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  • US House Approves Bill to Help Fund Greater Diversity in PT, Other Health Care Education Programs

    APTA-supported legislation to encourage greater diversity in physical therapy programs has cleared an important hurdle: this week, the US House of Representatives passed a bill that would appropriate additional federal money for scholarships and stipends for students from underrepresented populations. Next stop—the US Senate.

    The bill that passed the House unanimously, called the "Educating Medical Professionals and Optimizing Workforce Efficiency and Readiness for Health Act" ( HR 2781) broadly focuses on educational issues in health care. Included in that bill was the Allied Health Workforce Diversity Act of 2019, a bill that specifically targets education programs in physical therapy, occupational therapy, audiology, and speech-language pathology. The diversity act was sponsored by Reps Bobby Rush (D-IL) and Cathy McMorris Rodgers (R-WA) and strongly supported by APTA.

    The diversity act would provide grants for use by accredited education programs in physical therapy, occupational, therapy, audiology, and speech-language pathology. The funds would allow programs to issue scholarships or stipends to students from racial and ethnic minorities, as well as to students from disadvantaged backgrounds including economic status and disability. That bill was included in its entirety as part of the broader health care education package.

    The provisions are consistent with APTA's strategic plan, which identifies greater provider diversity as necessary to ensure the long-term sustainability of the physical therapy profession. APTA, the American Occupational Therapy Association,the American Speech-Language-Hearing Association, and the American Academy of Audiology are working together to press for adoption.

    "The idea that health care professions should be as diverse as the populations they serve is an important one for APTA, and this legislation is a welcome step in the right direction," said APTA President Sharon Dunn, PT, PhD. "Diversity strengthens our profession, which in turn makes us better able to meet the needs of our patients and clients. That diversity must include the education programs that are creating the next generation of physical therapists and physical therapist assistants."

    “We are grateful to Representatives Bobby Rush and Cathy McMorris Rodgers for their leadership and support in getting this bipartisan bill through the House of Representatives,” said Justin Elliott, APTA vice president of governmental affairs. “We are also grateful to all of the APTA members who advocated in support of this important legislation.”

    A companion bill is expected to be introduced in the US Senate on Wednesday, October 30.

    The legislation is just one of several bills and issues APTA is advocating on during this session of the US Congress, which includes APTA-supported legislation aimed at addressing administrative burden and prior authorization (HR 3107), PT student loan debt (HR 2802/S. 970), home health payment issues (S 433 / HR 2573), Medicare fee schedule, self-referral, and more.

    Study: Despite Guidelines for OA, Rates of Physician Referral to Physical Therapy Remained Low, Orthopedic Surgeon Narcotic Prescriptions Increased between 2007 and 2015

    In this review: Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings
    (e-published ahead of print in Arthritis Care & Research, October 2019)

    The message
    Despite longstanding guidelines that recommend physical therapy and lifestyle changes over pharmacological approaches as a first line of treatment for knee osteoarthritis (OA), orthopedic surgeons and primary care physicians (PCPs) don't seem to be getting the message, according to researchers. If anything, they say, the situation deteriorated between 2007 and 2015, with orthopedic surgeons moving in the opposite direction from the guidelines, and PCPs making no significant changes apart from increasing a tendency to prescribe nonsteroidal antiinflammatory drugs (NSAIDs).

    The study
    Researchers reviewed data from National Ambulatory Medicare Care Surveys (NAMCS) administered between 2007 and 2015. The surveys, conducted by a branch of the US Centers for Disease Control and Prevention, focus on non-federally employed office-based physicians in direct patient care, and involve collection of data over a 1-week period, as well as practice visits and physician interviews.

    For the study, researchers focused on visits associated with a knee OA diagnosis, tracking whether the physician prescribed physical therapy, provided advice on exercise and/or weight reduction, or provided pain medications during the visit. The prescribed pain medications were categorized as NSAIDs, "narcotic analgesics," or "other." Researchers also tracked patient demographic data, as well as physician specialty, practice location, type, and ownership, among other characteristics.

    Researchers crunched the numbers to establish triennial rates of various recommendations during the 9-year study period. The results were based on 2,297 knee OA-related visits, which they approximated to about 8 million visits per year between 2007 and 2015. APTA members Samannaaz Khoja, PT, PhD; Gustavo Almeida, PT, PhD; and Janet Freburger, PT, PhD, coauthored the study.


    • Authors found a "significant decline" in rates of physical therapy referral by orthopedic specialists, from 158 per 1,000 visits in 2007-2009 to 86 per 1,000 in 2013-2015. Lifestyle counseling also dropped, from 184 per 1,000 to 88. During the same 9-year period NSAID prescriptions increased from 132 per 1,000 visits 2007-2009 to 278 per 1,000 in 2013-2015. Even more concerning, prescription rates for narcotics tripled during the study period, from 77 per 1,000 visits in 2007-2009 to 236 per 1,000 by 2015.
    • Among PCPs, low initial rates of referral to physical therapy increased but remained low throughout the study period, moving from 26 per 1,000 visits to 46 per 1,000 visits. Recommendations for lifestyle changes remained about the same during the study period, ranging from 243/1,000 to 221. Researchers noted a slight uptick in prescriptions for narcotics (233 per 1,000 to 316 per 1,000), and a notable increase in NSAID prescriptions, from 221 per 1,000 visits in the 2007-2009 study period to 498 per 1,000 visits during 2013-2015.
    • Patients who visited an orthopedic specialist were more likely to be prescribed narcotics and NSAIDs if they were Hispanic, and more likely to receive a physical therapy referral if they were non-white and non-black. A decreased likelihood of receiving a physical therapy referral or lifestyle counseling was associated with orthopedic surgeons in rural areas.
    • In terms of referrals and prescriptions, patient demographics were not as much of a factor among patients who visited a PCP for knee OA, although there was a slightly higher likelihood of receiving narcotics among females and individuals who were black. Visits that included imaging were more likely to include narcotics prescriptions; visits covered by workers compensation were less likely to result in a prescription for NSAIDs.
    • Narcotic prescriptions were more likely among advanced practice orthopedic surgeons. That wasn't the case for PCPs.
    • The study sample was mostly white, female, and non-Hispanic, with an average age of 64. A chronic problem was the most common reason for the visit.

    Why it matters
    Knee OA is widely experienced, and its prevalence is on the rise, growing from an estimated 9 million individuals with the condition in 2005 to 15 million in 2012. Guidelines stressing the effectiveness of physical therapy and lifestyle modifications have been around since as far back as 1995, authors write, and the evidence supporting those recommendations has only increased. At the same time, the nation faces an opioid crisis at least partly linked to the use of prescription medications.

    Authors believe their study suggests a "counterintuitive" picture—"adherence to guideline-based care for non-pharmacological, non-surgical treatments such as [physical therapy], exercise, or weight loss is low for knee OA and does not seem to be improving over time." They write that "this contrasting trend suggests that knee OA is primarily managed from a perspective of symptom control and not from the perspective of improving physical function, fitness, and overall well-being."

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    APTA offers multiple resources to help physical therapists and physical therapist assistants develop community-based arthritis programs, including a reference guide to various programs, a consumer-focused webpage that helps patients and clients understand the importance of movement to address OA, and links to offerings from the US Bone and Joint Initiative, such as its "Experts in Arthritis" program. Further information is available at PTNow, including tests and clinical guidelines.

    Keep in mind…
    Authors write that because the study was based on visits and not the patient, the analysis may have missed referrals to physical therapy or counseling on lifestyle that was not a part of the NACMS data collection effort. The study was also limited by drug groupings that did not distinguish between types of opioids, and a lack of indicators for disease severity and degree of disability.

    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.

    Foundation, CoHSTAR Offer Fellowship and Scholarship Opportunities

    Research-minded postdoctoral physical therapists (PTs) and PTs currently enrolled in a doctoral studies program, take note: multiple opportunities for fellowships and scholarships are now available. Here's a quick take on recent calls for applications.

    The Foundation for Physical Therapy Research (Foundation) is now accepting applications for 2 major funding programs.
    Eligibility and application information for the postprofessional 2020 Promotion of Doctoral Studies (PODS) Scholarship and the New Investigator Fellowship Training Initiative (NIFTI) (a $100,000 award over a 2-year period) is posted on the Foundation website. The deadline to apply is January 8, 2020.

    Applicants are encouraged to start the submission process early to allow for potential questions to be answered. Award recipients will be notified in June.

    Contact lizjackson@foundation4pt.org for more information, or call 800/875-1378, ext 1378.

    Important tip: Thoroughly read through all instructions and funding mechanism deadlines before beginning your application. Want to stay on top of what's available? Sign up for the Foundation newsletter and be first to know about Foundation funding opportunities.

    The Centers on Health Services, Training, and Research (CoHSTAR) is accepting fellowship applications for 4 opportunities.
    All fellowships have a February 15, 2020, application deadline. The positions are:

    • Full-time postdoctoral fellowships: Trainees may focus their activities on a unique research focus area or craft an individual experience that involves activities at 2 or 3 collaborating sites.
    • Part-time faculty fellowship: Faculty fellows will retain their faculty appointments at their home institutions while using CoHSTAR support to maximize their protected time for research activities.
    • Part-time faculty fellowship at Brooks Rehabilitation: The selected faculty fellow will retain current faculty appointments while using CoHSTAR support to maximize protected time to engage in research activities as a Brooks visiting scientist. The fellow will be paired with a CoHSTAR faculty mentor and a Brooks Rehabilitation mentoring team.
    • Postdoctoral fellowship at Johns Hopkins: This part-time fellowship provides an opportunity to work with data, administrators, researchers, and clinicians at Johns Hopkins. The focus will be on measurement of function of patients and promotion of hospital inpatients’ activity and mobility. Investigating the relationship between activity and mobility and key outcomes such as falls, discharge disposition, and other hospital associated harms is also a key part of this work.

    CoHSTAR was established with a grant of $2.5 million from the Foundation for Physical Therapy Research. Funding for this initiative was made possible with a $1 million lead gift from APTA, gifts from 50 APTA components, and donations from physical therapists, foundations, and corporations with a shared passion for the field of physical therapy.

    MedPAC Updates its Medicare 'Payment Basics' Series

    Need a quick, big-picture take on how Medicare payment works in various settings? The Medicare Payment Advisory Commission (MedPAC) offers an updated resource that can help.

    Now available for free download: MedPAC's latest version of "Payment Basics," a series of informational sheets that describe the need-to-know elements of 20 different Medicare payment systems. Areas covered include outpatient therapy, skilled nursing facilities, home health services, hospital acute inpatient services, and more. The newest version of the resource updates the 2018 edition.

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

    Quick facts from MedPAC Payment Basics: According to the MedPAC report on outpatient therapy, in 2017 Medicare spent $8 billion on outpatient therapy services, a 6% increase from 2015. Physical therapist services accounted for 72% of all spending in this area. In terms of settings, nursing facilities and physical therapy private practice clinics accounted for 71% of the spending, at 37% and 33%, respectively. Hospitals were next, at 16%.

    New Medicare ID System Goes Fully Operational on January 1, 2020

    Time's (nearly) up: if you haven't transitioned to Medicare's new patient identifier system, you need to make the switch by December 31.

    Recently, the US Centers for Medicare and Medicaid Services (CMS) announced that the 21-month period for transition to the Medicare Beneficiary Identifier (MBI) is nearly complete, meaning that beginning January 1, 2020, claims submitted with Health Insurance Claims Numbers (HICNs) will be rejected.

    The MBI cards feature a unique Medicare identification number that helps CMS move away from identifications that contain the beneficiary's Social Security number. The change, intended to thwart fraud, was required by provisions in the Affordable Care Act and the Small Business Jobs Act.

    According to CMS, participation is already high: it estimates that as recently as the week of October 4, 80% of all fee-for-service claims were submitted with MBIs

    Providers can learn more about the MBI system by way of a Medicare Learning Network MLN Matters article as well as CMS guide to understanding the MBI format. CMS also offers beneficiary-focused flyers on the new system in English and Spanish.

    JAMA: Easing Administrative Complexity, Eliminating Low-Value Care Among Ways to Reduce Health Care Waste and Lower Expenditures

    In this review: Waste in the US Health Care System: Estimated Costs and Potential for Savings
    (JAMA, October 7, 2019)

    The message
    A review of published research and government reports found that the estimated annual cost of health care waste ranged from a total of $760 billion to $935 billion in the areas of failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Interventions that reduce waste could significantly "reduce the continued increases in US health care expenditures," authors write.

    The study
    Researchers analyzed data from peer-reviewed articles and government reports published between 2012 and 2019 that focused on US cost of health care waste or savings from interventions to address waste. The study categorized waste by the following domains identified by the Institute of Medicine: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity.

    Authors were interested in a number of causes of waste, including clinician-related inefficiencies, lack of adoption of preventive care practices, unnecessary admissions or avoidable complications and readmissions, low-value interventions and tests, payer-based health services pricing, and administrative burden.

    Studies of savings from interventions addressing waste included initiatives targeting the reduction of adverse hospital events and hospital-acquired infections, bundled payment models to reduce unnecessary variability in care, care coordination within accountable care organizations (ACOs), prior authorization, payer-focused interventions, and strategies to reduce fraud and abuse.


    • The cost of waste from failure of care delivery ranged from $102.4 billion to $165.7 billion. Authors estimate that interventions to address this category could save from $44.4 billion to $93.3 billion annually.
    • Waste from failure of care coordination costs from $27.2 billion to $78.2 billion each year. Implementing initiatives in this area could save anywhere from $29.6 billion to $38.2 billion.
    • Overtreatment or low-value care costs between $75.7 billion and $101.2 billion annually. Researchers project that successful initiatives to minimize such care could result in savings ranging from $12.8 billion to $28.6 billion.
    • Overpriced medication and other health services cost an estimated $230.7 billion to $240.5 billion each year. Interventions such as pricing transparency initiatives could save between $81.4 billion and $91.2 billion.
    • Medicare fraud and abuse cost from $58.5 billion to $83.9 billion. Legislative, administrative, and integrity strategies could result in annual saving of $22.8 billion to $30.8 billion.
    • Annual cost of waste due to administrative complexity was $265.6 billion—the largest contributor of all 6 categories. However, no studies addressed savings from interventions in this area.

    Why it matters
    The United States spends more money each year than any other country on health care costs—projected to be more than $3.8 trillion for 2019, approximately 18% of the nation’s gross domestic product. According to authors, addressing unnecessary waste could reduce total health care expenditures by 25%.

    Value-based arrangements, "payer-health system collaboration to improve care coordination and transitions in care," and "greater alignment between payers and clinicians" could greatly reduce waste, as well as low-value care, authors write.

    More from the study
    "Fragmentation in the health care system is one of the causes of costs from administrative complexity, the largest contributor to waste," authors write. They believe that as value-based care models continue to be more widely adopted, there will be "increasing interdependency" among all 6 categories of waste. They estimate that interventions to address waste in care delivery, failure of care coordination, and overtreatment or low-value care categories alone could reduce cost of waste by as much as half.

    Related APTA resources
    APTA's Integrity in Practice website offers resources and information on reducing fraud, waste, and abuse. The association continues to advocate for reducing administrative burden, and members can encourage their House representatives to address the burden of prior approval by supporting H.R. 3107, the "Improving Seniors' Access to Care Act," through the Legislative Action Center or the APTA Action app.

    Keep in mind…
    Authors note several limitations in the existing studies reviewed for this study. Much of the research comes from data on Medicare enrollees, which may not be generalizable to the entire Medicare population or private insurance. Thus, the resulting costs estimated are conservative. Similarly, some studies included multiple sites, rather than nationwide data, limiting the generalizability of the results. In addition, more realistic estimates of cost savings from interventions to address waste would be possible if studies included data on costs of implementing the interventions. Estimates do not include pediatric health care spending, because research in this area is limited.

    Senate Report Calls for More Emphasis on Falls Prevention

    The US Senate Select Committee on Aging has released a report on falls prevention that presses for more concerted efforts to prevent falls among the elderly—including wider access to physical therapy and community-based programs. APTA 's comments submitted in advance of the report helped to shape the committee's final recommendations.

    Writing that "the statistics are staggering, and the stakes are high," the committee asserts that despite ample evidence supporting the effectiveness of falls prevention strategies, such programs aren't used widely enough in the country's health care system. The lack of attention to falls prevention comes at a cost to public health, the report states, with an estimated 25% of adults 65 and older experiencing a fall each year, resulting in falls now being ranked as the leading cause of death from unintentional injury among older adults in the US. And the costs are literal as well, according to the report, which cites estimates that falls-related health care spending topped $50 billion in 2015.

    The report calls for improvements in 4 broad areas: raising awareness, screening and referrals for preventive care, addressing modifiable risk factors such as home safety, and better understanding of the impacts of drugs—and drug combinations—on falls risk. Specific recommendations include a call for the Centers for Medicare and Medicaid Services (CMS) to better incorporate falls risk screening and medication review in its Annual Wellness Visit benefit, more research into the effects of polypharmacy on falls risk, and "continued investment in the development of and expanded access to evidence-based falls prevention programs."

    On the day the report was released, the committee held a special hearing on the topic that included representatives from the National Council on Aging (NCOA), the National Osteoporosis Foundation (NOF), and MaineHealth, a hospital system that has incorporated an effective falls prevention program throughout its facilities and in communities. Nearly every speaker mentioned the importance of physical therapy and physical therapists (PTs) in effective prevention and rehabilitation programs, with NCOA Senior Director for Healthy Aging Kathleen Cameron calling for expanding payment to physical and occupational therapists in the Welcome-to-Medicare and Annual Wellness Visit programs, and the witness for NOF describing physical and occupational therapy as "critically important" to recovery from a fall.

    "The evidence is clear that falls prevention efforts work, and there are a host of prevention programs out there that have a potential to make a difference in what is becoming an increasingly alarming trend," said Justin Elliott, APTA's vice president of governmental affairs. "We're extremely pleased to see that the select committee not only understands the need for change, but sees the role physical therapists and physical therapist assistants can play in responding to this public health challenge."

    That understanding of physical therapy's role after a fall wasn't just theoretical, at least for Committee Chair Sen Susan Collins (ME).

    Before entering all stakeholder remarks—including APTA's—into the record, Collins recounted her own experience of recovering from a broken ankle she sustained after a fall a few years ago. "I am forever grateful to the [occupational therapist] and PT who helped me gain function again," Collins said. "It was the [occupational therapist] and PT who really got me back on my feet and walking again."

    APTA offers a wide range of resources related to balance and falls. Check out this PT in Motion News article from September for links to tests and measures, learning opportunities, patient-focused resources, and more.

    Roundtable: Exercise Could 'Transform' Cancer Treatment, Prevention

    A coalition of health and professional organizations led by the American College of Sports Medicine (ACSM) and including APTA is making it clear: physicians, oncologists, policymakers, and all other stakeholders need to recognize that exercise has a crucial role to play in both the prevention of cancer and improving quality of life for individuals who have been diagnosed, and it's time for them to do more to include exercise prescription as a standard of care.

    Authors of an article recapping the findings and recommendations of the coalition were even more blunt in their assessment, writing that "a drug with a similar benefit profile would likely be prescribed broadly." At the moment, they add, "current practice is failing those with cancer."

    The article, which appears in CA: A Cancer Journal for Clinicians, is 1 of 3 published after ACSM brought together 17 organizations in 2018 for a roundtable to evaluate the evidence supporting exercise in cancer prevention and treatment recovery, and to develop guidelines and recommendations to foster a stronger embrace of the concept at all levels of health care. Participating organizations included APTA, the American Cancer Society, the National Institutes of Health's National Cancer Institute, the Centers for Disease Control and Prevention, and the American Society of Clinical Oncology, among others. The roundtable was a follow-up to the first such gathering held in 2009. APTA and ACSM established a formal partnership earlier this year.

    The roundtable's recommendations are bolstered by articles that make the case for exercise as both a cancer preventive and as part of cancer treatment. One of the studies concludes that evidence supports exercise as a way to lower the risk of developing several types of cancer including colon, breast, and lung cancers; a second study establishes a strong link between exercise and improved cancer-related health outcomes such as reduced anxiety, better quality of life, and less fatigue; and the third article summarizes the first 2 and establishes prescription guidelines and a call to action. Taken as a whole, the roundtable and related studies "create a global impact through a unified voice," according to Katie Schmitz, PhD, ACSM's immediate past president and lead author of the summary article.

    Steve Morris, PT, PhD, president of the APTA Academy of Oncologic Physical Therapy, a coauthor of all 3 studies, and an APTA representative to the roundtable, sees the latest findings and recommendations as a significant step forward.

    "Much has changed since the findings from the previous roundtable were published," Morris said. "The number of cancers that inactivity has been linked to have increased, and data supporting those links are strong. Also in 2010 there were insufficient data to allow recommending specific exercise prescriptions for either specific cancers or cancer-related health outcomes—that's all changed this time around, and we're providing a care model to the medical community that offers suggestions in how to determine the exercise behavior of an individual and use that information to direct individuals to an exercise program consistent with that patient's reconditioning and medical needs. These new guidelines recognize that all members of the cancer care team can contribute to this effort to get survivors to exercise and exercise safely."

    Those suggestions encourage oncology clinicians to adopt an "assess, advise, refer" approach with their cancer patients. The clinician first evaluates the patient's current level of physical activity (PA, both aerobic and resistance training) and ability to safely exercise without medical supervision, then advises on the importance of PA and its benefits, and finally refers to an outpatient rehabilitation health professional such as a physical therapist (PT).

    As for the exercise prescription itself, the coalition found strong evidence to support the health effects of 30 minutes of aerobic activity 3 times a week, and resistance exercises twice a week, structured as 1 exercise per major muscle group, 8-15 repetitions per set, and 2 sets per exercise, progressing in small increments.

    The CA article makes it clear, however, that oncology clinicians "are not expected to give specifics of exercise prescriptions…or to do extensive screening and triage to determine whether exercise needs to be done in a rehabilitative versus community setting." Instead, authors write, they should approach exercise recommendations much in the way they would approach making recommendations to address a patient's psychosocial distress, making referrals when appropriate.

    Morris believes the recommendations are easy to use—and, above all, timely.

    "Given the epidemic of obesity in this country and the strong avoidance of exercise, we have truly a national problem, and turning to the health care community to help manage this problem is certainly reasonable and judicious," Morris said. "The call to action included in these guidelines provides a straightforward way to assess the exercise behavior and hence exercise needs of patients when visiting their physician or other health care provider, and they provide an algorithm that helps health care workers to direct the patient to an exercise program that can safely meet that patient's needs."

    The summary article includes calls to action for not only oncology clinicians, but also policymakers, researchers, clinical educators, health care providers, the health and fitness industry, and oncology patients and survivors, with authors writing that a shift in thinking and behavior about exercise in cancer treatment "has the potential to transform health and well-being from cancer diagnosis, through treatment, and for the balance of life."

    Morris sees an opportunity for the physical therapy community to play a major role in shaping that transformation.

    "We need to advocate supporting physical activity at all levels in public policy discussions," Morris said. "Let's get physical education back in schools. Let's fund community exercise programs. Let's include an exercise prescription or exercise program for every patient at the time they're admitted to our service, and again at discharge. Physical therapists and physical therapist assistants are uniquely qualified to help individuals make some level of physical activity a part of their daily lives no matter their health status, and by doing so, and we can make a difference in the lives of all of our patients, not just cancer survivors."

    In addition to Morris, APTA members Kristen Campbell, PT, PhD, BSc, and Nicole Stout, PT, PhD, coauthored 1 or more of the roundtable-sponsored studies.

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    The Good Stuff: Members and the Profession in the Media, October 2019

    "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!

    Quotable: “She pushes me almost to the limit every time I have physical therapy, which is twice a week. I encourage her to give me all I can take.” – Former President Jimmy Carter on the importance of physical therapy—and his PT—to his health at age 95. (Atlanta Journal Constitution)

    Honoring the "silent teachers": Tyler Tice, SPT, was among the University of Delaware College of Health Sciences students who spearheaded an effort to create an on-campus labyrinth honoring anatomical donors to the school. (University of Delaware UDNews)

    What lies beneath: Theresa Marko, PT, DPT, MS, describes the musculature that surfaces as sought-after "V-line abs"—after dietary change and a little exercise, of course. (openfit.com)

    Healthily ever after: Jenna Kantor, PT, DPT, is cofounder of Fairytale Physical Therapy, a program that incorporates theater and physical therapy in children's hospitals. (Good Morning America)

    Snooze, you win: Justin Ho, PT, DPT, outlines the importance of adequate sleep on overall health. (425 magazine)

    Getting out of a slump: Laurie Bell, PT, offers tips on attaining better posture. (Coshocton, Ohio Tribune)

    Aging should be a moving experience: Marion Marx, PT, age 90, helps her senior living community neighbors stay active. (Piedmont, California Patch)

    Putting a fine point on it: Josh Smith, PT, explains what dry needling's all about. (Lewes, Delaware Cape-Gazette)

    In sickness and in running shorts: David Ryland, SPT, managed to work in a marathon relay race on his wedding day—and his team earned second place. (Akron, Ohio Beacon Journal)

    Quotable: "Two minutes of being in there ... she knew. She put my arm up in the air and felt around and held my pulse. ... My pulse was just completely gone in my hand." – Madison Stoffel, a swimmer who experienced thoracic outlet syndrome that went undiagnosed—until she visited a PT. (Arlington Heights, Illinois Daily Herald)

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

    CMS, HHS Propose More Exceptions to, Safe Harbors in Self-Referral Law

    The so-called "Stark law" that bars physicians from referring Medicare patients to services in which the physician has a financial interest turns 40 this year, and the US Department of Health and Human Services (HHS) thinks it's time to bring some of its provisions up-to-date in ways that accommodate alternative payment models (APMs). The proposals that have emerged are a mixed bag, some of which were opposed by APTA because of how they may weaken the self-referral law and create an uneven playing field for physical therapists (PTs).

    The changes surfaced as 2 sets of plans, one from the HHS Office of the Inspector General (OIG) and one from the Centers for Medicare and Medicaid Services (CMS). The CMS changes are aimed at decreasing regulatory burden and promoting coordinated care and APMs, while the HHS OIG proposals are focused on creating safe harbors in the law's anti-kickback provisions. In a fact sheet, CMS describes the proposals as including "a carefully woven framework of safeguards." But those safeguards don't touch APTA's main criticism of the Stark law—that it contains too many loopholes around the provision of "in-office ancillary services" (IOAS) that include physical therapy.

    The IOAS loophole in Stark has been a major focus of the association's advocacy efforts for years. As lawmakers on Capitol Hill were mulling over possible changes to Stark in 2018, APTA representatives met with federal legislators and staff, and provided comments to the US House of Representatives Ways and Means Health Subcommittee advising a caution around relaxing self-referral prohibitions. Later that year, the association provided comments to a CMS request for information on reform of Stark and created customizable letters for members to submit to add their individual voices to the effort. The APTA message: the uneven playing field created by the IOAS exceptions make it difficult for small and medium-sized PT-owned practices to meaningfully participate in APMs.

    In the end, the proposals released by CMS and OIG contain both understandable and potentially problematic elements. Among the proposed changes:

    New permanent exceptions to Stark for certain value-based arrangements: Participants in a "value-based enterprise" (VBE) would be able to access an exception to Stark, as long as the VBE meets requirements that it operates as a legitimate arrangement intended to achieve a value-based purpose.

    Exceptions for "non-abusive, beneficial arrangements between physicians and other healthcare providers": For example, hospitals would be able to donate cybersecurity technology to providers, and allowances would be made for data-sharing between primary care physicians and specialists.

    Safe harbors for certain types of relationships and activities: The HHS proposal offers protection from Stark for activities related to cybersecurity, electronic health records, warranties, and local transportation and telehealth for in-home dialysis, in addition to a safe harbor for a number of relationships between eligible participants in value-based arrangements.

    CMS is also soliciting comments about the role of price transparency in the Stark Law—specifically, whether to require that providers present patients with cost-of-care information for an item or service at the point of referral. The agency believes price transparency could empower patients to have conversations about costs with their physicians at the point of care and serve as an additional safeguard during referral. To that end, APTA will remind CMS, as it has in the past, that the IOAS exception creates a conflict of interest that can prevent patients from making well-informed decisions about their care. In particular, APTA will advocate for CMS to, at the very least, impose disclosure requirements around physician-owned physical therapy that are similar to those used for imaging—namely, that physicians must notify patients in writing that they are permitted to receive the service elsewhere at a potentially lower cost.

    "CMS' move toward APMs and other value-based care approaches is laudable, and all obstacles to that evolution should be examined," said Kara Gainer, APTA's director of regulatory affairs. "But at the same time, the dangers of conflict-of-interest should never be ignored, particularly if a system builds in the potential for conflicts that prevent providers from fully participating in these important new APMs. These proposals contain some sensible, much-needed provisions but may not go far enough in promoting fairness and patient choice."

    APTA will submit comments in response to both proposals. APTA also will continue to advocate for changes that close loopholes around IOAS, including adoption of the Promoting Integrity in Medicare Act (PIMA) of 2019 (HR 2143), a bill that seeks to end the IOAS exception.

    New Tool for Managing Arthritis Focuses on Prevention and Management in Primary Care

    Nearly 1 in 4 adults in the United States has arthritis—some 54 million people, according to the US Centers for Disease Control and Prevention. Chances are more than good that many of your patients and clients are among them. A new tool developed by the Osteoarthritis (OA) Action Alliance, the US Bone and Joint Initiative, and numerous experts in the field—including a representative from APTA—can expand your knowledge of OA. In addition to provider-facing information, the Osteoarthritis Prevention and Management in Primary Care Toolkit also includes patient handouts and resources that you can use to empower your patients and clients to engage in self-management strategies that complement your clinical care.

    October 12 is World Arthritis Day—spend some of it educating yourself on OA by visiting APTA's arthritis webpage, which links to the OA toolkit and other resources such as community-based programs that can extend the benefits of your treatment and help patients and clients maintain their movement and independence.

    APTA: New SNF Payment System Should Drive Quality Patient Care, Not Staff Layoffs

    Fewer than 48 hours after the launch of a new Medicare payment system for skilled nursing facilities (SNFs), APTA began receiving word from physical therapists (PTs) and physical therapist assistants (PTAs) that a number of providers were announcing layoffs or shifts to PRN roles with reduced hours and fewer or no benefits. Many were told by their employers that the new system, known as the Patient-Driven Payment Model, or PDPM, was the reason for reduced staffing levels and less therapy.

    There's one problem with that explanation: it isn't true.

    That's the message APTA is delivering to SNFs, association members, and the media as it works to debunk myths surrounding a system that was designed to support clinician decision-making and push SNFs toward a more patient-focused payment model.

    "Yes, this is a new payment system, but it doesn’t change the reality that staffing and service delivery must continue to be grounded in quality patient care," said Kara Gainer, APTA's director of regulatory affairs.

    What PDPM changes—and what it doesn't
    The US Center for Medicare and Medicaid Services (CMS) describes the PDPM as an attempt at "better aligning payment rates…with the costs of providing care and increasing transparency so that patients are able to make informed choices." In that sense, PDPM is another step in the overall evolution of health care toward a more outcome-based, patient-focused system. And it didn’t arrive out of nowhere: CMS has been floating proposals for revamping SNF payment since at least 2017.

    Still, the new system, with its basis on classifying SNF residents among 5 components (including physical therapy) that are case-mix adjusted and employing a per diem system that can be adjusted during a patient's stay, marks a big change for SNFs. For SNFs that embraced volume-based approaches to care, the shift is even more significant.

    That may be true, Gainer said, but some of the most important elements of PDPM are the things that haven't changed under the new system.

    "Absolutely nothing changed between September 30 and October 1 [the startup date of PDPM] about patient needs in SNFs, or the value of physical therapy in meeting those needs," Gainer said. "PDPM is predicated on the idea that rehabilitation professionals will exercise clinical judgment and furnish reasonable and necessary services to patients."

    APTA created a 1-page handout that summarizes what's different about the PDPM—more patient focus, reduced administrative burden, a new definition of group therapy and a 25% combined limit on group and concurrent therapy, and a new way to determine function scores—but the resource also points out what remains unchanged: medically necessary care as a baseline standard, the criteria for skilled therapy coverage, and the centrality of clinical judgment, among other elements. Additionally, the need for daily skilled nursing services or rehabilitation services has not changed.

    The bottom line, according to Gainer, is that decisions that override clinical judgment and reduce or compromise patient care shouldn't be attributed to any requirements contained in PDPM.

    "Assertions that the PDPM mandates cuts in care are untrue, as are claims that PDPM requires the maximum use of group or concurrent therapy, sets out productivity requirements, and dictates how many minutes of care therapists can provide based on payment categories," Gainer said. "Whether deliberate or simply a misinterpretation of the rule, these myths need to be put to rest."

    A big incentive for SNFs to get past the myths: CMS is paying attention
    As APTA members began sharing their stories of layoffs and status shifts attributed to PDPM, APTA President Sharon Dunn, PT, PhD, took to Twitter with a simple message:

    "PDPM changed Medicare payment methodology for SNFs on Oct 1. It did not change the value of physical therapy services or patient needs. Reducing PT and PTA staff 46 hours into this model reflects poorly on the commitment to patient access and quality of care. And CMS is watching."

    SNFs should pay particular attention to the last sentence of Dunn's tweet, Gainer said.

    "Anyone who's followed CMS rulemaking over the past few years knows that patient outcomes data and their link to plans of care are becoming extremely important in how CMS shapes payment and other rules—and rightly so," Gainer said. "CMS has already indicated to us that they are closely monitoring the actions of health care facilities post-PDPM to determine if patient needs are driving decision-making, and may propose changes to counter any trends that impede the overall goals of the system."

    In an interview for an article on PDPM published in Skilled Nursing News, Robert Lane, a consulting director for health care consulting firm BKD, called the SNF layoffs and adjustments "premature," and stated his surprise that the SNFs didn't "pump the brakes a little for 90 days to see where we're at after the first quarter, couple of billing cycles."

    And like Gainer, Lane told Skilled Nursing News that it's certain the sudden drastic changes will "draw attention from CMS."

    APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have issued a joint statement noting that they have shared reports of layoffs directly with CMS and will continue to keep the agency abreast of reductions that put patients at risk.

    APTA's continued work
    The first versions of what evolved into PDPM emerged in spring of 2017, and APTA immediately began advocating to CMS on behalf of patients and the physical therapy profession. The association's efforts, fueled by member engagement, led to some significant changes to the final rule—including CMS' decision to implement a combined limit of 25% of group and concurrent therapy.

    But now, with PDPM in place, APTA's efforts need to shift to careful monitoring of how the rule is being interpreted and implemented, and its impacts on patient care and the PTs and PTAs providing that care. The reason is simple, according to Gainer: rules can be changed.

    "Another myth that's being circulated is that the PDPM is now written in stone and that no adjustments can be made," Gainer said. "That has never been the case with rules from CMS, and certainly isn't the case with this system—especially given the amount of attention CMS will be paying to how SNFs interpret and implement PDPM, and the degree to which those changes impact patient access to medically necessary care."

    Get the facts on PDPM and stay up-to-date on news about the new system: visit APTA's Skilled Nursing Facility and Home Health Payment Models webpage. Do you have your own story about how the PDPM has affected your work? Contact advocacy@apta.org.

    Biased? Me? PT in Motion Magazine Takes a Look at Unconscious Cultural Attitudes

    Want to get an up-close glimpse at a person with cultural biases? Follow these instructions:

    1. Grab a mirror.
    2. Look into it.

      That's one way to summarize the starting point for "Battling Bias's Distorted Images," the cover story for the October issue of PT in Motion magazine. The article makes the case that while unconscious bias—also known as implicit bias—is very much a part of the human condition, it's something that can be acknowledged and managed in ways that minimize its impact on relationships. For health care providers including physical therapists (PTs) and physical therapist assistants (PTAs), that's an important step to take in effective patient care.

      Through interviews with PTs in a variety of settings, author and Associate Editor Eric Ries explores how implicit bias—and these PTs' recognition of it in themselves—has impacted and changed their lives, particularly at the professional level. Several describe the journey as a path that's not always easy, but absolutely crucial to providing the best possible person-centered care.

      The article also delves into how you can uncover implicit biases through self-tests such as the Implicit Association Test series, and what to do after they're identified. PTs interviewed for the article provide insight on how physical therapy education programs can respond to the challenges of implicit bias, and provide practical tips on making behavior changes that may in turn lessen, if not eliminate, a particular bias.

      According to Hadiya Green Guerrero, PT, DPT, interviewed for the story, efforts to counter implicit bias are necessary for PTs and PTAs because the stakes are high.

      "Do your best to think about your biases and check them at the door," Green Guerrero says in the article. "Seek to learn and understand each patient or client to the clinic, what constitutes his or her biggest health concerns, and what barriers that person faces to optimal well-being and needed interaction with the health care system."

      "Battling Bias's Distorted Images" is featured in the October issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA.

      Where Things Stand, What APTA's Doing: Fee Schedule, SNF, and HH Rules From CMS

      The Centers for Medicare and Medicaid Services (CMS) spends much of its spring and summer churning out regulatory rules for the coming fiscal and calendar years. That means it's an equally busy time for APTA, its members, and other stakeholders to stay on top of the proposals, respond to whatever challenges emerge, and advocate for change when needed.

      This year's standout challenge: advocacy efforts around the CMS proposed physician fee schedule (PFS). The rule as proposed includes at least 2 troubling provisions that demanded a strong response—1 around how CMS would go about determining whether therapy services were delivered "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), and another that proposes an estimated 8% cut to reimbursement for physical therapists (PTs) and several other professions.

      APTA has been aggressively fighting these changes through comments, creating a platform to facilitate a flood of individual member letters to CMS, multiprovider organization sign-on letters, meetings with CMS representatives, and the latest: a bipartisan letter signed by 55 members of Congress urging CMS to rethink the cuts.

      So where do things stand with CMS rulemaking, and what is APTA doing around the PFS and other developments? Here's a guide to 3 of the biggest rules issued to date in 2019, along with information on our advocacy efforts.

      Medicare Physician Fee Schedule
      Status: Proposed (comment period closed); final rule expected in early November

      Quick take
      A misguided attempt by CMS to define (and pay less) when services are delivered "in part" by a PTA or OTA, and an arbitrary 8% cut in 2021 to PT and OT services as well as similar cuts to services furnished by clinical social workers, clinical psychologists, audiologists, and other providers could have major impacts on patient access to care. The rule also includes changes to the Merit-based Incentive Payment System (MIPs) and other areas.

      Our advocacy

      Resources: CMS fact sheet; PT in Motion News stories on PTA modifier and proposed cut; recorded webinar (from August 15); upcoming "Insider Intel" phone-in session (November 20)

      Skilled Nursing Facilities (SNFs) Prospective Payment System
      Status: Final, effective October 1, 2019

      Quick take
      CMS followed through with plans to dramatically change the payment system for SNFs by adopting the Patient-Driven Payment Model (PDPM), a system based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employing a per diem system that adjusts payment rates over the course of the stay. In a win for APTA and its members around group therapy, CMS moved away from a rigid 4-person definition and adopted the association's recommendation that the definition of group therapy as 2 to 6 patients doing the same or similar activities—the same definition used in inpatient rehabilitation settings.

      Our advocacy

      • APTA comment letter
      • In-person meeting with CMS representatives
      • Multiprofession coalition sign-on letter
      • Templated comment letters for individual clinicians

      Resources: CMS fact sheet; APTA fact sheet; PT in Motion News stories on proposed and final rule; APTA SNF PDPM webpage; recorded webinar series; recorded Insider Intel session (May 22)

      Home Health Prospective Payment System
      Status: Proposed for 2020 (comment period closed), final rule expected in early November

      Quick take
      Similar to its efforts around SNFs, CMS wants to transition to a new payment system for home health agencies (HHAs), known as the Patient Driven Groupings Model (PDGM). That system moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The proposed rule would also allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist and would end the HHA split payment approach in favor of a more efficient notice-of-admission approach.

      Our advocacy

      Resources: CMS fact sheet; PT in Motion News story on proposed rule; APTA webpage on PDGM; recorded webinar (August 5)

      Other advocacy efforts
      APTA has also provided comment letters on CMS rules on outpatient payment, Medicaid access, inpatient rehabilitation facilities, and hospital payment; and signed on to multiprofession coalition letters to CMS on outpatient payment and rules around durable medical equipment, prosthetics, orthotics, and supplies.

      Stay tuned
      As APTA continues to advocate for the profession, the association also provides its members with plenty of opportunities to get up-to-speed with both proposed and final rules. Keep the following upcoming events on your radar for more insight on payment and regulation:

      CMS Hospital Discharge Rule Puts the Focus on Patient Choice, Goals in Postacute Care

      In this review: Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies, and Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care (final rule)
      Effective date: November 30, 2019
      CMS Press Release

      The big picture: A better patient discharge process that falls short in some areas
      The US Centers for Medicare and Medicaid Services (CMS) has released a final rule intended to support patient preferences around discharge planning for a move from a hospital or critical-access hospital (CAH) to a home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long-term care hospital (LTCH).

      While the new requirements include APTA-supported changes that help put patients at the center of discharge to postacute care (PAC) providers, the rule lacks provisions that would strengthen patient choice by including physical therapists (PTs) on the discharge planning team.

      The rule goes into effect on November 30, 2019.

      Notable in the final rule

      • Patients will receive a list of potential PAC facilities for discharge. Under the new rule, the hospital's discharge plan must include a list of the HHAs, SNFs, IRFs, or LTCHs that participate in Medicare and that serve a particular geographic area—in the case of HHAs, that would be the area as defined by the HHA; in the case of SNFs, IRFs, and LTCHs, it would be the geographic areas requested by the patient. The discharge planning team would also share key performance data related to the PAC providers under consideration.
      • The process for providing the PAC provider list is designed to keep the playing field level. In response to commenters who asked how hospitals and ACHs can avoid steering patients toward 1 PAC provider over another, CMS states that facilities are required to present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences for all available PAC providers. Providers will also have to document all interactions around PAC care in the patient's medical record.
      • Patient goals must be the focus of the discharge plan. In an effort to create a more patient-centered process for discharge, CMS makes it clear that the plan must focus on the patient's goals and treatment preferences, and must include that patient and/or her or his active partners in the planning process.
      • Patients will be entitled to access their medical records. The final rule establishes that patients have the right to access their medical records in whatever format they prefer, providing that format is able to be produced.
      • HHA discharge planning time estimates will get an additional 5 minutes. CMS upped its estimates for the time it should take HHA PTs or nurses to complete information for discharge from the HHA from 5 minutes to 10 minutes. Some commenters advocated for as much as a 15-minute estimate, but CMS believes that most discharges will be uncomplicated and that the 10-minute estimate will be closer to an overall average.
      • The HHA discharge process will supply more information to patients. HHAs will be required to provide more information to patients who are discharged or transferred to another postacute care provider to help them select a provider that meets the patient’s needs and goals.

      What the rule doesn't do

      • PTs (and other relevant providers) aren't part of the discharge team requirements. Despite APTA and other commenters advocating that providers such as PTs, nutritionists, mental health professionals, and others be required to be included in the discharge team, CMS didn't make any changes, citing potential increases to the cost and complexity of the discharge process
      • Rehab nurses and respiratory therapists won't be required, either. CMS refused to follow the recommendations of some commenters that rehabilitation nurses and respiratory therapists be involved in the discharge needs evaluation and creation of the final plan.
      • Discharge instruction requirements aren't as detailed as in the proposed rule. Commenters expressed concerns with the proposed rules’ overly prescriptive discharge instructions for hospitals. CMS acknowledged these concerns and didn't finalize the requirements; however, under the new rule, hospitals can develop discharge instructions or share discharge information in accordance with applicable law earlier than the time of discharge.

      APTA will provide information on how to comply with the new requirements as it becomes available.

      APTA Helps You Spread the ChoosePT Message During National Physical Therapy Month

      It's October, which means one thing: you’re itching to get out into the community and promote your profession during National Physical Therapy Month (NPTM). But where to begin?

      As shared in an earlier PT in Motion News story, there are multiple ways to participate in this year's NPTM and deliver the message that physical therapy is effective for a wide range of conditions including pain. But you can't be everywhere at once—that's why it's a good idea to load up on handouts and share graphics that help spread the word.

      APTA has you covered. Just stop by our ChoosePT Toolkit webpage to browse a collection of free downloadable resources that help you get out the NPTM message. Here are a few examples:

      Handouts. Boot up your printer and create your own supply of flyers that make the case for physical therapy. Handout topics include an explanation of PTs and the benefits of physical therapy, how physical therapy is a safe alternative to opioids for pain management, questions to ask your health care provider about pain management, the APTA pain profile, and a handout on what PTs and PTA s need to know about the opioid epidemic.

      Postcards and signs. It's easy to produce professional-looking NPTM postcards and signs. Just take 1 of the files on the toolkit webpage to your local professional print/copy store, and they'll take it from there. Options include 11x17-inch posters and 5x7-inch postcards, such as this one available in available in English and Spanish.

      Social media graphics. APTA offers 5 different easy-to-download graphics that you can use on Facebook, Twitter, and anywhere else you make your social media mark. Some of the messages are focused on pain treatment and opioids, while others promote physical therapy as a wise overall health choice.

      Just in time for NPTM: APTA has refreshed the ChoosePT brand and consumer website in ways that promote physical therapy as an effective option for much more than pain management. We've also launched an improved Find a PT database that helps patients connect with local PTs. Be sure to update your Find a PT profile and help consumers choose physical therapy—and you.

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