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  • You Down With QPP? Watch and See (And Take the Quiz)

    Medicare payment is poised to change in big ways for physical therapists (PTs) in private practice. Are you ready?

    APTA can help. Since late 2015, the association has been rolling out new resources to help members prepare for what's coming down the pike as the US Centers for Medicare and Medicaid Services (CMS) implements its Quality Payment Program (QPP). The program already is significantly changing how some health care providers report to Medicare, and those changes likely will be required of PTs in the near future.

    The association's latest offering: a 4-minute video featuring Heather Smith, PT, MPH, APTA's director of quality, on reporting through MIPS and APMs, 2 of the biggest changes to how CMS will be doing business.

    Don't miss the video. But before you do, take this quick PT in Motion News quiz to find out just how much you know about what's happening. Consider it a kind of warm-up exercise—answers are at the bottom of this quiz. Also check out another quick questionnaire that looks at your readiness for payment reform in general.

    1. What does MIPS stand for?
    A. Meta-Inquiry on Performance Statistics
    B. Medicare-Implemented Payment Scale
    C. Madness-Inducing Participation Structure
    D. Merit-Based Incentive Payment System

    2. Successful participation in Advanced Alternative Payment Models (APMs) could result in a lump sum additional payment each year of how much?
    A. An amount equal to 2% of the previous year's fee-for-service payments
    B. An amount equal to 3% of the previous year's fee-for-service payments
    C. An amount equal to 5% of the previous year's fee-for-service payments
    D. An amount equal to 7% of the previous year's fee-for-service payments

    3. How soon can PTs expect to be required to participate in QPP?
    A. 2018
    B. 2019
    C. 2020
    D. They are required to participate this year

    4. Which MIPS performance category will include measures that were reported under the Physician Quality Reporting System?
    A. Advancing care information
    B. Improvement activities
    C. Cost
    D. Quality

    5. How high will MIPS noncompliance payment penalties be by 2022?
    A. 5%
    B. 7%
    C. 9%
    D. 12%

    6. True or false: clinicians participating in an advanced APM must continue to participate in MIPS.

    7. True or false: the Comprehensive Care for Joint Replacement model is considered an APM.

    8. To qualify as an approved APM, a program must require at least 50% of eligible clinicians to use certified electronic health record technology during the first year. What percentage is required in the second year?
    A. 50%
    B. 64%
    C. 70%
    D. 75%

    9. How can the APTA Physical Therapy Outcomes Registry help PTs participate in QPP?
    A. Participation in the Registry earns PTs points toward MIPS improvement activities.
    B. The Registry can package data for submission to MIPS.
    C. PTs are able to receive real-time feedback on their performance throughout the year.
    D. All of the above.

    10. True or false: QPP changes will be limited to only Medicare Part B for the forseeable future.



    1. Answer: D. It's the Merit-based Incentive Payment System, and although the change might spark the fear of madness among PTs, things may not be as dire as all that: PTs who report to PQRS already know how to do much of the quality reporting required by MIPS, and PTs can voluntarily participate in MIPS risk-free this year so they can hit the ground running when QPP participation becomes a requirement.

    2. Answer: C. When APMs succeed in reducing providers’ spending, they may receive a payment equal to 5% of the previous year's payments. The payments will be made 2 years after the performance period being evaluated.

    3. Answer: B. While not certain, there is a strong likelihood that PTs will be required to participate beginning in 2019.

    4. Answer: D. Data previously reported under PQRS will be included in the Quality category. The Cost category will contain new measures still being worked out by CMS; Improvement Activities will include elements such as practice access, population management, care coordination, and beneficiary engagement; and Advancing Care Information encompasses the former electronic health records (EHR) "meaningful use" program under PQRS. Although PTs weren't required to participate in the meaningful use under PQRS, they will be required to do so under MIPS—meaning if you haven't established a relationship with an EHR program, now would be a good time to start.

    5. Answer: C. CMS is not playing around. Penalties for noncompliance could be as steep as 9% by 2022.

    6. Answer: False. Clinicians can choose to participate in QPP either through MIPS or through participation in an APM—they don't have to do both; in fact, they have to choose 1 or the other.

    7. Answer: True – for the most part. One of the CJR tracks is an APM, along with several others listed on the CMS Centers for Medicare and Medicaid Innovation webpage.

    8. Answer: D. At least 75% of eligible clinicians must use certified EHR technology by the second year of operation.

    9. Answer: D. APTA's Physical Therapy Outcomes Registry is a storehouse, a data packaging service, and an ongoing feedback loop all in 1.

    10. Answer: False. Look for QPP provisions to spread to private payers—and probably sooner than you think.

    From PTJ: PTs Should Wake Up to Their Role in Promoting Sleep Health

    The old "you snooze, you lose" adage couldn't be further from the truth.

    Researchers are gaining more and more insight on the role of sleep in overall health, and physical therapists (PTs) should be equipped to help their patients and clients understand that role, according to authors of an article that provides guidance on basic screening tools and sleep hygiene education. In fact, authors argue, it's an especially important consideration for PTs, who often work with patient populations whose conditions are associated with sleep disruption.

    Appearing the August issue ofPhysical Therapy(PTJ), APTA's scientific journal available for free to all members, the "Perspective" article lays out some stark numbers: between 50 and 70 million adults in the US experience chronic sleep disturbances, and 62% of all Americans experience a sleep problem several nights a week—and it's likely those numbers are low, authors write, because estimates are that as many as 90% of sleep problems go undiagnosed. The problem is so pervasive that the US Centers for Disease Control and Prevention has designated insufficient sleep as a public health problem.

    Writing that sleep "has an important role in the proper functioning of most, if not all, body systems," authors explain sleep's role in immune function and tissue healing, pain modulation and perception, cardiovascular health, depression and anxiety, motor skill learning, and cognitive function. Among the physical therapy patient population, sleep disturbance can be an especially prevalent issue for individuals with Parkinson disease, Alzheimer's diseases, multiple sclerosis, spinal cord injury, neck and back pain, and postoperative status, among a host of neurological and orthopedic conditions, authors write.

    "It is suspected that the prevalence of sleep disorders and disturbances in physical therapy clients is very high, although studies are needed to verify this concentration," state the study's authors. "There is much opportunity for PTs to play an active role in providing sleep health education … and potentially reduce the onset of chronic conditions in addition to promoting sleep health in all clients."

    So what can the PT do? Authors suggest a multistep approach that begins with an assessment of overall sleep health and screening for the risk of a sleep disorder, with a referral for additional assessment if the PT finds increased risk. Additionally, PTs should provide "sleep hygiene education"—the basics of health sleep that include regular sleeping and waking hours, changes to diet to avoid eating large meals close to bedtime, and avoiding light-emitting electronics within 30 minutes of trying to sleep, among other tips (the entire sleep hygiene education list is included in the article).

    Authors write that PTs also should provide an appropriate exercise program that can help regulate sleep, and consider discussions about body positioning in bed, as well as bed mobility issues for clients where indicated.

    In addition to the sleep hygiene tip list, the article includes charts on suggested screening tools to assess for the 3 most common sleep disorders—chronic insomnia, obstructive sleep apnea, and restless legs syndrome—as well as questionnaires to help determine overall sleep quality and daytime sleepiness. Authors also discuss the use of wearable consumer electronics to track sleep, saying evidence supporting their reliability is slim but that they may be useful as a way to help individuals feel they have more control over regulating their sleep patterns.

    Authors of the study also argue that given the increasing weight of evidence showing the relationship of sleep to almost all facets of health, PT clinical education programs "should consider including information about sleep, screening for sleep disorders, and methods to optimize sleep in their curriculum."

    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.

    'Choosing Wisely' App Now Available

    Now it's easier than ever for consumers to make well-informed health care choices—including choices about physical therapist interventions.

    The American Board of Internal Medicine Foundation has unveiled the first "Choosing Wisely" app for iPhone (iPad and Android versions to follow soon), a tool that enables consumers and clinicians to access more than 500 specialty society recommendations on procedures that tend to be done frequently, yet whose usefulness is called into question by evidence. The program was developed in partnership with Consumer Reports.

    Through the new app, clinicians and consumers will be able to search the recommendations using keywords and filter by specialty, age, setting, and service (for example, imaging, medication, treatment, lab, or test). Recommendations are linked to relevant patient-friendly resources, and information can be shared via text or email.

    APTA was the first nonphysician group to release a "Choosing Wisely" list in the fall of 2014, joining more than 50 medical specialty societies participating at the time. The 5 APTA recommendations, which are expanded upon with citations at the Choosing Wisely website and in the downloadable list of "5 Things Physical Therapists and Patients Should Question," are:

    • Don't use (superficial or deep) heat to obtain clinically important long-term outcomes in musculoskeletal conditions.
    • Don’t prescribe under-dosed strength training programs for older adults. Instead, match the frequency, intensity, and duration of exercise to the individual’s abilities and goals.
    • Don’t recommend bed rest following diagnosis of acute deep vein thrombosis (DVT) after the initiation of anti-coagulation therapy unless significant medical concerns are present.
    • Don’t use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement.
    • Don’t use whirlpool for wound management.

    The process for developing the list began with an open call for APTA members to submit their lists of questionable procedures. After receiving more than 170 submissions, APTA convened an expert group of physical therapists from a wide range of practice settings and areas of clinical expertise. The group reviewed all nominations and conducted extensive literature reviews to narrow down the list to 9 procedures. The list of 9 was presented to the members of APTA, who voted on the final 5.

    APTA's participation in "Choosing Wisely" is part of the association's Integrity in Practice campaign to support the profession of physical therapy as a leader in the elimination of fraud, abuse, and waste in health care. The APTA Center for Integrity in Practice houses information on the "Choosing Wisely" program as well as a primer on preventing fraud, abuse, and waste, an online course on compliance and professional integrity, and other resources.

    APTA Launches New Nutrition Webpage

    Yes, there's a role for the physical therapist (PT) in helping patients understand how nutrition affects function, but there are nuances to be considered and no shortage of factors that could affect just how to fulfill that role. Fortunately, there's now an APTA webpage that helps PTs navigate the issues.

    New to the APTA website: "Nutrition and Physical Therapy," a webpage with a collection of resources that delivers context for APTA's position that it's the role of PTs to "screen for and provide information on diet and nutritional issues to patients, clients, and the community"—within the bounds of the PT's scope of practice. That means, among other things, that PTs wishing to provide information on nutrition need to be certain that they're doing so in ways that are consistent with state licensing laws for both physical therapy and nutrition services, and assess whether this ability is within their personal scope of practice.

    The webpage provides factors to consider related to the PT's role in nutrition and diet, including additional certifications that may be required, use of the designation "nutritionist," and when to refer a patient or client to a specialist for nutritional education. Other resources on the page include links to dietary recommendations, a registered dietician nutritionist lookup, and information on how to pursue additional certifications.

    Utilization Management Toolkit Helps PTs Navigate Difficult Landscape

    It looks as if utilization management (UM) will be sticking around for the foreseeable future, but that's not necessarily because it's working so well everywhere. In fact, it's the combination of prevalence and variability that prompted APTA to launch a new toolkit to help physical therapists (PTs) and physical therapist assistants (PTAs) understand—and be successful in—the UM environment.

    APTA's UM Toolkit offers members a range of information on UMs that includes everything from the history of the concept to strategies for working with UM vendors and tips for reducing authorization denials. The toolkit's resources can be used by individual PTs and PTAs as well as APTA chapters, and are offered through both a collection of webpages and a single downloadable pdf document.

    Although the concept of UM has been around since the 1950s, the real growth in use came after the adoption of the Affordable Care Act in 2010. With the ACA's expanded coverage, inclusion of "essential health benefits," and emphasis on improved patient experience and reduced costs, insurers felt pressure to more tightly control the kinds and duration of treatments being used by clinicians. The physical therapy profession's experience of this shift was intensified by the fact that the effectiveness of physical therapy is increasingly better understood by a public that now has greater access to PTs—an evolution that has made PTs a target for "cost containment" efforts, according to the toolkit.

    Making things even more difficult is the fact that UM—often conducted by third-party vendors on behalf of insurers—has developed in sometimes-haphazard ways, putting much of the onus for advocating for consistent, effective patient care on the clinicians themselves. That's why APTA's UM toolkit exists.

    "There are inherent conflicts and difficulties when balancing access, quality, and cost," APTA says in the UM overview section of the toolkit. "The ultimate goal is a UM program that facilitates effective use of limited resources, improves appropriateness of care, and imposes only reasonable burdens on patients and providers."

    APTA continues to engage with UM vendors and insurance companies to develop systems that are more responsive to PTs and their patients. The toolkit and other UM information is found on the APTA’s Third-Party Administrators (TPA): Utilization Management & Utilization Review webpage.

    Rethinking Rehab's Role in Infectious Disease Response: 'Narrow the Gap' Interview With Mike Landry

    Michel Landry, BScPT, PhD, knows a thing or 2 about responding to health crises around the world—it's knowledge you tend to pick up when you've spent more than 20 years working with people in need, from Bosnia to Haiti.

    Along with coauthors Sudha R. Raman, Kai Kennedy, PT, DPT, Janet Prvu Bettger, and Dawn Magnusson, PT, PhD, Landry used that insight to look at reassessing the role of rehabilitation in responding to infectious disease, using the recent Zika virus outbreak as a springboard. That article appeared as a "Point of View" in the March 2017 issue of Physical Therapy, APTA's science journal.

    The article drew attention for its call for a more comprehensive approach to infectious disease outbreaks, and, recently, PT in Motion News caught up with Landry to dive deeper into the issue. A transcript of the conversation with Landry has now been published in the association's "Narrow the Gap" blog series.

    “You save people’s lives [when responding to a disaster or disease crisis]," Landry says in the interview. "But they also live with spinal cord injuries, massive burns, amputations. We have to be as concerned with the long-term consequences and quality of life among those people who survive, just as much as the kids and the adults who survived an infection. And that’s where the overlap between rehabilitation, global public health, and infectious disease has to start to advance our consciousness here. … We owe it, I believe, morally and ethically, to those survivors to gain some sort of quality of life.”

    Read the full Q-and-A on the "Narrow the Gap" blog.

    PTJ Perspective: PT Education on Medical Marijuana Highly Recommended

    Medical marijuana is no longer a novelty: In fact, physical therapists (PTs) in half the United States may be treating patients who use the drug, says Charles D. Ciccone, PT, PhD, FAPTA, in a recent "Perspective" column published in Physical Therapy (PTJ), APTA's science journal.

    The growing prevalence of medical marijuana means that PTs should be aware of the marijuana options available to their patients, potential benefits for certain conditions, and possible adverse effects on “cognition, coordination, balance, and cardiovascular and pulmonary function,” Ciccone writes.

    The "Perspectives" article outlines methods of consumption (each has "benefits and drawbacks," Ciccone writes), the differences between THC and cannabidiol, the drug's positive effects on certain conditions, and links to possible negative effects, such as increased risk of stroke, myocardial infarction, and falls. Ciccone writes that it would be “unwise” for a PT to advise a patient on the use of marijuana; patients should always be referred to their physician for a consultation. But, he notes, “Patients and their caregivers may approach physical therapists with questions about medical marijuana,” so PTs should educate themselves about its potential effects on patient function.

    Ciccone also writes about current barriers to research that could make a stronger case for or against the use of medical marijuana for particular conditions, not the least of which are federal regulations that aren't always sympatico with state laws. While some states may allow access to it, marijuana’s legal classification (in plant form) as a class I controlled substance (highest abuse potential) clouds the issue, making it difficult to conduct well-designed randomized controlled trials on its potential benefits, Ciccone observes. And despite pleas from the medical community, the FDA refuses to reclassify it—even though synthetic compounds are classified at a lower risk.

    While still controversial, “medical marijuana continues to gain acceptance” for treating a variety of disorders, Ciccone concludes. While more research clearly needs to conducted, “clinicians must be aware of the potential side effects of medical marijuana” and “should be able to educate their patients about the current status of medical marijuana” and refer them to their physicians for more information.

    Note: the PTJ article access process has changed. To view a PTJ article:

    • Go to https://academic.oup.com/ptj
    • Click on Sign In (righthand top of page)
    • Click on “Sign in via society site” (do NOT use Oxford Academic account)
    • Enter your APTA username and password
    • Click on “Click here to continue” to return to PTJ’s main page
    • Use the search, or navigate to desired article

    If you already are logged in at apta.org and want to go to PTJ, you can click on “PTJ” under the News and Publications tab, but you will still need to login again at the PTJ website to access articles.

    From PT in Motion: Ethics Under Pressure

    Making 100% ethical decisions with 0% internal conflicts would be easy if it weren't for … well, just about everything.

    This month's "Ethics in Practice" column in PT in Motion magazine uses a fairly uncommon setting to get at a fairly common issue: namely, the ways in which external pressures can cloud the ability of a physical therapist (PT) or physical therapist assistant (PTA) to stay true to professional ethics.

    The scenario involves a PT for a pro football team—not exactly a common gig—but the larger issues will be all-too-familiar to readers, who, for example, may receive pressure from parents of a pediatric patient, or feel conflicted over a working patient who believes he or she must return to the job as soon as possible.

    The PT in Motion column presents a PT for a pro team who is charged with overseeing rehab for a high-value player after meniscal surgery. The player is progressing in a fairly normal way, but as a big playoff game looms, the PT starts experiencing pressure to hurry things along and make a positive return-to-play decision.

    Some of the pressure is overt, coming from the team's coach and even the player in question. But some of that pressure comes from within the PT. The work with the team is rewarding, both personally and financially, and the PT feels the pull to make everyone—maybe even himself included—happy with a process that will get the star player on the field in time for the crucial game.

    While the particulars involve a setting most PTs will never experience, the conflicts are familiar. Column author Nancy Kirsch, PT, DPT, PhD, and guest coauthor Bruce Greenfield, PT, PhD, ask readers, "Have you faced similar situations, in which you have questioned your own clinical judgments and motives? What did you do about it? How did you subsequently feel about your action—or lack of action—as the case might be?"

    " A Game-Time Decision " is featured in the March issue of PT in Motion  magazine, and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    Also open for public access: " Beyond Rest: Physical Therapists and Concussion Management ." Check it out!



    Webinar, Q-and-A Session Help PTs and PTAs Make the Case for Physical Therapist-Led Workplace Programs

    If physical therapists (PTs) and physical therapist assistants (PTAs) are to be truly successful in taking a leadership role in prevention and wellness efforts, they'll need to take that message to a group that has the potential to make a difference: employers. A new free webinar from APTA provides insight on the whys, hows, and what-nexts for PTs and PTAs ready to take on population health initiatives in the workplace, and a follow-up Q-and-A session will explore questions from webinar viewers.

    "Direct-to-Employer Physical Therapy: Building Supply and Demand" is rooted in the idea that employers are motivated to lower health care costs and maintain a healthy and productive workforce, and are increasingly creating employer-based population health programs that attempt to do just that. This trend creates an opportunity for PTs and PTAs to step up and make the case directly to employers for the effectiveness of physical therapist-led efforts to meet those employer needs.

    The program essentially is a 2-part presentation: attendees are asked to listen to a prerecorded webinar that provides the compelling reasons that PTs and PTAs are so valuable in population health efforts as well as the potential challenges and pitfalls of establishing employer-based programs. Then, attendees are invited to participate in a live webinar on March 9 2:00 pm-3:00 pm ET, when experts will answer questions sent in by viewers of the introductory presentation.

    The presentation was developed through an APTA employer initiative work group that is creating additional resources on the topic.

    Presenters for the recorded session are Mike Eisenhart, PT; Todd Davenport, PT, DPT, MPH; Heidi Ojha, PT, DPT; and Holly Johnson, PT, DPT. Others on the employer initiative work group are Mark Amir, PT, DPT, MPH; Joe Shine, PT, DPT; and Zach Jones, PT, DPT, will join the live webinar.

    Cracking the Code: 6 Resources to Help You Navigate the 2017 CPT Code Changes

    When it comes to the new CPT evaluation coding system set to start on January 1, 2017, 2 things are inarguable: 1, this is actually happening; and 2, navigating and even thriving in the new system will require physical therapists (PTs) to stay engaged, learn as much as they can, and actively participate in shaping the future of the codes and how they're applied.

    With that in mind, here are 6 worthwhile resources that can help you understand and prepare for the big change in coding.

    1. Cut to the chase with APTA's quick guide to the codes.
    Want the basics? Check out the easy-to-read guide available online (it was also shipped with the December-January issue of PT in Motion magazine). This is the bare-bones, bottom-line content you need to know right now, accompanied by a set of definitions that help clarify what the Centers for Medicare and Medicaid Services mean by terms such as "activity limitations" and "body systems."

    2. Dig deeper with a free 60-minute webinar.

    This recording of a September 22 webinar covers the basics and then some. APTA staff are joined by Kathleen Picard, PT, and Helene Fearon, PT, in an in-depth review of the new coding system, including a brief history of how the system came to be, and case vignettes that show the codes in action.

    3. Get another perspective—in just 30 minutes.

    APTA has partnered with CEU provider MedBridge to deliver an online course that explores the elements of an evaluation and what conditions must be met for each level of complexity, accompanied by practical, interactive examples to help you practice documentation and proper code selection.

    4. Learn on your schedule with this self-paced course.

    One of the newest offerings from APTA, this free slide deck with accompanying notes explains the basics, and then puts heavy emphasis on seeing the codes in action through case scenarios focused on cardiovascular and pulmonary, neurology, pediatrics, orthpedics, and geriatrics.

    5. Join the conversation on payment.

    APTA has launched an online community on the Hub focused solely on payment reform. Ask questions, exchange thoughts with other PTs, and get a better sense of how your peers across the country are responding to the changes—not just in CPT codes, but other areas.

    6. Mark your calendars for more learning coming early in 2017.
    The opportunities to get up-to-speed don't end in 2016. Viewers of the APTA webinar from September 22 (see #2 above) are invited to participate in a live Q-and-A session set for January 19, 1:00 pm–2:00 pm, ET. Fearon and Picard will once again join the APTA staff team to provide updates on the codes, and then answer participants’ questions (deadline is January 12 to submit questions).

    Also in the near future: PT in Motion magazine articles in 2017 on the new system. While PT in Motion did cover the CPT codes in a 2016 article, both the February and March “Compliance Matters” columns will include even more information.

    The CPT codes aren't the only moving part in the evolving payment scene. Make it easy on yourself to keep up with all the news related to payment for physical therapist services: sign up for the Payment edition of APTA's Friday Focus series, a monthly collection of the top payment-related stories from PT in Motion News, the latest APTA resources, and more learning opportunities.