This Is APTA: Senora Simpson, PT, DrPH
Senora Simpson, a clinician and educator, has been inspiring PTs for over half a century — first through her bravery as a PT struggling to pursue her career during segregation, and later as an influential educator, policy maker, and advocate for people with mental health and intellectual disabilities. She also was recognized with the Lucy Blair Service Award in 2008. Here is her story.
Senora Simpson, PT, DrPH, has been an active APTA member since 1957, and has lived in Washington, D.C., most of her life. A proud 1953 graduate of D.C.'s academically elite Paul Laurence Dunbar High School, Simpson originally wanted to be a pianist, until her mother persuaded her to pursue a more lucrative career in physical therapy.
At Boston University's then all-female Sargent College of Allied Health Professions (now Sargent College of Health and Rehabilitation Sciences, Boston University), Simpson earned her bachelor's degree in physical therapy. She was one of two African American students in her class. Her professors included the late Margaret L. Moore, PT, EdD, and Helen K. Hickey, PT, MEd, who became mentors along the way.
According to Simpson, Moore and Hickey, who later served as members of the APTA Board of Directors, were "very protective" of her, because, as an African American woman, her "chances of success were slim." In fact, Hickey would not allow her to complete an affiliation at DC Children's Hospital because she feared that Simpson would be failed due to racial bigotry. Instead, she sent Simpson to Cooley Dickinson Hospital in Northampton, Massachusetts — a fortuitous move, because there she learned the groundbreaking technique of spine and joint manipulation and became quite skilled at manual muscle testing while treating patients with polio.
"I Cured Polio!"
It also was Hickey who called on Simpson soon after graduation to fill a position in Brownsville, Texas, where there was a breakout of polio. Hickey had become affiliated with The National Foundation for Infantile Paralysis (now known as the March of Dimes) and learned that physicians there were in need of PTs with superior manual muscle testing skills. It seemed like a natural fit, until the Texas hospital administrators learned that Simpson was African American. In a time when segregation was still in legal effect, the hospital gave up her valuable skills. In her 2003 APTA oral history, Simpson joked that when she heard the hospital "didn't need anybody" after all, she thought to herself, "I cured polio!"
From Hands-on Clinician to Testing New Models of Care
After a stint at Goldwater Memorial Hospital in New York City, part of the Rusk Institute of Physical Medicine, in 1959 Simpson moved back to D.C. to take a position as staff PT at D.C. General Hospital, beginning a more than 30-year career in government service. After nearly a decade at D.C. General, Simpson made the move from clinician to administrator, going on to develop the rehabilitation department at St. Elizabeth's Hospital, which served patients with mental illness.
In 1965, the U.S. Department of Health, Education, and Welfare — precursor to the Department of Health and Human Services — began the Comprehensive Home Care Project, a demonstration project to see whether rehabilitation could be performed for older adults in their homes, which was a novel idea at the time. Until then, home health rehab outside the hospital setting was not an option. Simpson took on the role of overseeing this effort for the D.C. region, coordinating PTs, occupational therapists, and speech-language pathologists.
Policy and administration appealed to Simpson, leading her to earn a doctorate in public health from University of Southern California in 1978. "I think about physical therapy differently [from how a clinician does]," she says, "because I think about the broader picture, about health care provision in a community, in a state."
"I Have To Be Part of the Solution"
Simpson began to pursue her master's in public health at The Johns Hopkins University while working at Forest Haven, an institution for people with intellectual disabilities. Her experience there as the first nonphysician head of health services inspired her involvement in the movement for deinstitutionalization for people with intellectual disabilities.
Her ongoing interaction with regulators and legislators led her to get involved in developing the health policies that affected patients, first writing HHS regulations for early and periodic screening, diagnostic, and treatment and later working as director of regional operations at the Office of Human Development Services, which oversaw Head Start, children and youth services, and the Office on Aging.
After watching her grandson struggle with dyslexia, Simpson became an advocate for special education and continues to be active in community advocacy organizations. She also has served in leadership roles with District of Columbia ARC and the National Capital Area United Way.
Although she retired from the federal government and her 25-year evening private practice many years ago, Simpson is assistant professor at Howard University and previously taught at George Washington University. "Students and their interest in learning are keeping me alive!" she declares. "They are teaching me things. But I'm tough. I don't do extra credit. I don't do anything that won't result in a good clinician."
She also spent 15 years on the D.C. Board of Physical Therapy, including as chair. Throughout her career, Simpson has remained involved with the D.C. Chapter of APTA, at various times holding the offices of president, membership committee chair, secretary, and delegate. The chapter even named an annual award for her: the Senora Simpson Service Award.
Currently Simpson serves on the board of directors of Qlarant, a company that performs quality review for the Centers for Medicare and Medicaid Services, and chairs Qlarant's Quality Solutions Committee.
#PTTransforms blog spoke with Senora Simpson to get her thoughts on the state of the profession, where we've been, and where we need to go.
#PTTransforms: You had some good mentors early in your career. What advice do you have for future or new PTs and PTAs seeking mentorship?
Simpson: Be true to yourself. Be sure about why you are going into this profession. If you don't want to do it for the long-term, get out now. You've got to want to do this work with all your heart and soul. I see some people going into the profession for the title or the money, and no true passion for helping people. You aren't going to get a mentor unless you are truly interested.
Some students may say, "I want you as a mentor," but really they just want to use my name. Helen Hickey called me because she remembered my skills in school. They needed someone who was skilled in manual muscle testing to help physicians. It wasn't because I asked her to be my mentor. She knew what they needed, and she knew what I could do.
#PTTransforms: You have said that "there is still a lot of work to do" with regard to diversity in the profession. What do you think the profession needs to do?
Simpson: There is no group of people who should be treated differently [from the population as a whole]. You don’t need to separate out groups and learn how to treat them. You shouldn't have to have special training. You need to learn how to be a human being. You've just got to be a good person to begin with. You can't legislate morality. You either have boundaries and morals that were taught to you, or you don't. You can take every class in the world, but if you really don't believe in it you are going to keep doing [the wrong thing].
APTA has tried to increase minority participation. We can have all kinds of goals, but it's at the ground level that it counts.
#PTTransforms: So what should the profession do in this area?
Simpson: There is hope in the world. There has to be societal change first, and then it will come into our profession. It is amazing to me what the #MeToo movement was able to do in a short period of time. We need a #MeToo movement in health care with regard to inclusion. We need to study what #MeToo did to move society. It's the only thing that will change the complexion of APTA.
[For some], the bottom line is image; sincerity is what we need.
#PTTransforms: In your oral history, you said that if you talk about a problem, you feel you have to be part of the solution. There are some strong voices in the debates over issues such as health care reform, school loan debt, and payment for services. What do you have to say to PTs, PTAs, and students who want to speak up but feel drowned out by those voices?
Simpson: Most of the things [the profession has] achieved started out with one voice. If you are a reasonable person, people will listen to you. Be careful to do your research in order to support your position with facts — not because your grandmother said so. Know what the rules are, know what is being proposed, in depth, to decide [how you will make your case]. And listen to other viewpoints.
If we can get one person who speaks truth to power, that's all we need. But you have to believe it when you speak it.
Part of the reason I joined APTA was to raise hell [about Medicare]. It was so much fun. I recently went down to [Capitol Hill to] testify in favor of the Physical Therapy Compact! That [willingness to speak up] is what I want to see in all health care providers. Get out of smoothing salve on people, and improve the health of America [through advocacy].
Busting Medicare Myths (and Regulating Your Expectations), Episode 3
PDPM, Maintenance Therapy, and the Medicare Outpatient Therapy Threshold
By Kara Gainer, JD
The U.S. Centers for Medicare and Medicaid Services isn't known for easy-to-understand rules and regulations around Medicare. Unfortunately, that complexity can lead to misinformation, which can spread quickly.
In an effort to get everyone on the same page, I'm debunking some of the most prevalent Medicare myths I've been seeing lately on social media and in other venues. (Have a question that you would like addressed in a future installment? Send your ideas to email@example.com with "mythbusting" in the subject line.)
Myth: CMS changed the coverage requirements of OT, PT, and SLP services furnished in a skilled nursing facility.
Although the payment methodology for SNFs changed in October of last year, the criteria for skilled therapy coverage didn't: Patients must receive the skilled therapy services they need. Skilled therapy services are now reimbursed by Medicare under the Patient-Driven Payment Model, or PDPM. While PDPM does change the manner in which patients are classified into payment groups under the SNF prospective payment system, it does not change any of the coverage criteria or documentation requirements associated with skilled therapy service coverage. But most important, PDPM does not change the care needs of SNF patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies made on their behalf.
CMS Fact Sheet on PDPM
APTA handout: What You Should Know About the Patient-Driven Payment Model
Myth: SNFs should require therapists and assistants to deliver the maximum amount of concurrent and group therapy (25%) for each discipline for each patient.
Although the PDPM includes a combined limit on group and concurrent therapy of 25%, you should deliver the mode(s) of therapy best attuned to individual patient needs and goals, and incorporate the provision of group and concurrent therapy into the patient’s plan of care. Group therapy documentation requirements remain the same: You must plan for a group in advance and document how group therapy will help each patient achieve their goals.
CMS Fact Sheet on PDPM (see "Concurrent and Group Therapy Limit")
APTA webpage: SNF Patient-Driven Payment Model
APTA handout: group vs. individual care decision tree
Myth: Medicare does not cover skilled maintenance therapy.
This one has persisted for a few years. There has been a longstanding myth that Medicare does not cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible. But it's just not true, and the Jimmo v. Sebelius final settlement sought to dispel this fallacy and clarify the rules to safeguard against unfair denials by Medicare contractors. The settlement agreement and the resulting revised manual provisions clarify that the Medicare program covers skilled therapy and skilled nursing services under the SNF, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline or deterioration (as long as all other coverage criteria are met). Specifically, the Jimmo settlement agreement required revisions in various CMS manuals to clearly state a "maintenance coverage standard" for both skilled nursing and therapy services. Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist ("skilled care") are necessary for the performance of a safe and effective maintenance program.
APTA webpage: Skilled Maintenance
CMS webpage: Jimmo Settlement
Myth: Maintenance therapy is not supported by PDGM.
Here's how CMS puts it in 2020 home health final rule: "It is the responsibility of the patient’s treating physician to determine if and what type of therapy (that is, maintenance or otherwise) the patient needs regardless of clinical grouping. CMS expects the ordering physician, in conjunction with the therapist, to develop and follow a plan of care for any home health patient, regardless of clinical group, as outlined in the skilled service requirements when therapy is deemed reasonable and necessary. Therefore, a home health period’s clinical group should not solely determine the type and extent of therapy needed for a particular patient." Also, beginning this year, PTAs can perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements.
CMS 2020 home health final rule
APTA handout: What You Should Know About the Patient-Driven Groupings Model for Home Health Services
CMS MLN Matters: Manual Updates Related to 2020 Home Health Payment Policy Changes
Myth: You must discharge patients from physical therapy when they reach the Medicare payment outpatient therapy threshold or targeted medical review threshold.
As long as skilled physical therapy continues to be medically necessary, you shouldn’t discharge Medicare patients when they reach the outpatient therapy threshold or the targeted medical review threshold. What used to be the Medicare therapy caps now are annual thresholds that you can exceed when you append claims with the KX modifier for medically necessary services. This change from the earlier "hard" therapy caps is the result of the Bipartisan Budget Act of 2018 (BBA of 2018), which provides for Medicare payment for outpatient therapy services including physical therapy, speech-language pathology, and occupational therapy services. If services exceed the annual threshold amounts, nclude the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. If you furnish medically necessary services over the targeted medical review threshold of $3,000, continue to affix the KX modifier and maintain the documentation to justify it. This medical review focuses on categories of providers deemed a higher risk for rejected claims.
Remember that the threshold is for physical therapy and speech-language services combined. I'll cover why that's the case in the next installment of this series.
APTA mythbusting blog series, episode 1
APTA webpage: Medicare Payment Thresholds for Outpatient Therapy Services
CMS Q&A sheet: Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage
CMS webpage: Therapy Services
Kara Gainer is APTA's director of regulatory affairs.
The PTA Differential: How We Got Here, and What's Next
By David Harris, PTA, MBA
If you've spent much time following APTA's social media feeds or reading comments on the association's news or blog posts, you know that the payment differential for services provided by physical therapist assistants (PTA) set for 2022 is sparking a significant amount of concern and frustration in the physical therapy community.
And with good reason: Nobody wants to see payment decrease for such a crucial profession. On top of that, the coding system CMS was compelled by the legislation to implement to document when services are delivered "in whole or in part" by a PTA or occupational therapy assistant, while improved over its original plan, still has flaws.
But for some, there's another element to the frustration they're feeling: They’re wondering how we got here and what APTA is doing about it. And that's understandable, too, because legislation and regulatory rulemaking are complicated and sometimes messy, and it can be a challenge to keep up even if you’re working hard to pay attention.
So let's walk through it.
Where It All Started: One Enormous Piece of Legislation
The PTA modifier and payment differential weren’t changes dreamed up by CMS — Congress put this policy in the legislation that became the Bipartisan Budget Act, or BBA, of 2018.
You may remember this law when it was passed, because it was huge. It included, among other provisions, $90 billion for hurricane relief efforts, two years of funding for community health centers, $6 billion over two years to address the opioid crisis, a four-year extension of the Children’s Health Insurance Program, a suspension of the debt ceiling, and much more.
The BBA also required that by January 1, 2019, CMS establish a modifier to indicate when an outpatient physical therapist service is furnished in whole or in part by a PTA. The use of the modifier was mandated as of January 1, 2020, for outpatient therapy providers across almost all settings — including private practices, skilled nursing facilities, home health agencies, outpatient hospitals, rehabilitation agencies, and comprehensive outpatient rehabilitation facilities. Starting January 1, 2022, outpatient physical therapy services covered under the Medicare physician fee schedule that are furnished at least in part by a PTA — as identified by the modifier — will be paid at 85% of the applicable fee schedule rate. A similar modifier was designated for services provided by an occupational therapy assistant, which also will be subject to the 85% payment differential.
A Last-Minute Addition With no Chance for Discussion
So how exactly did this mandate to CMS get included in the BBA? Basically, it was included in the legislation at an 11th-hour by members of the U.S. House of Representatives. This policy had not been part of any of the discussions or negotiations during the previous year regarding the therapy cap, nor was it included in any proposed fixes, such as the Medicare Extenders package announced in October 2017. On the evening of Monday, February 5, 2018, with no warning to APTA, the PTA differential policy appeared in the House budget proposal.
As soon as the proposal was released, APTA leaped into action, along with the American Occupational Therapy Association. Both associations objected to the change and gave alternative legislative language to members of the U.S. Senate on Tuesday, February 6, and Wednesday, February 7. The Senate’s response? They told us there was no opportunity to alter the policy. Both the House and Senate packages were “baked” prior to release. The BBA was signed into law on Friday, February 9.
Therapy Cap Tradeoff? Nope
There's a notion floating around that the PTA differential was adopted to "pay for" the therapy cap fix. Not true. The PTA policy was just one of many policies adopted by Congress to pay for its legislative initiatives within the BBA legislation. Rather than allow for timely discussion about its merits among stakeholders, Congress waited until the very last minute to insert the change and then refused to listen to the therapy associations’ suggested improvements or refinements to the legislative language. Just because the therapy cap fix was a positive development of the BBA doesn’t mean that Congress traded one thing for the other. And with $38 billion in adjustments to the current operating models of the health care programs, the physical therapy profession was going to be touched somehow.
From Legislation to Rulemaking
With the legislation now signed into law, CMS was required to adopt a modifier in order to identify when a service is furnished in whole or in part by a PTA or OTA. It also had to interpret what Congress meant by "services furnished in whole or in part" — no small task. Recognizing the ball was now in CMS’ court, APTA directed its advocacy to CMS to ensure that the agency interpreted the policy to, as much as possible, have minimal impact on patients and providers.
The journey toward the system now in place was a bumpy ride. In the 2019 physician fee schedule proposed rule (released in July 2018), CMS proposed a definition of “in whole or in part” as a service for which any minute of a therapeutic service is furnished by the assistant. Needless to say this was completely unacceptable, as well as unworkable from a practical standpoint. APTA fought back.
Responding to feedback from APTA and other stakeholders, CMS revised its proposed definition in the 2019 physician fee schedule final rule and defined a standard for "in whole or in part" as more than 10% of the service being furnished by the PTA or OTA—an approach known as use of a "de minimis" standard. While the finalized definition was less than ideal, it was an improvement upon the “any minute” proposal. And it occurred because we met with CMS and submitted detailed comments against the “any minute” proposal — otherwise it would've been full steam ahead on a terrible plan.
In the 2020 physician fee schedule proposed rule (released in July 2019), CMS proposed how this de minimis 10% standard would be applied. When CMS proposed how the modifiers would be used—"CQ" for PTAs and "CO" for OTAs —it forwarded a needlessly complicated system that threatened patient care and ignored the realities of PT practice. (This PT in Motion News story outlines the problems with the proposed rule from APTA's perspective.) APTA members, association staff, and other organizations pushed back hard by way of thousands of responses to the agency, in addition to meeting with the CMS Administrator and agency staff.
A Better — But Far From Perfect — Final Rule
Because of the collective efforts of APTA members and staff, CMS took notice and clarified how the new standard would be applied. While it hung on to the policy that the modifier must be applied when 10% or more of the service is delivered by a PTA or OTA, the agency’s final rule for 2020 backed away from many of the more problematic elements of its proposed plan.
And that's where we are now.
About All That Letter-Writing…
Our efforts to shape the final version of the application of the CQ modifier involved extensive communication with CMS, including meetings with the agency and submitting comment letters, both from the association itself and thousands of individual members and other stakeholders. You may think that letter-writing isn't an especially effective way of doing advocacy. That's just not so.
Submitting written comments to CMS (or any federal agency) on a proposed rule is an important way to have your voice heard on regulations that can have a large impact on your and other people's lives. Public comments provide regulators with information to help them improve their rules and may even lead to changes in regulations. This is why APTA is so passionate about having the profession use its voice to advocate to CMS and other federal agencies when there are opportunities for comment — it's one of our most crucial, most direct connections with the people actually crafting the rules we'll have to live by.
There's no denying that the PTA payment differential set to go into effect in 2022 is disappointing. But in figuring out the pathway forward it's essential to recognize that the physical therapy profession isn't being singled out: Other essential health care providers, such as physician assistants, clinical social workers, and nurse practitioners, are paid at 85% of the fee schedule. And while it's true, for now, that these providers are able to be paid at 100% of the fee schedule through an allowance known as "incident to" billing, policymakers are looking at getting rid of those provisions and always paying these providers at 85% of the fee schedule.
The reality is that we’re in an increasingly challenging payment landscape across health care, as the health care system is in the midst of a paradigm shift away from the fee-for-service payment structure, in which providers are rewarded solely by the volume of services provided, and toward a structure that holds providers accountable for patient outcomes and costs (value-based payment, or alternative payment models).
I’m hopeful this article gives some insight into what actually happened with the differential and how we've fought tooth and nail to improve the policy since its surprise appearance in federal legislation on February 5, 2018. Health care payment is a volatile landscape right now, and we have to keep striving for progress and working together.
David Harris, PTA, MBA, is vicepresident of integrations at Upstream Rehabilitation and chief delegate of the PTA Caucus.
The Five Things I've Learned as a Cash-Based Physical Therapy Practice Owner
By Aaron LeBauer, PT, DPT
What's the greatest number of patients you've treated in one day? My record is 43. I treated 43 patients one day, as a student. That's more than four people per hour during a 10-hour workday.
In that environment (and business model) I wasn't able to spend any quality time with my patients or treat them the way I thought was most effective. I wasn't able to work out, go to yoga, or even spend time with my wife. It was insane.
But it doesn't have to be this way.
Fast forward from my days as an exhausted student to today, where I am the proud owner of LeBauer Physical Therapy, a 100% cash-based practice in Greensboro, North Carolina. We help active people stay fit, healthy, and mobile without medications, injections, or surgery. And we do it without the time-consuming hassles from CMS or third-party payers who seem to constantly want to pay less for more.
For me, starting a cash-based practice wasn't a lifelong dream. I started a cash-based practice because I really did not feel that I had any other options.
I knew I was going to live here in Greensboro, and I looked around and thought, "Where can I get a job?" I didn't like working in a hospital; I didn't like skilled nursing. I knew my strengths were using my hands, doing soft tissue work, mobilization/manipulations, and spending time with patients to learn their stories and educate them. I didn't see a place here that was going to employ me and allow me to spend 45 minutes to an hour, one-on-one with patients, doing the type of physical therapy I wanted to practice.
My practice gives me the freedom to treat patients my way. It gives me freedom in my schedule. It gives me freedom to choose the quality of life I want. I get time! I can spend Monday and Friday afternoons with my family. I pick up my kids from school, hang out in the backyard, and grill some steaks.
Along the way, I've learned a ton and made plenty of mistakes. Here are five (of many) things I've learned as a cash-based business owner:
1. Mindset Is everything
To be successful, you've got to have the right mindset.
You are no longer worth what you earned for your salary or what the patient paid in copays each visit. You have to decide what you are worth, and then ask people to pay you that much. How much did it cost you to go to school? How much do you need each month to live and to operate your practice? What is the going rate for PT services? Be careful about charging too little or underselling your services. Find a price that's a little above your comfort zone and start there.
Once you start to change your mindset from a person who provides a treatment directed by someone else to a primary care provider who decides on the treatment, you will begin to thrive.
2. Low Overhead Is Key
It's important to have a low-overhead practice to minimize your expenses, especially when starting up, but also to maximize your profits in the long run.
The less you spend and the more you collect, the larger your profits. It's as simple as that! As a startup cash physical therapy practice owner, there are many ways you can leverage your dollars to get quality services in the creation and operation of your practice.
For instance, you can spend hundreds to design a logo and get business cards printed, or you can get 250 free business cards from VistaPrint and your logo created for $5 at Fiverr.
3. Give to Get
You've got to give in this business; when you give other people something they value first, especially if it's something they aren't expecting, they will feel compelled to give back to you.
Give your knowledge to others by creating educational programs and providing valuable resources such as newsletters and instructional videos. When you position yourself as the expert in your community by creating something of value that helps your "referral partners," potential patients will begin to seek out your advice and services when they need help, are hurt, or are injured.
But remember: Don't give anything when you expect something in return. Just give and watch what follows.
4. Live in Abundance
I'm going to say this right now: PTs need to stop putting each other down. We need to work together to lift everyone up. There is more than enough (money, land, patients, etc.) for everyone to succeed. It's known as an "abundance mindset," and it's crucial to our profession.
5. Market Directly to Patients
To have a successful practice means you need to market directly to patients. Patients are the consumers of our services — not physicians, insurance companies, or hospitals — and we have to connect with them.
Instead of spending money on traditional brand advertising, spend time and effort writing online articles and updating the content of your website to let patients know exactly how they will feel and what they will experience when they come to your office. Patients want to know what's in it for them, and they are searching on Google to find answers. You can be the one providing those answers.
Your patients should be the ones making the decision to come to you, so make it easy for them.
There you have it! Those are five things I've learned as a cash-based business owner. I hope you were able to see that opening a cash-based clinic isn't as daunting as it sounds. I did it first and made the mistakes so you wouldn't have to.
Aaron LeBauer helps physical therapists scale their time, income, and impact without relying on insurance. He's the host of The CashPT Lunch Hour Podcast, author of The CashPT Blueprint, and founder of The CashPT Nation Facebook group. Contact him at www.AaronLeBauer.com.