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  • Study: 61% of Opioid-Related Deaths Linked to Chronic Pain Diagnosis

    In a study that underscores the need to rethink pain treatment in the US, researchers have found that more than 6 out of 10 individuals who died of an opioid-related cause had received a diagnosis for a chronic noncancer pain condition within the preceding year. The same group was also more likely to have been diagnosed with psychiatric disorders and prescribed psychotropic medications--including benzodiazepines, which can increase the risk of death when combined with opioids.

    The study, published in the American Journal of Psychiatry (abstract only available for free), focused on 13,089 opioid-related deaths among Medicaid patients under 65 years old. Researchers divided the decedents into 2 groups—those who had received a chronic noncancer pain diagnosis in the year preceding death, and those who didn't—and looked at other clinical diagnoses, filled medical prescriptions, and nonfatal poisonings during the 12 months preceding death as well as 30 days before death.

    Among the findings:

    • Out of the 13,089 decedents included in the study, 61.5% were diagnosed with a chronic pain condition in the year preceding death. Within the chronic pain group, 59.3% were diagnosed with back pain, 24.5% with headaches, and 6.9% with neuropathies. Authors write that "virtually all the decedents in the chronic pain group were also diagnosed with other bodily pain conditions." Decedents in the chronic pain group were more likely to be female and white
    • Overall, 66.1% of decedents filled opioid prescriptions during the last 12 months, and 61.6% filled prescriptions for benzodiazepines—the class of drugs typically used to treat anxiety. During the last 30 days of life, decedents diagnosed with chronic pain were more likely to fill 1 or more prescriptions for opioids (49%) and benzodiazepines (52.1%) than the nonpain group (17.2% and 26.6%, respectively).
    • Decedents with a pain diagnosis were about twice as likely as those without a diagnosis to have experienced a nonfatal overdose during the 12 months prior to death.
    • In the chronic pain group, 45.6% of the fatal opioid poisonings were from natural and semisynthetic opioids, and 16.7% from other synthetic opioids. Among nonpain decedents the rates were 39% and 12.2%, respectively.
    • Within the last 12 months of life, the chronic pain group was more likely than the nonpain group to receive a mental health diagnosis, including drug use disorder (40.8% compared with 22.1%), depression disorder (29.6% compared with 13%), and anxiety disorder (25.8% compared with 8.4%). Authors note that although a diagnosis of substance use disorder was relatively common among both groups, a specific diagnosis of opioid use disorder was not—only 14.7% in the pain group, and 11.8% in the nonpain group.

    Authors highlighted the prevalence of opioid prescriptions within the last 30 days of life as a particular concern, pointing out that the 36.8% average far exceeds the 8.8% average among all Americans for filling a prescription for an analgesic over a 30-day period. "This pattern raises the possibility that health care professionals may frequently be proximal sources of opioids in fatal overdoses," they write.

    The researchers also asserted that given the high rate of mental health diagnoses, particularly among the pain group, health providers need to be particularly wary of prescribing benzodiazepines with opioids. They write that physicians should limit opioid and benzodiazepine coprescribing "to patients for whom alternative strategies have proven inadequate, carefully monitoring for sedation and respiratory depression, and limiting such coprescription to the minimum clinically required dosage and duration."

    The study lends support to the idea that reliance on opioids for noncancer pain treatment is helping to fuel the opioid crisis in the US—a crisis that APTA is helping to address through its #ChoosePT opioid awareness campaign. The campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    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.

    CNN Money Looks at Challenges Faced by PTs, Other Providers, Whose Jobs Require Touch in the Workplace

    A recent article in CNN Money looks at the issue of touching in the workplace from the perspective of professions that typically involve physical contact—including physical therapy.

    "No Touching in the workplace. But what if your job requires it?" includes interviews with long-term care workers, a nurse, and Jill Boissonnault, PT, PhD, co-author of a recent study on inappropriate patient sexual behavior (IPSB) involving physical therapists, physical therapist assistants, and students. That study, which appears in Physical Therapy (PTJ), found that 84% of respondents had experienced IPSB at some point during their careers or training, and that 47% had experienced IPSB within the past year. The study is also the subject of a recent PTJ podcast.

    In the CNN article, Boissonnault points out that PTs and other health care workers experiencing IPSB are in a complicated situation that can pit the unacceptability of the patient's actions against the provider's ethical commitment to patient care. "That doesn't mean we would tolerate a client jeopardizing our safety…but the clients' best interests need to be forefront in our minds," she tells CNN.

    'Hollywood' High Tech May See Wide Release in Physical Therapy, but PTs Will Remain Feature Attraction

    Tech site CNET is making the case that technologies such as motion-capture interfaces may be the next big thing in physical therapy, but representatives from APTA are tempering that enthusiasm for virtual reality with a dose of actual reality: there needs to be a real, live physical therapist (PT) involved to evaluate patients and help them get the most benefit from any technology.

    In a recent article titled "Hollywood tech lands a leading role in health care," CNET writer Abrar Al-Heeti writes that cutting-edge video technology is "starting to find its way into physical therapy" in what proponents believe are promising ways. The article focuses on the use of motion-capture technology—the same video-based tracking interface that animated the indigenous characters in Avatar—and virtual reality headsets but also touches on simpler technologies including motion-tracking and video games.

    The CNET article quotes developers touting the ways in which the new technologies could help patients adhere to and properly perform postoperative home exercise programs. "The patient becomes more engaged in their therapy," one analyst tells CNET. "The patient is able to perform therapy at their convenience, at their own time, and their own location."

    Maybe, say Matt Elrod, PT, DPT, MEd, and Hadiya Green-Guerrero, PT, DPT, but not without a PT. Both Elrod and Green-Guerrero are practice specialists at APTA.

    "If somebody has a shoulder problem, just to say 'Go do this technology' is really not the best bet," Elrod tells CNET. "What you need is a thorough evaluation…[and] examination to determine where the dysfunction really is."

    Green-Guerrero points out that at the end of the day, any technology is a tool—and tools require someone who knows how to use them. "Technology can definitely augment what we do as physical therapists [but] those who use it know that it's not a replacement for a physical therapist," she says in the article.

    Older Black Americans More Likely to Have Low Physical Function, Less Likely to Receive Rehab Than Older White Americans

    Among patients aged 65 and older, white Americans were 1.38 times more likely than black Americans to use any type of rehabilitation services, while more black patients had low functional mobility, say authors of a study e-published November 8 in the Journal of the American Geriatrics Society (abstract only available for free). Better access to rehab, they suggest, “has the potential to improve late-life function” among black Americans.

    Using in-person interview data from the 2016 National Health and Aging Trends Study (NHATS), authors compared self-reported use of rehabilitation services, therapy setting, reason for rehabilitation, and perceived change in function following rehabilitation. The study sample included 6,309 community-dwelling adults enrolled in Medicare, of which 1,276 reported receiving rehabilitation services in the previous 12 months. Individuals were asked about “rehabilitation” services broadly, which included physical therapy, speech therapy, and outpatient therapy.

    Researchers identified several predictors of rehabilitation use that varied by therapy setting (home-based, outpatient, or inpatient). The study’s co-authors included APTA members Tamra Keeney, PT, DPT, and Alan M. Jette, PT, PhD, editor in chief of Physical Therapy (PTJ), APTA's scientific journal.

    Some of the major findings include:

    White patients were more likely to receive home-based and inpatient rehabilitation. After adjusting for other variables, white patients were 1.53 times more likely than black patients to have used home-based rehab services, and 1.63 times more likely to have used inpatient care. Researchers found no significant differences in use of outpatient rehab services. Lower functional mobility and the presence of more chronic conditions also predicted the use of home-based and inpatient rehab.

    A greater percentage of black individuals had low functional mobility. For all rehab settings, more black individuals (49.2%) compared with whites (29.6%) were in the lowest functional category in the prior year, according to the Short Physical Performance Battery. In inpatient care, 66.8% of black patients vs 58.4% of white patients were in the lowest functional mobility level; in outpatient care, 47.9% of black patients were at the lowest functional level compared with 33.5% of white patients.

    Access to reliable transportation may influence provider referral patterns. Individuals who had access to reliable transportation were more likely to have used outpatient rehab services, but those who had little or no access were more likely to have used inpatient rehab or home-based therapy.

    Out-of-pocket costs may influence the type of rehab setting accessed. Overall, 29.4% of black interviewees who received any type of rehab services were “dual eligible” for Medicare and Medicaid, compared with 7.7% of white individuals. Among individuals who received services in an outpatient or home-based setting, white individuals more often had supplemental insurance (74.7%) than did black individuals (66.3%), write authors. Dual Medicare-Medicaid coverage “usually covers inpatient rehabilitation services,” authors note, while outpatient care usually requires a copayment, and “these differences in payment mechanism and added costs may be contributing to the differences in use of rehabilitation according to income level and for those with Medicare supplemental insurance.”

    There were no significant differences between the groups with respect to self-reported functional improvement or meeting patient goals. Over 60% of both blacks and whites reported “overall improvement,” and over half said they met their rehab goals. More than one-third of interviewees indicated no change after receiving rehabilitation services.

    While the survey data did not allow authors to account for diagnosis, severity of condition, or differences in type of therapy and was based purely on patient self-reported information, authors found the results useful to inform future research.

    “A higher proportion of older blacks were low functioning, and they had lower odds of undergoing rehabilitation, suggesting that greater use of rehabilitation services by older black Americans has the potential to improve late-life functioning in this population,” authors write.

    Future study, they say, should focus on “the contribution of rehabilitation to differences in functional decline and resultant disability prevalence at the population level and to quantify the likely effects on population-level disparities of equalizing access,” as well as “strategies aimed at identifying possible barriers to use of rehabilitation services for vulnerable groups of aging individuals, particularly those who are black, dually eligible, and of the oldest age groups and lowest functioning.”

    APTA offers resources on addressing racial disparities at its Racial and Ethnic Health Disparities webpage. Resources include information on the role of cultural competence in addressing health care disparities in the physical therapy clinic.

    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 Fact Sheets on 2018 Outpatient Payment, Home Health Now Available

    Now available to APTA members: context and details to help you understand final 2018 rules from the Centers for Medicare and Medicaid Services (CMS) on the home health (HH PPS) and outpatient (OPPS) prospective payment systems.

    The final OPPS rule includes provisions that APTA supported—particularly moves toward reimbursement for outpatient-based total knee arthroplasty (TKA) and "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical-access hospitals and rural hospitals with fewer than 100 beds. The rule also includes an overall 2% payment increase for outpatient hospitals and a 1.9% boost for ambulatory surgical centers. To access the fact sheet, visit the APTA Medicare Payment and Policies for Hospital Settings webpage. Scroll to the "Outpatient Care" area and look under "APTA Fact Sheets and Summaries."

    After receiving significant opposition from APTA, the APTA Home Health Section, and other professional and consumer advocacy organizations, CMS backed off on a proposed rule to adopt a payment system that, among other changes, would have removed therapy service-use thresholds from the payment mix. For now, CMS plans to leave the payment system as-is for the most part, but the agency will use 2018 as an opportunity to explore changes with stakeholders. In terms of payment amounts, CMS will enact an $80 million reduction in 2018, a cut mandated by the Affordable Care Act. The APTA fact sheet can be accessed on the association's Medicare Payment and Policies for Home Health webpage, under "APTA Fact Sheets and Summaries."

    Want even more information on CMS-related changes in store for 2018? Don't miss the December 13 Insider Intel call-in program that will include information on HH PPS and OPPS provisions. The program is available at no cost to APTA members.

    4 Things to Do Now That the 2018 Fee Schedule Is Out

    By now, most physical therapists (PTs) have heard the news: the final 2018 Medicare Physician Fee Schedule (PFS) released in early November by the US Centers for Medicare and Medicaid Services (CMS) included some significant variations from the PFS proposed in July. Instead of finalizing CPT code values that were the same as—and occasionally larger than—current values, CMS opted to offer up a more complicated combination of cuts and increases that could affect PTs in different ways, depending on their case-mix and billing patterns.

    So what should PTs do in the wake of the new PFS? Here are APTA's top 4 suggestions.

    1. Know the design process for the fee schedule.
    It's important to understand what led to the changes to provide context, a slight sense of relief, and a reminder of why payment needs to move toward value-based models and away from fee-for-service.

    The PFS now set to debut January 1, 2018, is the CMS response to an American Medical Association (AMA) committee's recommendation on potentially "misvalued" codes associated with a wide range of professions, not just physical therapy. When the process began in early 2016, many predicted that the final outcome would be deep cuts to nearly all valuations—as much as 10% or more overall. APTA and its members fought hard to substantiate the validity of the current valuations, and even the need for increases in some areas. The end result was a significant improvement from where things were headed at the start of the process.

    That's not to say it's been an entirely satisfying process from start to finish. This recent PT in Motion News story goes into more detail about the sometimes-frustrating journey from points A to B.

    2. Understand what's being changed.
    Just about everything that happens at CMS is complicated, and the process that led to the new CPT code valuations is no exception. Still, a working knowledge of how CPT codes are valued is helpful in understanding why the PFS contains such a mix of positives and negatives.

    One important thing to understand is that code valuation is actually a stew of 3 separate elements, known as relative value units (RVUs). These are estimations of the labor, expense, and possible professional liability involved in performing any given treatment or evaluation task associated with a CPT code. The 3 types of RVUs are known as "work," "practice expense" (PE), and "professional liability." The coding valuation differences between the proposed and final PFS were due to changes to the PE RVUs only.

    This wasn't part of the proposed rule. While the AMA Relative Value Scale Update Committee Health Care Professions Advisory Committee did recommend changes to PE RVUs, CMS initially opted to not adopt those suggestions. When the final rule was released 3 months later, CMS—without seeking input from APTA or any other stakeholders—did an about-face and adopted the changes to PE RVUs.

    So what? The answer is twofold: first, the tweaks to PE RVUs mean it's difficult to make many sweeping generalizations about how the new PFS will affect individual practices and clinics; second, it's worth noting that individual work RVUs either remained unchanged or increased.

    A more detailed explanation of how the codes were affected is available in an APTA fact sheet on the 2018 PFS (listed under "APTA Summaries and Fact Sheets"). For a more complete explanation of RVUs and the differences between the 3 types, check out this APTA podcast on the CPT valuation process.

    3. Get a sense of how you might be affected.
    A sense of history and understanding of detail are all well and good, but the bottom line is your bottom line.

    Here's the complication with the 2018 PFS: because of the wide variation in upward and downward adjustments, it's hard to make statements about how PTs in general will be affected. CMS estimates the overall impact at a 1%-2% reduction, but a lot depends on the types of patients a PT or clinic typically sees and what interventions are commonly used. Some providers could see increases.

    In an effort to clear up some of the uncertainty, APTA offers a calculator than can help you see how your typical case-mix would fare in the new PFS. The calculator, offered in Microsoft Excel, allows you to enter different codes to see what changes to expect, given your Medicare service area.

    4. Keep learning.
    There's much more to understand about the PFS—not just in terms of the details of how the new rule will work, but in terms of APTA's work to safeguard CPT codes throughout the misvalued codes review process.

    One great way to learn more about what to expect is coming up in December, when the association hosts a free webinar on Medicare changes for 2018 on December 6 from 1:00 pm to 2:00 pm ET. The webinar will be presented in a "flipped" format, meaning that when you register, you'll be provided with a prerecorded presentation to listen to in advance. That way, more of the actual session can be devoted to live interaction with the presenters. Be sure to sign up—and listen up—soon.

    Another opportunity is available December 13, when APTA hosts an "Insider Intel" phone-in session that will cover many of the same topics, albeit in a pared-down 30-minute session, from 2:00 pm to 2:30 pm ET. Instructions for signing up for this session are on APTA's Insider Intel webpage.

    Innovation 2.0 Learning Lab to Focus on PTs as Key Players in PCMHs to Address Childhood Obesity

    Managing childhood obesity in a patient-centered medical home setting is the fourth and final installment of APTA’s online Learning Labs series based on the Innovation 2.0 initiative. Interested members are invited to register for the interactive session, scheduled for December 15, 1:00 pm–4:00 pm.

    Like the first 3 labs, the January 18 event will enable participating APTA members to hear firsthand from the physical therapist innovators who were selected to pursue new, creative models of care. This fourth lab is your chance to hear from your colleagues about working in a patient-centered medical home (PCMH).

    In this innovative health care model, the physical therapist (PT) plays a key role in measurements of obesity-related signs and symptoms that affect the human movement system, including aerobic fitness and strength deficit, lower extremity joint pain, gait dysfunction, and motor control deficit. The PT also evaluates and monitors children's physical activity and sedentary behaviors, and is trained in behavioral strategies to enhance physical activity and parental support. The model measures cost-effectiveness by tracking incidence of disease rates and hospitalization for obesity-related conditions.

    Referrals to specialists (such as PTs when a cluster of impairments appear that indicate a movement disorder associated with obesity) are coordinated so that appropriate care is received. Regular follow-ups document progress and help the young patients and their families with self-management. This model also could provide support for including PTs in PCMHs that target other chronic health conditions that affect movement.

    The Learning Lab is a free online event intended as an advanced experience for providers who are currently active in innovative programs or ready to explore them. Participants will be expected to actively engage in the lab session, and materials will be provided beforehand to help them do so. If that’s you, visit the Innovation 2.0 webpage and scroll to the "Learning Lab" section to register.

    APTA will post a recording of the event afterward, which also will include the prerecorded presentation and downloadable template—all free to APTA members.

    Visit the Innovation 2.0 webpage to register for the PTs as Key Players in a PCMH Program for Childhood Obesity Learning Lab. For details on all of the projects selected for development, as well as projects that received honorable recognition, go to Innovation 2.0 Background. Profiles of each project were also featured in a September 2015 article in PT in Motion magazine.

    The 2018 Physician Fee Schedule: Where We Are, How We Got Here, What's Ahead

    Here are a few things that can be said about the 2018 Medicare physician fee schedule (PFS) released by the US Centers for Medicare and Medicaid Services (CMS):

    1. It's a mixed bag in terms of adjustments to current procedural terminology (CPT) codes commonly used in physical therapy, with some values going up, and others being cut.
    2. Physical therapy isn't the only profession that saw CPT code reductions: otolaryngologists, nurse anesthetists, and urologists, to name a few, are also bracing for cuts.
    3. It could've been a lot worse—up to a 10% cut or more based on changes to the practice expense.
    4. Statements 1-3 aren't much consolation when you're a physical therapist (PT) facing estimated average payment reductions between 1.3% and 2% (but again, this is hard to pinpoint: there will be increases, but in other cases decreases will be even worse).

    What happened?
    Just a few months ago, the outlook was good for PTs when it came to next year's PFS. After a 2-year American Medical Association analysis of CPT codes that CMS believed may have been potentially "misvalued," the proposed rule that emerged was a clear win for the profession: no cuts to codes values, and even a few increases. From the perspective of the profession, the proposed rule adopted all of the positive recommendations from AMA—namely, no cuts and a few increases to work relative value units (RVUs)—and none of the damaging AMA recommendations, which included adjustments to practice expense (PE) inputs that would affect payment. Things were looking good, and APTA and its members advocated strongly for the rule as proposed.

    When the final rule was issued in November, things stopped looking so bright. Between release of the proposed rule and publication of the final version, CMS veered away from its typical process when it announced—without warning and without allowing opportunity for input from any stakeholders, including APTA—that it would reverse its decision and adopt the recommendations related to PE inputs. The rule change has altered the payment landscape for PTs in ways that are still being worked out by APTA. The association has published a summary of the rule on its website (listed under "APTA Summaries and Fact Sheets").

    Mapping the landscape
    While it's true that the final rule will result in increases in some areas, some of the payment reductions that will go into effect next year will hit home for some PTs. What is known for certain is that a few of the most commonly used codes in physical therapy will see a drop, including manual therapy, therapeutic exercise, mechanical traction therapy, and aquatic therapy.

    At the same time, other codes will increase—some significantly. Gait training therapy values will increase, as will neuromuscular reeducation, and therapeutic activities. Values for the 3-tiered evaluation codes adopted by CMS in 2016 also will rise (although the single value for all 3 tiers is maintained), in addition to orthotic management and training (first encounter), and prosthetic training (first encounter).

    APTA is putting final touches on a calculator that will help members get a more precise estimate of the potential impact of the new rule, given their particular practice circumstances. The calculator is set to be released early next week.

    "While it's clear that the CMS reversal from its proposed rule will result in drops to some of the codes used frequently by PTs, the bottom line effects of the new rule will vary depending on case mix and billing patterns," said Carmen Elliott, MS, APTA vice president of payment and practice management. "The overall 2% drop estimated by CMS doesn't take that variation into account. There will be some providers who will see reductions in payment of anywhere from 1% to 2%, but we anticipate that others could see overall increases."

    How we got here
    "This is frustrating, both in terms of the payment reductions as well as the way CMS surprised stakeholders with its reversal from the proposed rule. The cuts will be hard on some physical therapist practices," said APTA Vice President of Government Affairs Justin Elliott (no relation to Carmen Elliott). "It’s also true that the initial projections, long before the initial proposed rule, were far more bleak."

    Justin Elliott is referring to the way CMS handles codes that it believes may be "misvalued"—often read as a euphemism for "overpaid." It's a complex, multi-year process overseen by the AMA's Relative Value Scale Update Committee (known as RUC) Health Care Professions Advisory Committee (HCPAC). The RUC HCPAC engages in dialogue with stakeholder groups, including APTA, and conducts surveys of individual providers before issuing recommendations on how codes should be valued. The survey of PTs was conducted in October 2016.

    When the process began in early 2016, indications were that, overall, CPT codes commonly associated with physical therapy could see a double-digit cut. APTA staff and CPT advisors worked with the RUC HCPAC to move recommendations away from that potentially catastrophic change, and survey responses from PTs helped to reinforce the notion that current code values were not far off—at least in terms of averages across all codes.

    Given where things seemed to be headed in 2016, the release of the final rule, though far less than ideal, does amount to a win—of sorts. And context is important: physical therapy wasn't alone in professions with codes on the CMS chopping block, with otolaryngologists, anesthesiologists, nurse anesthetists, urologists, and vascular surgeons all seeing overall code reductions between 1% and 2%, according to CMS estimates.

    What's next?
    According to Justin Elliott, "APTA is exploring all avenues to advocate against these cuts before they take effect on January 1, 2018." He added, "All options are on the table and every path is being evaluated for our response to the final rule."

    Those advocacy efforts will require APTA and its members to have a solid understanding of just how the CPT changes impact them during the coming year, according to Carmen Elliott, who said that the key to getting insight on the effects is for PTs to continue to code and document appropriately while they evaluate their case mixes and other factors. "The only way to truly understand the effects of these changes is for our coding efforts to remain consistent," she said.

    At the same time, APTA President Sharon Dunn, PT, PhD, thinks there's an even bigger picture to be considered.

    "We can't yet say what the overall impact will be as a result of these code value changes, and we know that the effects will vary from provider to provider," Dunn said. "What we can say for sure is that these kinds of adjustments and recalculations truly underscore the need for health care providers to move toward value-based payment models that truly reflect the value of physical therapist services’ triple aim—improving the experience of care, improving population health, and reducing costs. The CPT code structure has 1 foot firmly planted in the outmoded fee-for-service world. That needs to change."

    Bill Allowing PTAs in TRICARE Ready for President's Signature

    Well, that was quick: a week after an agreement was reached on legislation that would allow physical therapist assistants (PTAs) to participate in the TRICARE payment system used throughout the US Department of Defense health care system, both the US Senate and House of Representatives have passed the bill. It's now ready to be signed by the president.

    The PTA provisions are part of the National Defense Authorization Act (NDAA) that includes language proposed by APTA to add PTAs and occupational therapy assistants to the TRICARE program.

    "This is a significant win for PTAs, but an even bigger win for patients in the TRICARE program," said Michael Hurlbut, APTA senior congressional affairs specialist. "The important services PTAs provide should be as accessible as possible, regardless of payer."

    The Good Stuff: Members and the Profession in Local News, November 2017

    "The Good Stuff," is an occasional series that highlights recent, mostly local 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!

    According to a recent survey, PTs have the sixth lowest divorce rate compared with other professions. (MentalFloss)

    Marika Molnar, PT, director of physical therapy for the New York City Ballet and the School of American Ballet, received national recognition for her work. (Dance magazine)

    Robert Gillanders, PT, shares tips on exercising without a gym or equipment while traveling. (The Washington Post)

    Joey Cadena, PT, DPT, explains the importance of maintaining muscle balance in runners. (McAllen, TX, Monitor)

    Julie Fritz, PT, PhD, and Steven George, PT, PhD, discuss a study on the effects of exercise on low back pain. (Reuters news service)

    Kelly Hutto, PT, is the subject of a feature story highlighting PlayBig Therapy & Learning Center, a local facility that uses play therapy and other methods to help children with autism, developmental delays, and social, emotional, and behavioral issues. Hutto is a co-owner. (Tallahassee Democrat)

    Gregory Massie, PT, DPT, offers advice on staying motivated to exercise during dark and cold winter months. (Stroudsburg, PA, Pocono Valley Record)

    Sasha Cyrelson, PT, DPT, provides suggestions for yoga poses that can help relieve low back pain. (Self magazine)

    The APTA Hawaii Chapter comes to the rescue for Global Physical Therapy Day of Service by delivering flip-flops and sandals to a local school. (Lihue, HI, Garden Island)

    Nicola Owen, PT, discusses her work with a young athlete experiencing Ewing sarcoma. (Atlantic City, NJ, Press)

    "Our existing health care system is designed to treat pain through easily delivered products, like opioids, injections, and surgery. Its inability to adjust to the inherent individual nature of pain has caused tremendous societal problems." - Steven George, PT, PhD, writing in The Hill

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

    Choosing Wisely at 5: Is It Making a Difference (And What About the Next 5 Years)?

    Five years into the American Board of Internal Medicine (ABIM) Foundation's "Choosing Wisely" campaign, most health care providers and consumers who've heard about it agree that the initiative has something important to say about avoiding unnecessary tests and procedures, including some associated with physical therapy. But has that awareness increased significantly, and does it translate into changes in behavior? Some say no—or at least not yet.

    ABIM's recently released special report on the first 5 years of the Choosing Wisely program characterizes the initiative as a sorely needed effort that is gaining momentum. Since its beginnings in 2012, the collection of ineffective and overused treatments and tests has expanded to 525 recommendations from more than 80 specialty society partners, according to ABIM. In 2014, APTA became the first nonphysician organization to contribute to Choosing Wisely when it released its list of "5 Things Physical Therapists and Patients Should Question."

    The initiative, which partnered with Consumer Reports, has received wide media attention during the past 5 years and has even expanded to 19 other countries around the world. "Clinicians and patients all across the United States—and now the world—are engaging in conversations about avoiding unnecessary care thanks to the efforts of medical specialty societies, health systems, clinical practices, consumer groups, and community collaborations to advance Choosing Wisely," the report states.

    But has the program gained traction? And more to the point, are the Choosing Wisely recommendations being followed on a wide scale? Answers to those questions may not be as positive, say researchers writing in Health Affairs.

    To find out the extent of Choosing Wisely's impact, researchers followed up on an ABIM survey of 600 practicing physicians conducted in 2014 with a survey of their own, conducted this year. Authors of the study wanted to find out if knowledge of the program has grown since 2014, and whether physicians were actually following Choosing Wisely recommendations.

    The results of the 2017 survey are based on an underwhelming response rate—just 5.5%—but the researchers pressed ahead, asserting that the low response rate may, if anything, skew results in favor of physicians who know and support Choosing Wisely and were thus more willing to participate.

    Authors of the study found that the percentage of physicians aware of the campaign in 2017 (42%) had not grown significantly since 2014 (39%), nor had the percentage of physicians who believe campaign is valuable, from 91% in 2014 to 93% in 2017.

    When asked for their opinions on what is driving the continued use of low-value care identified in Choosing Wisely, 87% of the 2017 respondents cited malpractice concerns (87%), followed by physicians' desire for more information (84%) and "just to be safe" (78%). As for changes to health care that would help to decrease use of low-value care, most physicians surveyed pointed to malpractice reform (92%), followed by spending more time with patients (88%) and financial rewards (72%).

    Authors were skeptical that malpractice concerns are truly a driver of use of low-value care, citing research that estimates "defensive medicine" adds roughly 3% to overall health care spending. Similarly, the argument that patient demand drives the use of low-value care is also not supported by research, according to the study's authors.

    The relatively slow decline in the use of unnecessary care since Choosing Wisely's debut points to a need to develop a "roadmap" for the next 5 years, 1 that will lead to a greater impact on care, say authors of a separate analysis and commentary that also appeared in Health Affairs. They stress the need for more robust efforts at almost all levels, from stronger recommendations from societies to the use of more rigorous study designs to evaluate barriers and outcomes.

    Authors cite 4 major areas that they believe need to be strengthened if the Choosing Wisely campaign wants to make a real difference in usage of low-value care:

    Strong methods for developing recommendations. Authors assert that early on, societies tended to select tests and treatments that were fairly safe bets among their members—low-value, to be sure, but also not necessarily widely practiced. Recommendations now need to move into areas that have wider prevalence and potential impact, they write.

    Innovative intervention methods. More thinking needs to go into why providers and patients are not opting out of low-value services, including looking into behavioral science frameworks that shed light on decision-making, and investigating ways to pursue cultural change among clinicians and patients.

    Meaningful evaluation techniques. Rigorous research should be applied to studying the barriers to and facilitators of success, authors write, including measurement of clinically meaningful outcomes.

    Collaborative dissemination. Authors believe that states, communities, patients, payers, health systems, and academic partners need to be brought together in a more coordinated way to "test and disseminate successful approaches."

    "Clearly, [Choosing Wisely] has been changing the conversation and is beginning to influence culture, thus setting the foundation for the next 10 years," authors write, citing "a convergence of activities" for realizing the campaign's potential already exists, including support from organizations, increased use of accountable care organizations and value-based payment models, and the pressure patients face through higher health insurance deductibles.

    "Choosing Wisely has created a principal pathway through which patients and their doctors can discuss when health care services may not be needed," authors write. "As we have outlined, several important steps still remain to fulfill the promise of Choosing Wisely. It is now time to take those steps."

    To get a better sense of how the Choosing Wisely campaign intersects with APTA's efforts to help PTs and PTAs understand their role in reducing fraud, abuse, and waste, visit the association's online Center for Integrity in Practice.

    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.

    Review: Sport Specialization at an Early Age Can Increase Injury Risk

    Parents and coaches need to be educated on the risks and signs of overuse injuries common in children who specialize in a single sport at a young age, say authors of a recent research review published in theAmerican Journal of Sports Medicine. Surgery, they concur, should not be the first-line treatment for such injuries.

    An increasing number of children are focusing on 1 sport early, often because parents and coaches are enticed by the possibility of scholarships and professional participation, “increasing emphasis on sports accomplishment,” and perceived value of elite competition, authors note. But the evidence, say authors, suggests that children who wait until age 12 or older to specialize in 1 sport or begin intense training reach higher levels of athletic achievement than those who specialize at a younger age.

    In general, say authors, young athletes’ “underdeveloped musculature” and still-growing bones make them prone to overuse injuries such as rotator cuff tendinitis, shoulder instability, humeral epiphysiolysis, knee and elbow ligament injuries, hip impingement, and stress fractures, among others. The strain to a developing body also may increase their risk of injury as adults.

    The authors write that more research needs to be done to determine early specialization risks and injury patterns for specific sports, and to identify long-term consequences. In the meantime, they urge, it is important to inform parents and coaches about general injury risk and signs of overuse injuries in children. In addition, say authors, while “operative treatment is occasionally indicated for these injuries [it] should not be taken lightly or considered the first treatment option for most overuse injuries.”

    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.

    Available through the APTA Learning Center: "Repetitive Stress Injury in Youth Athletes," an online course that explores the most recent evidence related to differential diagnosis and treatment of common repetitive stress injuries in this population.

    Defense Bill Headed for Final Votes Will Include PTAs in TRICARE

    Physical therapist assistants (PTAs) are now closer than ever to being included as accepted providers under TRICARE, the payment system used throughout the US Department of Defense (DoD) health care system.

    Last week, the Armed Services Committees for both the US House and Senate reached an agreement on a National Defense Authorization Act (NDAA) that includes language proposed by APTA to add PTAs and occupational therapy assistants to the TRICARE program. The APTA-backed amendment was introduced by Sen Thom Tillis (R-NC) in July and was included in the Senate version of the bill that passed in September. The amendment can be found on page 379 of the NDAA.

    The legislation will next advance to the House and Senate, where it is expected to pass in both chambers.

    "This is great news for PTAs and patients in the TRICARE program," said Michael Hurlbut, APTA senior congressional affairs specialist. "We hope to see a bill ready for the president to sign sometime in December. Once signed into law, the changes will probably be issued through regulation, and we could see PTAs included in the TRICARE program as early as next year." APTA will work with the DoD as the process moves forward, he added.

    That wasn't the only piece of good news in the NDAA. Legislators also included amendments to address opioid prescribing within the DoD health care system, including instructions for the Secretary of Defense to "[Develop] methods to encourage health care providers of the [DoD] to use physical therapy or alternative methods to treat acute or chronic pain."

    Study: Direct Access to Physical Therapy Safe, Effective, and Cheaper Than Referral-Based Care

    In brief:

    • Researchers analyzed claims and outcomes data for 447 patients receiving physical therapy for back or neck pain either via direct access or medical referral
    • Patients in both groups received the same guideline-based care using the same outcome measures
    • Improvement in pain and disability was similar, but direct access patients with neck or back pain incurred $1,543 lower average costs than those who chose referral from a physician, with no adverse events
    • Authors suggest physical therapy direct access as 1 way to decrease cost of care in this population

    While opponents of direct access to physical therapy often cite patient safety as a concern, a new study comparing direct access and traditional access to care identified similar outcomes, no adverse events, and lower cost of care. Patients who obtained physical therapy via direct access had significantly lower medical costs—an average of $1,543 less per patient than those who chose referral from a physician. The study was e-published ahead of print in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free).

    Using a clinical registry, researchers compared 2 years' worth of claims data and patient outcomes for 447 patients who received physical therapy for back or neck pain in a “physical therapy-led spine management program” via medical referral versus patients who accessed physical therapist care without a referral. Outcome measures used for the study were the numeric pain rating scale, Oswestry low back pain index or neck disability index (as appropriate), the patient health questionnaire for anxiety and depression (PHQ-4), and the EQ-5D, a standardized overall health status measurement instrument.

    The 276 patients who chose direct access had “significantly fewer” physical therapy sessions (mean = 0.9) and days in care (mean = 10.5). The average cost per direct access patient was $260 less for physical therapy, $169 less for radiology, and $53 less in “other costs” such as medications compared with individuals who accessed physical therapy after physician referral. Total cost savings for the entire direct access group equaled $400,000.

    “These findings are pragmatic and reflect the impact of patient choice to access care for neck and back pain in a real clinical environment,” say authors. “Our results suggest who sees a patient with neck and back pain first influences downstream costs over the next year.”

    This is significant, according to the researchers, because “spine-oriented conditions” cost $85 billion every year, not including costs of workplace productivity. And these costs continue to rise—the average cost per patient has increased 49% between 1997 and 2006.

    Authors note that the increase in costs has not led to improved outcomes, hypothesizing that 1 possible reason is the delay in care due to the process of medical referral. They believe direct access to physical therapy would lead to lower costs and outcomes similar to traditional medical referral avenues.

    Researchers merged clinical data from the ATI Patient Outcomes Registry with claims data from Blue Cross Blue Shield of South Carolina. All participants were adult employees or employee dependents of the Greenville Health System in South Carolina. The program included access to 8 physical therapy clinics in 3 counties. During the program, BCBS actively encouraged patients to seek physical therapy care first, rather than seek physician care first for low back or neck pain. BCBS plan benefits were the same for both groups.

    All patients received the same type of care based on clinical practice guidelines with progression criteria and were evaluated using the same outcome measures for pain, disability, psychosocial factors, and overall health. In a few cases, direct access patients were referred to a physician for consultation.

    “When patients chose to see a physical therapist first, there were no identified incidents of missed diagnosis or delays in care as a result of physical therapists’ clinical decision making," authors write. "This suggests that physical therapists utilizing a standardized, evidence based screening questionnaire can adequately determine appropriateness of physical therapist intervention. This is an important finding, as patient safety is often noted as a counter argument to direct access to physical therapy.”

    Authors of the study include APTA members Thomas R. Denninger, PT, DPT, Chad E. Cook, PT, PhD, and Charles A. Thigpen, PT, PhD, ATC.

    The study did have some limitations: The majority of the patients chose traditional referral. Patients in that group were younger, more likely to have acute onset of symptoms, and more likely to have widespread pain. The study also was potentially biased by “unmeasured factors” influencing patients’ choice of first provider, lack of prior health utilization data, and exclusion of patients who did not complete physical therapy.

    However, authors say the results “suggest that the availability of the choice to pursue direct access to physical therapy for back and neck pain is safe and provides similar outcomes with cost savings comparing to traditional medical referral.”

    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.

    Required Rehabilitation Benefits Under Threat: Time to Make PT Voices Heard

    The US Department of Health and Human Services (HHS) is pushing for changes that would allow states to dramatically alter the way essential health benefits (EHBs) are managed, opening up the possibility for consumer confusion, market disruption, and reductions in patient access to services including rehabilitation.

    APTA says it's time to push back.

    Now available on the APTA website: a template letter that makes it easy for physical therapists and physical therapist assistants to let HHS and the US Centers for Medicare and Medicaid Services (CMS) know how the EHB proposal will harm both patients and physical therapy practices. The letter allows sender to personalize contents to reflect their individual circumstances and practice settings, but ensures that the overarching message is consistent—that the proposed changes "are likely to have a detrimental impact on not only my practice, but also patients' ability to access medically necessary care."

    The HHS proposal would allow states to alter the minimum requirements for health insurance policies offered through a state's insurance exchange. Although states still would be required to only accept plans that included all 10 EHBs—rehabilitation among them—they could mix and match elements from other states when establishing the baseline for allowable plans, potentially shrinking coverage. Adding to the uncertainty, states would be permitted to reconfigure their so-called "benchmark plans" every year.

    Additionally, the proposal would lower the bar for benchmark plans overall, stipulating that they need be only slightly better than the skimpiest allowable employer-sponsored or self-insured group plan. More details are available in a PT in Motion News story on the proposal, as well as a notice from HHS.

    For more information on the effort to oppose the EHB proposal, contact APTA staff at advocacy@apta.org. Deadline for comments is November 27.

    Study: For Individuals With Knee OA, 3 Tests Can Predict Ability to Walk 6k Steps a Day

    Getting individuals with knee osteoarthritis (OA) to walk regularly is a crucial component in reducing knee pain, improving physical function, and staving off comorbidities such as cardiovascular disease. But how can a clinician know if a patient is capable of meeting minimum walking recommendations? Authors of a recent study believe it may come down to performance on 3 simple tests.

    In a study of 1,925 participants with or at risk for knee OA, researchers sought to link performance on the 5 times sit-to-stand test, the 20-meter walk test, and the 400-meter walk test to walking patterns outside the clinic. Participants ranged in age from 56 to 74 years, with an average age of 65. The study was e-published ahead of print in Arthritis Care and Research (abstract only available for free).

    Participants were given accelerometers and instructed to wear the devices during waking hours for 7 consecutive days. Participants' accelerometer data were later reviewed and compared with their performance on the 3 tests. Researchers divided participants into 2 groups—those who averaged 6,000 or more steps a day and those who averaged fewer than 6,000 steps. Here's what they found:

    • The overall steps-per-day average for all participants was 6,166 steps a day, but there was wide individual variation—by nearly 3,000 steps above or below the average.
    • Just over half (54%) of participants walked 6,000 or more steps a day.
    • Average performance on the tests were 10.5 seconds on the 5 times sit-to-stand test, 1.33 meters per second for the 20-meter walk test, and 306 seconds on the 400-meter walk test.
    • Each additional 1 second it took for a participant to complete the 5 times sit-to-stand test was associated with walking 130 fewer steps a day.
    • Walking 0.1 meter slower during the 20-meter walk test was associated with walking 342 fewer steps a day.
    • Each additional 10 seconds it took for a participant to complete the 400-meter walk test was associated with walking 125 fewer steps a day.

    The bottom line, according to researchers: taking longer than 12 seconds to complete the sit-to-stand test, walking slower than 1.22 meters per second during the 20-meter walk test, or taking longer than 5.22 minutes to walk 400 meters are reliable indicators that an individual with knee OA may not have sufficient physical function to reach the 6,000 steps-per-day walking goal.

    That, authors believe, is where the role of the physical therapist could make a big difference.

    "One possible implication of our study is [that] referral to rehabilitation, such as physical therapy, may be of benefit to those with or at risk of knee OA not meeting 1 or more of these physical function thresholds," authors write. "[Common] interventions that are employed by physical therapists are effective to improve physical function in people with knee OA."

    Authors of the study include APTA members Hiral Master, PT, MPH; Louise Thoma, PT, DPT; Meredith Christiansen, PT, DPT; Emily Polakowski, MS, SPT; Laura Schmitt, PT, DPT; and Daniel White, PT, ScD, MSc.

    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.

    Washington Post: Female PTs Will Spend Last 4 Weeks of 2017 Working 'For Free'

    Guess what the majority of physical therapists (PTs) will be doing beginning December 2? According to a recent article in The Washington Post, that's when female PTs start working for free for the rest of the year while their male counterparts continue to get paid. And that disparity is actually a bit smaller than the one faced by most women in the workforce.

    The Post article, published on October 26, examines the issue of gender pay gaps by way of establishing "work-for-free" dates in multiple professions—the date after which average wage disparities equate to the lower earning group (almost always women) working without pay for the remainder of the year. On a national level, according to the article, women's salaries are approximately 80% of what men receive, a gap that translates into 10 weeks of work without pay for women. Put into calendar form, that means that when averaged across professions, women began working for free on October 14.

    The physical therapy profession fares better than the national average, with an estimated work-for-free date of December 2 for women. That correlates with an average hourly pay difference of $37.23 an hour for male PTs versus $34.33 per hour for female PTs, according to the article. Data for the report were derived from a study by IPUMS, a census and survey research organization that specializes in microdata.

    The December 2 disparity date for physical therapists is the same as for elementary and middle school teachers. That date is better than the work-for-free date for physicians and surgeons (September 8) and dentists (October 19) but slightly worse than for registered nurses (December 6) and social workers (December 19).

    The article includes graphics, potential causes, and an exploration of various theories that attempt to explain the gap. Those theories include the idea that women tend to choose lower paying jobs ("sort of," the article states), that they choose to work part-time (that's not always by choice, according to the Post), and that younger, more educated women don't experience a wage gap (they do).

    "What this all hints to is that the causes of the gender gap are many and more nuanced than just individual choices or corporate discrimination," writes author Xaquin G.V. "However you slice the data, the gap is there."

    Move Forward Radio: Pain Does Not Discriminate, Even in Hollywood

    Karen Joubert, PT, DPT, treats patients of all ages and levels of fitness and ability—those recovering from injury and those seeking to maintain healthy lifestyles. But with an office in Beverly Hills, California, her clientele also happens to include famous entertainers and big-name athletes.

    Whether it is maintaining peak athletic performance for tennis superstar Serena Williams or achieving top fitness and stamina for Cher, Joubert says her physical therapist (PT) services provide a “back-to-basics” approach for all of her clients, celebrities and noncelebrities alike. “You don’t need expensive machines,” insists Joubert.

    “Everyone is unique; everyone has different goals,” Joubert notes, but reaching them “takes focus; it takes discipline.”

    Now available from APTA's Move Forward Radio: a conversation with Joubert, who shared her insights on the implications of living longer and “pushing our bodies harder” and described what she learned from swimmer Diana Nyad, who, at age 64, swam from Cuba to Florida without a shark tank after physical therapy for a rotator cuff injury.

    Move Forward Radio is archived at MoveForwardPT.com, APTA's official consumer information website, and can be streamed online or downloaded as a podcast via iTunes.

    Other recent Move Forward Radio episodes include:

    Neonatal Abstinence Syndrome
    Divya Rana, MD, Bertie Gatlin, PT, DSc, and Kalyani Garde, OTR, discuss signs and symptoms, treatment in the hospital, and aftercare for infants born with neonatal abstinence syndrome (NAS), which occurs when an infant who was exposed to opiates through his or her mother experiences withdrawal after birth.

    Diastasis Recti Abdominis: The Likely Cause of “Mummy Tummy”
    Carrie Pagliano, PT, DPT, discusses diastasis recti abdominis during or after pregnancy, misconceptions about the condition, and how women can work with PTs to correct the condition.

    Amplified Pain Syndromes: Treating a Pediatric Population
    Brandi Dorton, PT, DPT, and Misty Wilson, OTR/L, discuss the variety of tools and interventions they use to effectively treat individuals with increased sensitivity to pain, and help them improve and reclaim their lives.

    Five Domains of Sustainable Health
    Jennifer Gamboa PT, DPT, describes how her team of collaborative health care providers approaches sustainable health through 5 domains—because when it comes to total health, diet and exercise are just part of the equation.

    Living With Ehlers-Danlos Syndrome
    Victoria Graham, a beauty pageant champion, describes how she manages her constant pain, which has involvedphysical therapy, medication, and multiple surgeries.

    APTA members are encouraged to alert their patients to the radio series and other MoveForwardPT.com resources to help educate the public about the benefits of treatment by a physical therapist. Ideas for future episodes and other feedback can be emailed to consumer@apta.org.

    From PT in Motion: The Power and Potential of Clinical Registries

    To succeed in a value-based care environment, all health care providers—including physical therapists—must embrace accountability in the form of standardized patient outcomes data. Clinical outcomes registries are one way many health care professional societies and large health systems are doing so.

    This month’s issue of PT in Motion magazine includes a feature article on clinical outcomes registries such as APTA’s Physical Therapy Outcomes Registry, including a look at how they work, and how practices can increase the power of their electronic health record (EHR) data to inform and improve patient care.

    "Strength in Numbers: The Power and Potential of Clinical Data Registries" explores how other medical professional societies are using registries to collect and analyze outcomes to improve patient care. Nicholas A. Vaganos, MD, a cardiologist whose employer participates in a clinical registry, tells PT in Motion, "When you pay attention to the data…it helps improve your treatment and your documentation."

    The registry directors interviewed for the article share examples of how the findings from large amounts of clinical data can revolutionize the way providers practice by providing real-time insights to supplement clinical practice guidelines. The article includes practical insights from physicians, quality experts, and an EHR software vendor on the nuts-and-bolts of participating in a registry.

    To find out more about APTA's Physical Therapy Outcomes Registry, visit the registry website or email registry@apta.org.

    "Strength in Numbers: The Power and Potential of Clinical Data Registries" is featured in the November issue of PT in Motion and is open to all viewers—pass it along to nonmember colleagues to show them 1 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.

    Mary Edmonds, Founding Director of Cleveland PT Program, Dies at 85

    Mary Louise McKinney Edmonds, PT, PhD, FAPTA, well respected for her personal strength, her love of study, and her commitment to physical therapy and minority affairs, died on October 11 at age 85.

    Edmonds began her career as a clinician, including treating children with disabilities in Butlerville, Indiana, but she eventually moved into academia. In 1972 she became the founding director of the Physical Therapy Program at Cleveland State University and later was chair of health sciences. In 1981 Edmonds left Cleveland for a position as dean of Bowling Green State University’s College of Health and Community Services. About 10 years later, she joined Stanford University as vice provost and dean of student affairs, where she stayed until retiring from Stanford and in 2000 returning to her alma mater, Spelman College, as special assistant to the president.

    Throughout her career, Edmonds continued to be a student as well as an educator. After receiving an undergraduate degree from Spelman, she earned her first graduate degree, in physical therapy, from the University of Wisconsin, then a master’s degree from Western Reserve University (later to become Case Western University). She earned a second master’s degree and a PhD from Case Western Reserve University, and she completed a postdoctoral fellowship at the University of Michigan Institute for Social Research. Edmonds’ academic interest was what now is known as cultural competency, and she helped pioneer the study of how behaviors, attitudes, and policies affect the health outcomes of aged black women. She presented over 60 professional papers and was a visiting scholar in the United Kingdom, Brazil, South Africa, China, and former Yugoslavia.

    Edmonds had leadership roles in over 30 organizations and received over 20 honors and awards for her service, including 2 honorary doctorates. APTA named her a Catherine Worthingham Fellow of the American Physical Therapy Association in 1995.

    Memorial contributions can be made to the Mary M. Edmonds Scholarship fund at Bowling Green State University.

    Final Fee Schedule Rule a Mixed Bag; Outpatient Rule More Positive

    The US Centers for Medicare and Medicaid Services (CMS) has issued final rules for the 2018 Medicare physician fee schedule (PFS) and outpatient prospective payment system (OPPS) that don't vary significantly from the proposed rules released earlier in the year—except when it comes to 1 element involving the current procedural terminology (CPT) codes.

    As in the initial proposal, work relative value units (RVUs) for CPT codes will be maintained under the PFS as per recommendations from an American Medical Association review panel. However, CMS has changed its approach to practice expense RVUs: instead of maintaining those RVUs at 2017 levels as proposed, the agency will adopt the panel's recommendation for some reductions. APTA staff are analyzing the entire rule and will issue a detailed summary in the coming days that will clarify the impact those reductions might have. CMS has issued a fact sheet on the final rule.

    Taken as a whole the final PFS rule contains more good news than bad in the wake of a lengthy review of multiple CPT codes—many of which commonly are used in physical therapy—as potentially "misvalued." The review had put those codes at risk of sizable reductions for both work and practice expense RVUs. While some practice expense RVUs may drop, the final rule includes no cuts to the work RVUs and actually increases values for a few. Initial analysis indicates that overall, the increases and cuts likely balance out.

    More positive news related to the fee schedule: CMS will increase the therapy cap from $1,980 to $2,010 beginning in 2018. The therapy cap landscape could be seeing further changes, however, pending the outcome of an effort in Congress to repeal some elements of the therapy cap process.

    The PFS announcement comes on the heels of a final OPPS rule that also includes provisions supported by APTA—particularly moves toward reimbursement for outpatient-based total knee arthroplasty (TKA) and "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical access hospitals and rural hospitals with fewer than 100 beds. The final rule also mirrors the proposed rule's overall 2% payment increase for outpatient hospitals and a 1.9% boost for ambulatory surgical centers. A detailed APTA summary of the OPPS rule also is in the works. CMS has issued a fact sheet on the final rule.

    CMS Drops Home Health Payment Plan Opposed by APTA

    After receiving significant opposition from APTA, the APTA Home Health Section, and other professional and consumer advocacy organizations, the US Centers for Medicare and Medicaid Services (CMS) has backed off on a proposed rule that would have dramatically altered the home health care payment landscape in ways that would have reduced care.

    Issued on November 1, the home health prospective payment system final rule for 2018 does not finalize the proposed Home Health Groupings Model (HHGM), a payment system that, among other changes, would have removed therapy service-use thresholds from the payment mix. The proposed HHGM prompted immediate outcry from a wide range of stakeholders, with APTA characterizing the rule as one that would create "perverse financial incentives" for reductions in care in home health.

    In a fact sheet published in conjunction with the release of the final rule, CMS states that it won't adopt the HHGM model for 2018 and instead "will take additional time to further engage with stakeholders to move towards a system that shifts the focus from volume of services to a more patient-centered model."

    APTA staff are reviewing the final rule and will share more details in the coming days, but the news that the HHGM will not be implemented in 2018 represents a win for patients and the association.

    "APTA had significant concerns that the HHGM would have a dramatic, negative effect on patient care," said Kara Gainer, APTA director of regulatory affairs. "Together with the Home Health Section and many of our members, we initiated a strong congressional and regulatory advocacy campaign to stop CMS from adopting the HHGM. It appears our efforts—along with those of many others in the home health industry—were compelling."

    HHS Unveils Proposal Allowing States to Change Details of Essential Health Benefits

    The US Department of Health and Human Services (HHS) wants to change the ways the Affordable Care Act's (ACA) state insurance exchanges set up their coverage requirements. It's a detailed, complicated proposal, but wade in far enough and you'll get to the real story: a push toward a system that would allow states to dramatically alter the way they manage so-called "essential health benefits" (EHB) that include rehabilitation.

    The result? "Mass confusion and market disruption," according to APTA Director of Regulatory Affairs Kara Gainer, JD. "These changes, if adopted, would also impose a significant financial and administrative burden on consumers and providers, given they may face dramatic changes to their coverage on an annual basis." APTA is preparing comments to HHS on the proposal and will develop template letters for use by members in the coming days. Comments on the rule are due by November 27.

    At the heart of the proposal is a plan that would allow states to play mix-and-match with other states' provisions associated with EHB "benchmark" plans; essentially, the minimum health insurance requirements for policies offered through a particular state's insurance exchange. Although every state must require that insurance policies include coverage for 10 EHBs, just how that coverage is managed—elements such as number of allowed visits for physical therapy, or limits to the kinds of services that are included in an EHB category—can vary.

    Even though some variations in coverage are allowed under the current system, those variations must exist within certain parameters. States currently are restricted to adopting a plan that echoes 1 of several options: the 3 largest group plans in the state, the 3 largest state employee health plans, the 3 largest federal employee health plans, or the largest HMO offered in the state's market. States that opt not to adopt a benchmark plan are assigned a plan that mimics the largest small group plan in the state. Benchmark plans were stable from 2014 through 2016; some may have changed slightly in 2017.

    The proposed rule would change all that. States would be allowed to adopt entire plans or parts of plans from other states, or they could develop their own plan, so long as the new plan isn't more generous than it was before. In addition, the HHS proposal would significantly lower the bar when it comes to the extent of coverage: instead of adopting plans from the list of large plans, the state would be required only to offer a plan that is slightly better than the skimpiest allowable employer-sponsored or self-insured group health insurance plan. Plans could be rejiggered every year.

    This isn't good news for consumers, Gainer says.

    "While it's true that the 10 EHB categories aren't going away, allowing states such broad flexibility in setting their individual EHB benchmark plans could result in consumers losing coverage to a lot of services that fall under the EHB categories," Gainer said. "There is great potential for not only confusion among consumers but disruptions in access to care."

    Here's how it might work. Currently, some states—California, for example—have relatively broad EHB benchmark requirements for rehabilitation benefits, while other states, such as Arizona, have benchmarks that include visit limits for physical therapy and occupational therapy. Under the plan, California could choose to adopt all of Arizona’s EHB benchmark plan or just replace its rehabilitation category with Arizona's rehabilitation category of benefits, leaving consumers in California suddenly facing visit limits and other restrictions.

    Making matters even worse, according to Gainer, is the provision that a state's EHB-benchmark requirements need only be better than the most minimal allowable employer plan or self-insured group health plan, and not exceed the generosity of the state’s 2017 benchmark plan. Using Arizona as an example, if the state chose to build its own EHB-benchmark plan and define the benefits within each category, it could lower the amount of coverage offered, but it would be prohibited from developing a benchmark plan that is more generous than it is today.

    "Some employer and self-insured group health plans can be very restrictive and severely limit actual benefits under each EHB category," Gainer said. "If a state chooses to design its own EHB-benchmark plan, the new plan just has to be slightly better than that."

    APTA has been focused on preserving EHBs throughout 2017, as Congress made repeated attempts to repeal and replace the ACA with plans that would have greatly reduced or eliminated the concept. APTA President Sharon L. Dunn, PT, PhD, issued a statement describing the removal of EHBs as an action that would run counter to APTA principles on health care.