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  • Study: Number of Pills Prescribed Is a Stronger Predictor of Opioid Consumption Than Pain Severity Postsurgery

    According to psychologists, humans have a tendency to make decisions based on an overreliance on a single value, to such a degree that other values are minimized or ignored entirely. It's called the "anchoring and adjustment heuristic," and it's not uncommon: we tend to eat more food than normal (the adjustment) if we're presented with larger quantities of it (the anchor); we tend to think we're getting a good deal on something we're shopping for (the adjustment) if the price is lower than the one we've fixed in our minds, which is often the first price we saw (the anchor).

    Now researchers are wondering if this behavior phenomenon plays an even more insidious role when it comes to opioid use—namely, a tendency for patients to take more opioids if they're prescribed larger quantities of pills. That's what authors of a new study discovered after conducting patient surveys that revealed postsurgical opioid consumption rose by an additional 5 pills for every 10 prescribed. In fact, they claim, the relationship between opioids consumed and opioid quantities prescribed is stronger than the link between the level of pain experienced by patients postsurgery and their opioid consumption.

    The results, published in JAMA Surgery (abstract only available for free), are based on surveys of 2,392 patients in Michigan who were prescribed opioids after undergoing 1 of 12 targeted surgeries including cholecystectomy, appendectomy, femoral hernia repair, incisional hernia repair, colectomy (laparoscopic and open), ileostomy and colostomy takedown, small-bowel resection, thyroidectomy, and hysterectomy (vaginal and abdominal). Researchers conducted phone interviews with patients during a window between 30 days and 120 days postsurgery, asking them how many opioid pills they had consumed and gathering self-reports on pain using a 4-item scale. They then analyzed patients' answers in relation to various demographic variables, surgeries received, and oral morphine equivalents (OMEs) prescribed.

    Here's what they found:

    • The strongest predictor of opioid consumption was the amount of opioids prescribed to the patient. Researchers estimate that for each additional OME prescribed, patients used an additional 0.53 OMEs. Put in terms of pill equivalents, that's equal to using 5.3 more pills for every 10 additional pills prescribed. "A patient prescribed 100 pills could therefore be expected to use roughly 40 more pills than a patient prescribed 20 pills," authors write.
    • While pain severity also was linked to increased consumption, the relationship wasn't a strong as the tie to quantity of pills prescribed: compared with patients reporting no pain postsurgery, those reporting moderate pain used an additional 9 pills, and those reporting severe pain reported using an additional 16 pills, on average.
    • Tobacco use and obesity were related to increased opioid consumption; outpatient surgery was associated with decreased consumption, as was older age.
    • Overall, 24% of patients reported taking no opioids after surgery. The highest rate of nonuse was among patients who underwent thyroidectomy (48% nonuse rate) and lowest was for the group receiving abdominal hysterectomy (20% nonuse rate).
    • Consumption of the entire opioid prescription was reported by 22% of patients interviewed.
    • In all surgeries studied, the quantity of opioids prescribed was "significantly greater" than the quantity of opioids consumed, with an average of 30 5/325 mg of hydrocodone/acetaminophen pill-equivalents prescribed compared with an average of 9 pills taken. Consumption ranged from 3% of opioids prescribed following thyroidectomy to 67% of opioids prescribed after ileostomy/colostomy takedown.
    • Mean age of the respondents was 55, with 57% women; 77% underwent elective surgery as opposed to urgent or emergent surgery. Three surgical procedures made up more than half of the total surgeries analyzed: hernia repair (28%), cholecystectomy (25%), and appendectomy (9%).

    Researchers acknowledge that there may be a link between postsurgical consumption and preoperative opioid use—data they weren't able to gather—but they believe the key to their findings my lie with the anchoring and adjustment heuristic.

    "In this case, a larger amount of opioids may serve as a mental anchor by which patients estimate their analgesic needs," authors write. "The amount of opioids a surgeon prescribes to a patient may influence that patient's opioid consumption after surgery."

    Also concerning, according to the authors, is that the complete opioid prescription is seldom consumed—at least as part of recovery postsurgery. What's worse, "most patient who received opioids after surgery do not dispose of leftover medication," they write, adding that "it is well established that most individuals who misuse prescription opioids obtain the medication from a friend or relative as opposed to 'doctor shopping' or illicit sources."

    While the researchers think their findings may help in better customizing prescriptions based on individual patient variables, they believe there's an even more obvious first step that needs to be taken immediately: stop prescribing so many opioids, period.

    "Overprescribing occurred for all procedures included in this study, from relatively minor to major operations," authors write. "These data highlight the importance of significantly changing the way opioids are prescribed following surgery to decrease excess medication as a source for diversion and abuse."

    findings reported in the JAMA article echo the conclusions of a recently updated report from the Plan Against Pain, which asserts a link between opioid prescriptions postsurgery and later opioid dependence. APTA's #ChoosePT opioid awareness campaign is a selected partner of the plan.

    In addition to its flagship #ChoosePT opioid awareness campaign, APTA 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.

    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.

    The Good Stuff: Members and the Profession in the Media, November 2018

    "The Good Stuff," is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Don't back away from movement: Eric Robertson, PT, DPT, says there's more to avoiding back pain than correcting posture—movement is key. (Prevention)

    Quotable: "When the lights go on in their head, they’re like 'I can do that by myself now' it's just fun and so that's why I got into physical therapy, I just love it every day." – Lon Egbert, PT, DPT, ATC, on the additional rehabilitative possibilities offered by the addition of a new swing bed facility at his hospital. (KMVT11, Twin Falls, Idaho)

    Finding the next PT? Scott Humpal, PT, has launched a local high school program that helps students in the health sciences program gain certifications and college credits. (KRSTV, Corpus Christie, Texas)

    Here's the dill for people who relish pickleball: Bob Cairo, PT, checks out pickleball and offers advice on avoiding injury from the sport. (Delaware Coastal Point)

    Physical therapy in the hospital: Katie Martonik, PT, DPT, explains the role of PTs and PTAs in hospital settings. (Stroudsburg, Pennsylvania, Pocono Record)

    Quotable: "For those looking to build the best possible exercise program, it pays to use rehabilitation techniques. Core stabilization, postural improvement, rotator cuff training and lots of other exercise categories can be traced back to physical therapy. Without them, we'd be stuck with the same ol' bench presses and squats. Wow, we've come a long way." – Personal trainer Matt Parrott, on the effectiveness of "rehabilitative movement" in strength training. (Arkansas Democrat-Gazette)

    Finding the strength to battle back pain: Blake Dircksen, PT, DPT, shares core-building exercises that can help provide relief for LBP. (Self)

    Staying strong as you age: Mike Studer, PT, MHS, discusses the importance of strength training for healthy aging. (Salem, Oregon, Northwest Boomer and Senior News)

    Quotable: "I've had people tell me I shouldn't be running at my age. Jennifer is great about encouraging me and letting me know there's no reason for me to stop." – Susan Giordano, age 62, on the role Jennifer Penrose, PT, DPT, has played in her continued participation in distance running. (Thurstontalk.com)

    Providing care pro-bono: Sean Luzzi, SPT, and professor Maureen Pascal, PT, DPT, share their experiences from a recent pro-bono physical therapy clinical sponsored by the Misericordia University PT program. (WBRE-TV, Wilkes-Barre, Pennsylvania)

    Artificial intelligence and physical therapy: Marist College PT program faculty members Francine Sage-King, PT, DPT, ATC, and Claudia Fenderson PT, EdD, outline the potential for AI to provide PTs with important information to aid in rehabilitation. (Albany, New York, Hudson Valley Spectrum-News)

    Quotable: "Physical therapy improves lives, especially for seniors. Physical therapy can increase strength and endurance, restore range of motion, reduce pain and help with balance. People may even find that they go to physical therapy for one reason and discover added benefits in other areas. – Stevie Williams, director of Elder Care in Bartlesville, Oklahoma. (Bartlesville Examiner-Enterprise)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    New Physical Activity Guidelines Stress the Importance of Movement of any Duration

    You want blunt? The US Department of Health and Human Services can do blunt—at least when it comes to physical activity (PA) recommendations for Americans.

    "Adults should move more and sit less throughout the day," HHS says in its latest edition of nationwide guidelines for PA. "Some physical activity is better than none."

    That's the bottom-line recommendation that HHS rolled out this week in its revised Physical Activity Guidelines for Americans. And there's arguably little room for nuance: according to HHS, 80% of all Americans are not meeting current PA recommendations, a failure that is contributing the prevalence of a host of chronic health conditions.

    The new guidelines, with their emphasis on the importance of movement to prevent disease and extend life no matter an individual's age, echo many perspectives long-championed by APTA and its members.

    "These revised guidelines create a clear roadmap for where we need to be as a nation, and the physical therapy profession is here to help people get the movement they need to optimize their health," said APTA President Sharon L. Dunn, PT, PhD. "APTA will continue to advocate on behalf of our patients to ensure that our nation’s public policies align with these recommendations."

    The revision, the first in 10 years, doesn't alter many of the now-familiar PA goals for adults: at least 150 minutes of moderate-intensity PA per week, or 75 or more minutes of vigorous-intensity PA per week. But the new guidelines further reinforce the benefit of PA at any level by removing statements saying that PA must occur for at least 10 minutes to be effective, and by clarifying that virtually any kind of movement is better than nothing. "Adults who sit less and do any amount of moderate-to-vigorous [PA] gain some health benefits," according to the guidelines.

    The guidelines themselves vary by age and other factors. Here are the basics for each group identified by HHS.

    Preschool-aged children (3 to 5 years): HHS recommends that this age group "should be physically active throughout the day" and that caregivers "should encourage active play that includes a variety of activity types."

    Children and adolescents (6 to 17 years): The guidelines recommend 60 minutes or more per day of moderate-to-vigorous PA; with at least 3 days of vigorous-intensity PA per week, at least 3 days of muscle-strengthening PA per week, and at least 3 days of bone-strengthening PA per week.

    Adults: 150 minutes per week of moderate-intensity PA, or 75 or more minutes per week of high-intensity PA is recommended for adults; at least 2 or more days per week should include muscle-strengthening activities.

    Older adults: If possible, 150 minutes per week of moderate-intensity PA, tempered by an individual's "level of [PA] relative to their fitness," and a clear understanding of how various chronic conditions can affect the ability to reach PA goals. No matter what PA level is achieved, activities should include balance training, aerobic, and muscle-strengthening activities.

    Women who are pregnant and postpartum: The guidelines recommend at least 150 minutes of moderate-intensity PA per week, spread throughout the week, during both pregnancy and postpartum. The guidelines also advise that women "who are habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period."

    Adults with chronic health conditions and/or disabilities: These adults should follow the same targets as nonsymptomatic adults, but with a recommendation that should a chronic condition or disability interfere with their ability to meet these guidelines, PA should occur to whatever extent possible; individuals should avoid inactivity. The guidelines also recommend that people with chronic conditions "consult with a health care professional or [PA] specialist about the types and amounts of activity appropriate for their abilities and chronic conditions."

    A summary of the guidelines was featured in JAMA, accompanied by an editorial that emphasizes the importance of educating the public on the idea that PA has health benefits no matter the scale of the effort.

    "Probably the most important message…is that the greatest health benefits accrue by moving from none to even small amounts of [PA], especially if that activity is moderate…to vigorous..." editorial authors write. "The key point for patients is that large health benefits accrue from even small amounts of [PA] and that even short-duration activity lasting less than 10 minutes is beneficial."

    The JAMA editors also think that clinicians need to take care to avoid an overly cautious approach to PA recommendations for patients, writing that they "must avoid being a barrier to [PA] because of concerns about the cardiovascular and orthopedic risks…." They describe those risks as "extremely small with gradually progressive [PA]."

    Given PA's demonstrated effects on both physical and emotional well-being, and the relatively low costs involved in incorporating PA into patient lifestyles, "clinicians cannot afford to allow patients to miss out on this inexpensive path to healthier lives," the editorial authors write.

    Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness.

    Proposed Medicaid, CHIP Rule Reflects State Movement Toward Managed Care Systems

    As states continue to move toward wider use of managed care organizations (MCOs) in their Medicaid systems, the US Centers for Medicare and Medicaid Services (CMS) is looking at ways to guide the evolution while maintaining state flexibility. A few of those ideas have been fleshed out in a recently released proposed rule from CMS on both Medicaid and the Children's Health Insurance Program (CHIP).

    APTA regulatory affairs staff members are analyzing the proposed rule, and the association will provide comments to CMS by the January 19, 2019, deadline. In the meantime, here are a few basics:

    Allowing temporary pass-through payments for states transitioning to MCOs. Currently, providers in fee-for-services Medicaid arrangements are eligible for additional payments, known as "pass-through" payments, but these payments are being phased out for MCO Medicaid arrangements, and new payments are prohibited. But what about states that are transitioning to managed care? In response to some states' requests that pass-throughs continue to be allowed as a part of the transition process, CMS is proposing that new payments be allowed during a limited time period.

    Easing network adequacy standards and providing flexibility in the definition of "specialist." CMS proposes moving away from network adequacy standards based on travel time and geographic location, and toward a system that allows states to factor in other issues, including the availability of contracted providers who are accepting new patients, maximum wait times for appointments, and a facility's hours of operation. Additionally, the agency would like to give states more flexibility in defining which providers are considered "specialists."

    Loosening requirements for state quality-rating systems (QRS). CMS would like to allow states more leeway in their QRS systems: rather than requiring that the approaches provide data substantially similar to data provided by the CMS-developed QRS, the agency is proposing that state QRS systems need only be "comparable to the extent feasible to enable meaningful comparison across states." The proposed rule also would eliminate a requirement that states get CMS approval before starting up an alternative QRS.

    Making it easier for enrollees to navigate the appeals system. Under the proposed rule, Medicaid enrollees would no longer be notified of claims denials based on administrative errors; they would only receive notification of "substantive" denials. Additionally, enrollees who submit an oral appeal to a denial would no longer be required to submit an additional written and signed appeal.

    European Psychiatrists Recommend Physical Activity in the Treatment of Severe Mental Illness

    Could the effect of physical activity (PA) on the brain extend beyond a general sense of well-being? The European Psychiatric Association (EPA) thinks so and has issued guidance that recommends supervised PA as potentially effective treatment for individuals with severe mental illnesses (SMIs) such as schizophrenia and major depression. The recommendations are supported by the International Organization of Physical Therapists in Mental Health.

    The recommendations, appearing in European Psychiatry (abstract only available for free), are based on a review of 20 meta-analyses and systematic reviews gathered through January 2018. Researchers began with a pool of more than 2,000 studies but narrowed their review to studies of randomized controlled trials that specifically addressed exercise interventions for individuals with schizophrenia, major depressive disorder (MDD), and bipolar disorder (BP).

    Authors of the recently released guidelines were interested in the role of PA among the population of individuals with SMI not only in relation to its ability to lessen symptoms, but also as an intervention that could extend lifespans in that population. According to the researchers, individuals with SMI face an increased risk of early mortality by as much as 10 to 20 years, with physical disorders accounting for as much as 70% of those early deaths.

    The type of PA analyzed was focused on aerobic exercise, high-intensity exercise, resistance exercise, and mixes of aerobic and high-intensity exercise. Researchers excluded mind-body PA such as yoga and tai-chi, "since these activities are presumed to exert beneficial effects on mental health through additional factors distinct from the [PA] itself."

    In the end, authors found good evidence to support PA as a treatment for both schizophrenia and MDD, particularly when supervised by an exercise professional such as a physical therapist. For MDD, authors recommend 45- to 60-minute sessions of supervised aerobic training or aerobic and resistance training at moderate intensity 2-3 times per week. Research on optimal PA frequency, duration, and intensity for individuals with schizophrenia was harder to find, but authors make a general recommendation for 150 minutes per week of aerobic exercise to improve symptoms, cognition, and quality of life. Authors were unable to find sufficient research to reach a conclusion on the effects of PA among individuals with BP.

    Additionally, the researchers issued a recommendation, based on "some evidence," that PA should be used to improve the physical health of individuals with SMI—a recommendation that was limited by what authors describe as the "paucity of studies that have targeted this important topic." The set of guidelines also includes a recommendation, "based on expert opinion," that individuals with SMI should be routinely screened for PA habits in both primary and secondary care.

    Authors also include a set of 6 recommendations to address what they believe are the current gaps in research around PA and SMI. Recommended areas for research are investigation into the effects of PA in the early stages of SMI, the development of "pragmatic, scalable methods" for PA in the SMI population, establishment of optimal dose-response relationship between PA and SMI, exploration of interventions to reduce sedentary behaviors, identification of the underlying neurobiological mechanisms at work, and an analysis of the long-term cost-effectiveness of PA as a treatment for SMI.

    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.

    Survey Finds 'Considerable Variation' in Postsurgery ACL Rehab

    Authors of a new study say that while guidelines exist for rehabilitation after anterior cruciate ligament (ACL) reconstruction, there remains "a large degree of variation in rehabilitation progression" among physical therapists (PTs), particularly when it comes to timing of the progression, strength assessment, and use of patient-reported outcome measures

    Those conclusions, published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free) were based on results of an online survey of 1, 074 members of APTA’s Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, and Private Practice Section. Authors believe that this is the first time PTs' private practice patterns in this area have been studied.

    As for the respondent pool, the majority of PTs treated patients in a private practice or hospital-based outpatient facility. Just over half (52.5%) held American Board of Physical Therapy Specialties certifications in either orthopaedic or sports physical therapy, and 92.5% were APTA members. Authors of the study also classified respondents by the volume of post anterior cruciate ligament repair (ACLR) patients they treated annually, with 32.3% falling into the "low volume" category of 1 to 5 per year, 28.8% grouped into a "medium volume" category of 6 to 10 patients per year, and 37.9% categorized as "high volume," with 11 or more post-ACLR patients per year. Researchers also tracked respondents by years in practice.

    Here's what they found:

    • Overall 56% of respondents reported the duration of supervised physical therapy at 5 or fewer months.
    • Regarding the length of time PTs would wait before recommending a patient initiate sports activity, 58% said 3-4 months for jogging, 50% said 4-5 months for modified sports activity, and 40% said 9-12 months for unrestricted sports participation. Given that most respondents reported treatment periods of 5 months or less, the number of PTs who don't recommend unrestricted participation until after 9 months postsurgery "imply that there may be a long gap between the discontinuation of supervised rehabilitation and return to activity," authors write.
    • Over 80% of respondents used strength and functional measures to assess patients during rehabilitation. Most PTs used manual muscle testing (MMT) to assess strength before progressing patients to jogging (80.6%) or modified sports (74.3%). Of those, 56% relied solely on MMT as a mode of assessment—a potential concern, according to authors, because MMT "may lack the sensitivity to detect residual strength deficits that may be present at this phase of recovery, leading to poorly informed decision making." The tendency to rely solely on MMT was more prevalent among low-volume providers and uncertified PTs.
    • Before progressing patients to jogging or modified sports, most respondents assessed knee strength, function and balance, knee range of motion, and degree of knee effusion. However, there was significant variation among PTs regarding limb strength criteria for functional advancement. Authors speculate this may be due to a lack of clear evidence.
    • Only 45.3% of respondents reported using patient-reported outcome measures to quantify functional deficits. The most common measure was the Lower Extremity Functional Scale, used by 39.2% of respondents, with fewer than 10% of respondents reporting use of measures related to fear or athletic confidence. Authors describe the lower usage rates of patient-reported outcomes as "regrettable," writing that "it has become clear that physical recovery alone is not sufficient to ensure successful return to sports, and many authors have emphasized the importance of assess¬ing psychological readiness and fear of reinjury." The lack of attention to patient-reported fear and readiness "[neglects] the holistic framework highlighted within the biopsychosocial approach to patient management," they add.

    According to authors, across the survey areas reviewed, 1 consistent element emerged: PTs who treated a large volume of post-ACLR patients, more recent graduates, and those with specialty certifications were more likely to report practice patterns "that were more consistent with current best evidence."

    Authors caution that the results should be understood within the limitations of the study itself. Among those limitations: the survey instrument was not validated before dissemination, there were no questions that addressed the possible influence of payment systems on treatment patterns, and the respondents were overwhelmingly APTA members—a fact that authors believe may hide even greater variability among the entire PT population.

    Overall, however, authors call the results "surprising," and note that "one of the most noticeable findings was the degree of variability in clinical testing and decision making, particularly within the later phases of rehabilitation, during the transition back to sports activity." The variation, they write, points to the possibility that at least when it comes to on-the-ground PT practice, "there is no consensus about the ideal postoperative rehabilitation program."

    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.

    APTA Members Eligible for Interdisciplinary Orthopedic Conference Discount

    In this rapidly changing health care environment, it's crucial that practitioners and administrators learn as much as possible from each other—and orthopedics is no exception. An upcoming conference aims to provide a platform for just such an exchange and is offering APTA members a discount on registration.

    The Interdsciplinary Conference on Orthopedic Value-Based Care, set for January 18-20 in Newport Beach, California, is an event that brings physicians, health care executives, nurses, and physical therapists (PTs) together to learn and share insights on everything from improving patient outcomes to understanding how concepts such as "Medicare for all" could affect individual practice. Sponsored by the American College of Perioperative Medicine, the conference features a long list of leaders in orthopedic care, including APTA Board of Directors member Kip Schick, PT, DPT.

    Registration for the conference is open now, with early bird discounts ending November 21. APTA members are eligible for an additional 10% discount—just enter "PERIOP" in the "promotion code" box on the registration form.

    From PT in Motion Magazine: A Primer on Major Medicare Payment Changes

    It's hard to overstate the Medicare-related changes that many physical therapists (PTs) will be facing come January, now that the US Centers for Medicare and Medicaid Services (CMS) has adopted a final rule that includes eligible PTs in the agency's comprehensive Quality Payment Program (QPP). There's a lot to learn about the new value-based payment system, and PT in Motion magazine can help you get started.

    In "Moving Toward Quality Payment" in the November issue of PT in Motion, author Christine Lehmann breaks down the QPP into its 2 paths, particularly focusing on the Merit-based Incentive Payment System (MIPS) and its reporting requirements. The article includes an easy-to-follow decision tree that helps you understand whether you'll be required to participate in MIPS, and, if not, whether you should consider voluntary participation (hint: APTA thinks it's a good idea).

    Lehmann's piece also covers the other QPP path, advanced alternative payment models, as well as the ways in which APTA's Physical Therapy Outcomes Registry could serve as an important resource for PTs moving to value-based payment systems. Sidebars to the article include information on the elimination of functional limitation reporting requirements, and a list of additional APTA resources to help you get up to speed on the changes ahead.

    "Moving Toward Quality Payment" is featured in the November 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.

    CMS Finalizes 'Site Neutral' Outpatient Plan; New Approach to DMEPOS Bidding

    As it continues to roll out final payment rules for 2019, the US Centers for Medicare and Medicaid Services (CMS) is sticking to its pattern of mostly following through on its original proposals—this time by ending payment rates that favor hospital-owned outpatient facilities over independent physicians' offices, and adopting a new supplier bidding system for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

    Outpatient Prospective Payment System (OPPS)
    As it proposed, CMS will expand the use of a "site-neutral" payment model in its reimbursement for the clinic visit service (HCPCS G0463), the most common service billed under the OPPS. Currently, Medicare and beneficiaries often pay more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting. CMS is doing 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 for this service. According to a CMS fact sheet, the agency estimates that the change, implemented over a 2-year period, will save an estimated $380 million in 2019 alone. The change does not directly affect physical therapists (PTs) working in outpatient hospital settings, given that outpatient therapy services delivered by PTs are paid under the physician fee schedule, not OPPS.

    Also final-as-proposed: a CMS decision to make separate payments for nonopioid pain-management drugs that function as a supply when used in an ambulatory surgical center (ASC) procedure.

    Overall, OPPS rates will increase by 1.35% in 2019, with a 2.9% market basket update offset by a 0.8% productivity adjustment and a 0.75% adjustment related to the Affordable Care Act (ACA). ASC payment will increase by 2% and in the future will be updated based on the hospital market basket update instead of the "consumer price index-urban all item" system, a change that will remain until 2023 at the earliest.

    Although not reflected in the final rule, during the public comment period on the OPPS proposed rule, CMS asked for input on issues including wound care, price transparency, and the opioid crisis as it relates to outpatient services. APTA provided comments in all 3 areas, advocating for better promotion of and payment for nonopioid approaches to pain management, a collaborative approach to price transparency that emphasizes consumer education, and careful attention to wound care reimbursement recommendations provided by the Alliance of Wound Care Stakeholders, of which APTA is a member.

    CMS fact sheet on OPPS final rule
    Complete OPPS final rule

    The biggest news in the DMEPOS arena is the CMS decision to move ahead with its proposal to use "lead item pricing" as a way to improve competitive bidding for DMEPOS. The system eliminates the need for suppliers to submit multiple different bids on items in a product category—instead, they can anchor bids to an item with the highest Medicare-allowed charges in a product category, folding in services and equipment directly related to providing the item (as appropriate). CMS hopes this "composite bid" approach will simplify the bidding process and ease burdens on suppliers.

    APTA generally supported the proposal but shared concerns with CMS over creating lead pricing categories that are overly large, including an unwieldy range of DMEPOS. In response, CMS assured commenters that the system would be built around "discrete categories of like items that are generally provided together to address a beneficiary’s medical needs." CMS also assured APTA and other commenters that the lead pricing system would not allow suppliers to win bids on categories that they do not cover in full.

    In a second move supported by APTA, CMS followed through on a proposal to continue to apply a 50/50 blend of adjusted and nonadjusted reimbursement rates to "noncontiguous areas"—primarily Alaska and Hawaii. In its comments to CMS, the association urged the agency to consider the challenges faced by rural and noncontiguous areas when it comes to distances that must be covered to receive or provide care. CMS said that those challenges had been factored into its final rule.

    CMS fact sheet on DMEPOS final rule
    Complete DMEPOS final rule

    Physician Fee Schedule and QPP: A New Payment World Awaits PTs in 2019

    Many physical therapists (PTs) will face a new payment landscape beginning in January, now that the US Centers for Medicare and Medicaid Services (CMS) has finalized a rule that ends functional limitation reporting (FLR) and moves certain PTs into the Quality Payment Program (QPP). That program, which includes the Merit-based Incentive Payment System (MIPS), is at the center of a sweeping shift toward value-based payment in Medicare.

    The confirmation of PTs' inclusion in QPP came in conjunction with the release of the final 2019 physician fee schedule. For PTs and physical therapist assistants (PTAs), the final versions by-and-large mirror the rule proposed by CMS earlier this year. But a few important changes and clarifications, some in response to comments from APTA and other stakeholders, are worth noting—particularly in regard to the way CMS wants to approach coding and paying for services delivered totally or "in part" by a PTA or occupational therapy assistant (OTA).

    APTA regulatory affairs staff are reviewing the final rule and will publish a detailed summary in the coming weeks. In the meantime, here are some highlights.

    Bottom line: get ready for MIPS and other components of the QPP.
    It's official: beginning in 2019, PTs in private practice who furnish services under Medicare are included in QPP, an entirely new payment system for the profession. Under QPP, qualifying PTs have a choice of participating in the Merit-based Incentive Payment System (MIPS) or—if available to them—an advanced alternative payment model (Advanced APM). A subset of these PTs who meet volume thresholds will be required to participate in one or the other. PTs in private practice who don't qualify for participation in MIPS can do so voluntarily, something APTA encourages given that all signs point to further expansion of the QPP in the future.

    The program—particularly MIPS—is largely centered on reporting requirements. MIPS requires reporting in 4 performance categories (PTs in 2019 will be required to report under only 2 categories: quality and improvement activities), with providers earning points in each category. An annual MIPS score will determine whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Several of the data points must be reported electronically through certified electronic health record (EHR) vendors or registries such as APTA’s Physical Therapy Outcomes Registry.  

    The Advanced APM-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. The rule also includes an option for QPP participation through a Medicare Advantage demonstration.

    In addition to its acknowledgement of PTs as providers who are integral to the evolution toward value-based care, CMS also included a welcome change: the elimination of functional limitation reporting (FLR), a fraught system that met with criticism from APTA since its implementation.

    But that's just the big-picture picture. PTs and PTAs are well-advised to learn as much as possible about QPP and MIPS sooner rather than later, and to understand how this major shift may impact their practice. Scroll down to the end of this article for suggested links that help to fill in the details of how the program works.

    In terms of the fee schedule itself, the required adjustment factor for 2019 is 0.25% before applying other adjustments. But remember: this is the last year there will be an update to the physician fee schedule through 2025. Beginning in 2026, payment rates will be updated based on the eligible clinician’s participation in MIPS or Advanced APMs.

    CMS efforts to clarify PTA-related coding are a mixed bag.
    CMS was required by law to establish modifiers to indicate services provided by PTAs and OTAs. In the final rule, CMS clarifies that services furnished in whole or in part by a PTA or OTA will be identified –through payment modifiers—"CQ" for services delivered by a PTA and "CO" for services delivered by an OTA. The definitions of the therapy services codes (GP, GO, GN) remain unchanged. The new payment modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.

    The PTA and OTA issue isn't just about coding, however. CMS is also attempting to specify what it means by services delivered "in part" by a PTA or OTA. Despite significant advocacy efforts by APTA and other stakeholders, CMS made only a moderate change between the proposed and final definition of services furnished “in part.” In the final rule, CMS adopts a "de minimis" standard, establishing that anything over 10% of the total patient service delivered by a PTA constitutes "in part" services. Although many questions remain, CMS has stated it will further clarify the de minimis standard in 2020 rulemaking. APTA had advocated that CMS hold off on making a final decision on this issue until the agency gathered more information from stakeholders or, if it did move forward, that it adopt a higher bar for what constituted services delivered "in part" by a PTA or OTA.

    The modifiers and definition of services furnished “in part” are crucial concepts as CMS moves toward the implementation of an 85% payment differential for services delivered "in part" by PTAs beginning in 2022. There will be more opportunities for APTA to advocate on changes to the definition of “in part” in future fee schedules leading up to the 2022 final rule, and the association will continue to advocate for changes to the proposal. Among the association's concerns: the potential impact of the differential on patient access, particularly in rural and medically underserved areas.

    The KX modifier isn’t going away, and the therapy threshold amount will get a (tiny) boost.
    As CMS prepares for its second year in a post-therapy cap environment, it's holding on to the KX modifier process for claiming outpatient therapy services over a specified amount—next year, $2,040, compared with $2,010 in 2018. As is the case in 2018, that amount will be for physical therapy and speech-language pathology services combined.

    CMS will consider ways to facilitate participation in Advanced APMs by nonphysicians who may not use certified electronic health record technology (CEHRT) due to lack of certified systems for their specialties.
    APTA joined a host of other commenters in suggesting that nonphysician provider participation in Advanced APMs would be hindered by a CMS proposal to increase the CEHRT minimum use threshold—an important consideration, given that participation in an Advanced APM is one way qualified providers are supposed to be able to meet QPP requirements. The argument made by APTA and others was that CEHRT standards are built around the particulars of physician-focused electronic health records (EHRs) that aren't as applicable to nonphysician EHRs, thereby creating an artificial barrier to nonphysician participation in APMs.

    Not so, CMS responded in the final rule. "We reiterate that the Advanced APM minimum CEHRT-use threshold applies to APMs and the requirements they impose on participating APM Entities, not to the individual APM Entities participating in APMs," CSM writes. "This means there can be a percentage of eligible clinicians participating in an APM Entity who are not using CEHRT and the APM Entity will still be in compliance with the APM’s terms and conditions." However, CMS has promised to monitor the situation and consider possible solutions to facilitate participation in Advanced APMs by nonphysicians and nonprescribing eligible clinicians in the future.

    PTs are still mostly excluded from allowances for telehealth—but APTA has convinced CMS to think about making changes.
    Despite APTA's advocacy, the final rule allowing for "virtual check-ins" applies only to providers who are qualified for reimbursement for evaluation/management services—in other words, not PTs. Additionally, PTs aren't included among providers who can be reimbursed for "interprofessional internet consultations."

    This situation is fluid, however. CMS responded to APTA’s calls for more PT inclusion in telehealth by stating that it would consider exploring a demonstration or pilot through its Center for Medicare and Medicaid Innovation. And if a proposed Medicare Advantage (MA) rule is any indication, CMS may be seeing the light—that proposal allows MA plans to include telehealth services as a "basic benefit," and APTA is pressing for PTs to be included in the list of qualified providers who may furnish telehealth services to MA enrollees.

    "All in all, the final fee schedule and QPP rule is what was expected, but what was expected is a significant shift in payment methodology," said Kara Gainer, APTA's director of regulatory affairs. "It's now critically important that physical therapists learn as much as possible about QPP and how they can best navigate the new system."

    Learn more about QPP, MIPS, and APMS

    • APTA's MIPS webpage: includes articles, recorded webinars, podcasts, decision-making guidance for voluntary participation, links to a MIPS discussion board, and more.
    • APTA's QPP webpage: take a readiness quiz, watch a short video, download recorded webinars, get detailed fact sheets, connect with other websites, and more.
    • "Moving Toward Quality Payment" (November PT in Motion magazine feature)