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  • Home Health Faces Challenges in Wake of Budget Deal

    A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

    The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers' negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.

    The payment unit changes echo provisions included in CMS' failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system proposed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a "perverse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode." CMS dropped its efforts to adopt HHGM in the fall.

    Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there's 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in significant reductions in reimbursement.

    But that doesn't mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA's director of regulatory affairs, the budget deal also includes a provision directing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

    "We expect that HHS will attempt to create a case-mix system similar in nature to the HHGM," Gainer said. "However, HHS has said that its revisions will be based on feedback from a technical expert panel." That panel met on February 1 and included a representative from APTA. Gainer is hoping that at least 1 more panel meeting will be held in 2018.

    So does Diana Kornetti, PT, MA, president of the APTA Home Health Section. Kornetti is also a credentialed home care coding specialist.

    "Right now, it appears that only 1 technical expert panel meeting is required by law during 2018, and that's already happened," Kornetti said. "This is the first thing that needs to change. There is no guarantee that the home health industry and its stakeholders will have any future opportunity to review and discuss the issues and concerns that will arise."

    According to Kornetti, should stakeholders get that opportunity, the case for the right kinds of changes to the home health payment will be much stronger if it's backed by documented outcomes for physical therapy.

    "Patient acuity is critical," Kornetti said. "Capturing correct and thorough data, using objective measures, will be increasingly important to establishing an accurate payment for physical therapist services. We must speak the language of outcomes moving forward as a profession—our services must show our impact on reduction of costs, while continuing to strive for increasing clinical quality."

    With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer explained. The threats to home health will be 1 of the association's targets.

    But as with any other attempt to get policymakers to listen, the effort will require participation from physical therapists and physical therapist assistants, Kornetti added.

    "A key principle in our code of ethics speaks to advocacy for those we serve," Kornetti said. "It has never been more important for the postacute physical therapist and physical therapist assistant to become informed and participate in this process. One rung of our ladder toward a fully autonomous profession is having representation at the table where decisions are being made."


    • One of my concerns is how the issue will play out for patients with long-term chronic conditions. Specific example: a 69 year old patient with multiple sclerosis who has not needed hospitalization for a full year, receiving a new drug infusion which will hopefully slow the progression of the MS. I'm concerned about ongoing coverage; home care PT is less costly than LTC and should be used to delay further loss of function whenever possible.

      Posted by Barbara on 2/14/2018 10:28 PM

    • Agree. This is of great concern to advocates for people with longer term, chronic and debilitating conditions. It will exacerbate and already grave home health access problem.

      Posted by Judith Stein on 2/20/2018 11:42 PM

    • I have been a PTA for 20 years as of this month. I am shocked and saddened to hear about the change in reimbursement rate when a PTA provides the care for a patient, effective year 2022. I believe this will be the beginning of the end of the PTA profession. I was looking forward to the emergence of new educational opportunities for PTAs and getting my bachelors degree, as all PT educational programs will be graduating at the doctoral level by 2020 if they are not already. This new ruling has again changed my outlook on whether I should remain in the medical profession at all. I have been questioning it for several years as many of us have. Many of my colleagues have said “if we knew 20 years ago what it was going to be like now” we would’ve never gotten into the medical profession. Once the physical therapists, the doctors, the surgeons, the radiologists, the CFO’s. and other corporate executives no longer have their assistants, their secretaries, their transcribers; RN’s no longer have LVN’s, LVN’s no longer have CNA’s, they all will have to do everything themselves, Then maybe they will realize our worth and that they have cut their nose off to spite their face, that they let things go too far. Unfortunately by then it will probably be too late

      Posted by Laura W. on 9/23/2018 3:47 PM

    • I agree. It's too bad for our profession to go under such a humiliating policy. They always try to go after the PT profession since we are under a lower totem pole for Medicine in general. I have an out pt-PT clinic where we rely on the PTAs to treat and it is a blow to the profession and the business. We hardly have any profit anyway despite how hard we work. Our reimbursement went down to 43% of billable and been going down steadily each year. I have had the PT clinic more than 25 years now and it is getting harder to keep the doors open for the public. We need help in our system to protect companies like ours, PTs, and PTAs... Everyone should be complaining to Congress by now. Kristen P, DPT, RPT

      Posted by E.Kristen Park on 5/27/2019 6:36 PM

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