arrangement) as well as a 5% Medicare bonus

    There are 2 kinds of AAPMs to choose from.
    In the proposed rule, there are 2 varieties of AAPMs that would be open to PT participation: "Medicare Option" AAPMs and "All-Payer Combination Option" AAPMs.

    The Medicare Option path proposed for 2019 includes CMS-created models such as the Comprehensive Care for Joint Replacement Model (but only the CEHRT track), the Next Generation ACO Model, the Medicare ACO Track 1+, and others. To get a better idea of this grouping, check out the current list of Medicare AAPMs on the CMS website.

    For payment years 2021 and later, eligible clinicians may become QPs through a combination of participation in Medicare AAPMs and Other Payer AAPMs—a so-called "All-Payer Combination Option." This path allows providers to take a hybrid approach by participating in both a Medicare AAPM(s) and a CMS-approved AAPM(s) provided by Medicaid and other payers. Under this option, QPs are assessed by CMS through participation in both AAPMs.

    The real question: would you qualify?
    The AAPM-based QPP option allows participants to be exempted from MIPS and opens up the possibility of a 5% annual payment bonus (beginning in 2021 for the 2019 performance year) in addition to payment adjustments up or down; however, certain patient or payment thresholds must be met.

    What are the thresholds? Again, it depends on which AAPM path you're pursuing. For payment year 2021 (performance year 2019), in order to be considered a QP in the Medicare Option path, you must have provided services through Medicare AAPM(s) for at least 35% of your Medicare Part B patients or have earned at least 50% of all Medicare Part B payments through the AAPM(s).

    The All-Payer Combination is a little more complicated because it involves quotas for both Medicare and total payments and patients: at least 25% of Medicare Part B payments and at least 50% of all payments through AAPMs, and at least 20% of Medicare Part B patients and at least 35% of all patients served by way of the AAPMs.

    It's also possible that if you don't meet these thresholds, you can participate via a "partial QP threshold" option, with lower payment and patient thresholds. Partial QP participants are not subject to the MIPS reporting requirements and payment adjustments unless they choose to report to MIPS, but they do not qualify for the 5% bonus.

    CMS has proposed a possible QPP participation option based on Medicare Advantage.
    It's called the Medicare Advantage Qualifying Payment Arrangement Demonstration (MAQI), and under the proposed fee schedule, it would work like this: providers who participate "to a sufficient degree" with a qualifying payment arrangement through a Medicare Advantage organization could be exempted from MIPS reporting and payment adjustments. Providers also wouldn't be required to meet the QP thresholds associated with the AAPM options, but they would need to apply for the demonstration project in advance. CMS has issued a fact sheet that goes into more detail on the plan.

    Part 3 of the series: beyond QPP—the end of functional limitation reporting, future coding changes that could affect physical therapist assistant payment, and a telehealth shift.

    Get ready for the future of payment: APTA offers a wide range of online resources on value-based care, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    The 2019 Fee Schedule, Part 3: The End of FLR, the Move to PTA-Specific Codes, and a Nod to Technology

    Part 3 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment: there's more to the proposed rule than PTs being required to participate in the Quality Payment Program—including some very good news.

    The fact that physical therapists (PTs) could be widely engaged in a value-based payment model in 2019 is definitely the big takeaway from the proposed 2019 physician fee schedule released by the US Centers for Medicare and Medicaid Services. But the sweeping proposal also includes some other significant changes that could affect both PTs and physical therapist assistants (PTAs). Here's a rundown of 3 of the biggest non-Quality Payment Program-related changes included in the proposed rule.

    Something to celebrate: the end of functional limitation reporting (FLR).
    Criticized by APTA as an undue administrative burden that yields little of value, FLR would finally be put out to pasture if the proposed rule is adopted. In its reasons for eliminating the requirement, CMS described the "general consensus" of commenters responding to a CMS request for ways to reduce administrative burden that FLR was "overly complex and burdensome." The agency estimates that PTs in private practice would have saved between 130,000 and 190,000 hours of administrative work in 2017 had FLR not been in place.

    The change is a win for APTA and its members, and the association is mentioned in the proposed rule as a "specialty society" that supplied CMS with data on the inconsistent timing of FLR reporting—another issue that fueled the decision to eliminate the requirement.

    Something to be concerned about: is CMS setting the stage for the PTA payment differential?
    If enacted as proposed, the rule would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The modifiers, mandated by the Bipartisan Budget Act of 2018, would be used in place of the GP and GO modifiers—the ones currently used to identify PT and OT services furnished under an outpatient plan of care—and will pave the way for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022.

    Although the modifiers won't officially be in place until 2020, CMS plans on accepting voluntary use of the modifiers next year. CMS also proposes to define “in part” to mean any minute of the outpatient therapy service that is therapeutic in nature and that is provided by the PTA or OTA when acting as an extension of the therapist. The new modifiers would not be applied when a PTA or OTA furnishes non-therapeutic services—such as scheduling appointments, greeting the patient, or preparing the treatment area.

    APTA is opposed to the adoption of a payment differential system and will be advocating for changes before the 2022 implementation date.

    Something to keep an eye on: CMS may be warming up to broader use of technology.
    While it appears that, for now at least, the changes will be limited to physicians and other qualified health professionals who can report evaluation and monitoring services, CMS is proposing that activities such as virtual check-ins, interprofessional internet consultation, and remote evaluation of prerecorded patient information could qualify for some form of payment. APTA is seeking clarification from CMS as to whether any of these services could be furnished and billed by PTs.

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the Registry to submit their data to CMS.