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  • Study: For Children With Autism, Yoga Improves Motor Skills, May Buffer 'Cascading' Effects

    In this review: Creative Yoga Intervention Improves Motor and Imitation Skills of Children With Autism Spectrum Disorder
    (PTJ, November 2019 )

    The message
    There's mounting evidence that motor impairments are particularly prevalent among children with autism spectrum disorder (ASD), but research on how to address these impairments is scant. Authors of a new study believe they may have hit upon an approach: physical therapist-led "creative yoga," which they say improved both gross motor skills and the ability to imitate movement patterns among children with ASD. Those gains, they believe, could play a role in improving social communication and behavioral abilities.

    The study
    Researchers divided 24 children with ASD, ages 5 to 13, into 2 groups: the first group received an 8-week "academic intervention" that focused on reading, arts, crafts, and other "sedentary activities usually practiced within school settings"; the second group participated in an 8-week yoga intervention, led by a physical therapist (PT), that "was made fun and creative through the use of songs, stories, games, and props." The children were assessed for motor skills using the Bruininks-Oseretsky Test of Motor Performance-2nd Edition (BOT-2) at baseline and after completion of the programs, and tested for imitation skills at 3 points (baseline, midpoint, completion) using a researcher-created instrument. Sessions were conducted 4 times a week for 8 weeks, divided into 2 expert-led sessions lasting 40 to 45 minutes per week and 2 parent-led sessions lasting 20 to 25 minutes per week.

    Participants included in the study had a confirmed ASD diagnosis and showed social communication delays. All scored at average or below on the BOT-2 at baseline, and the groups were matched for baseline mobility scores as well as demographic, IQ, and other characteristics.

    APTA members Maninderjit Kaur, PT, and Anjana Bhat, PT, coauthored the study.

    Findings

    • After 8 weeks, the yoga group improved subtest scores for gross motor performance and bilateral coordination, whereas the academic group showed no statistically significant improvements in these areas.
    • The academic group improved scores related to fine motor precision and integration, but not so the yoga group, which recorded no statistically relevant changes.
    • Imitation skills improved for both groups, but at different points: the yoga group began showing improvements in imitation skills by the midpoint assessment, while the academic group's improvements didn't register significant change until the last assessment.
    • Among child-specific factors such as age, autism severity, and IQ, the only element that seemed to correlate to improvement in scores was IQ: in the academic group, children with higher IQs tended to achieve larger individual gains in imitation skills, while in the yoga program, children with lower IQs were the cohort that achieved larger individual gains in imitation (specifically, pose imitation).

    Why it matters
    A growing body of evidence suggests that children with ASD also tend to experience motor impairments of balance, postural control, gait, and coordination, as well as worse dexterity skills than do children with typical development (TD). In fact, authors write, researchers have estimated that children with ASD typically display motor development that is consistent with children half their age. Deficits in the ability to imitate demonstrated behaviors or movements are also associated with ASD.

    The concern, according to authors, is the possibility that these impairments could have "cascading effects on the social, communication, and cognitive development of children with ASD."

    "Given the evidence for motor impairments and their broader impact on social communication development," authors write, "there is a clear need to devise interventions that could offer opportunities to improve both motor skills and their use in developing social communication skills in children with ASD."

    More from the study
    Authors were surprised that the yoga group didn't report any improvements in balance, but they speculate that the unchanged BOT-2 scores may be related to the test's reliance on a mix of static and movement-based activities, as opposed to the yoga classes' focus solely on static balance. Additionally, they write, the BOT-2's balance subtest includes assessments with and without visual input, whereas the yoga classes consistently used visual input to help children hold poses.

    As for the academic group's improvements in fine motor skills, the effect sizes were relatively small, but researchers believe that may be due to the fact that most of the children were already engaged in similar activities in their school settings, creating a "smaller scope for improvement."

    Keep in mind…
    The study population was small and heterogenous, and the training duration was relatively short. Additionally, researchers weren't able to assess the long-term effects of the classes.

    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.  

    Getting a Handle on the Fee Schedule, Part 2: 4 Things to Know About the KX Modifier, MIPS, Dry Needling, and Revocation

    The final 2020 physician fee schedule rule released by the US Centers for Medicare and Medicaid Services (CMS) is generating lots of discussion among physical therapists (PTs), physical therapist assistants (PTAs), and other stakeholders for its potential future payment cuts and application of the PTA modifier, but there are other provisions in the rule that deserve attention too.

    Here are 4 things that you should know about the rule, set to go into effect on January 1, that might've been overshadowed by the headline-grabbing payment news. (For a more in-depth summary, check out APTA's regulatory review on the rule, and read part 1 of this PT in Motion News series, which covers the proposed cuts and PTA modifier)

    1. The Medicare payment threshold for outpatient therapy services will get a slight increase in 2020.
    The payment threshold system replaced the cap on therapy services under Medicare in 2018. As with the former therapy caps, the threshold amount is adjusted annually, and for 2020 the amount for the required addition of the KX modifier increases from $2,040 to $2,080 for physical therapy and speech-language pathology combined. (The occupational therapy threshold amount will be raised to $2,080 as well.) The threshold for targeted medical review will remain unchanged, at $3,000.

    2. Dry needling has codes—but that doesn't necessarily translate into payment.
    The final rule adds to the fee schedule 2 dry needling codes—one for needle insertions without injections in 1-2 muscles, and another for insertions in 3 or more muscles—but CMS has assigned a "noncovered" status to them, meaning that original (fee for service) Medicare won't pay for it. If you're working with any other insurance, including Medicare Advantage, check to see if they will pay for dry needling under the new codes. Also: Under Medicare fee for service, because these codes are "noncovered," an Advance Beneficiary Notice is not required, but it can be voluntarily provided (and is recommended).

    3. The Merit-based Incentive Payment System (MIPS) is getting tweaked, including its "opt in" offering.
    CMS is adjusting MIPS to include more measures such as diabetic foot and ankle care; falls screening and plan of care; elder maltreatment screen and follow-up plan; dementia: cognitive assessment, functional status assessment, and functional status change for patients with neck impairment; among others. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments. The MIPS scoring system also will be changed, with the required final score to receive a neutral payment adjustment increasing to 45 in 2020, and then to 60 points for the 2021 payment year.

    The MIPS program will also continue to offer an "opt in" program for PTs meeting some but not all of the MIPS participation requirements. Details on how that system works are available through the CMS Quality Payment Program website. Questions about MIPS? Contact us at advocacy@apta.org.

    4. CMS will have wider authority to deny or revoke.
    The final rule grants CMS an expanded ability to deny or revoke a physician’s or other eligible professional's Medicare enrollment if the provider has been subject to action from a state oversight board, a federal or state health care program, an independent review organization, "or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care." The action must be related to unprofessional conduct that resulted in patient harm, and CMS allows itself leeway in issuing revocations or denials based on the nature of patient harm, the professional's conduct, and the number and types of disciplinary actions taken.

    Visit APTA's Physician Fee Schedule webpage for summaries, links to online learning opportunities, and resources documenting APTA's advocacy efforts. Also, join APTA regulatory experts for "The Changing Landscape of Federal Payment, Coverage, and Coding Policies," a live Q&A session set for December 10, 1:00 pm–2:00 pm ET. Download a prerecorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the fee schedule, MIPS, TRICARE, and more.

    Getting a Handle on the Fee Schedule: 6 Things to Know About the New PTA Modifier and Estimated 2021 Cut

    The physical therapy profession can breathe a little easier after convincing the US Centers for Medicare and Medicaid Services (CMS) to back off from some of its more troubling proposals around work done by physical therapist assistants (PTAs) in the final 2020 Medicare Physician Fee Schedule (PFS). But the rule still includes policies that are cause for concern for many in the physical therapy community: notably, a planned cut that's estimated to reduce payment to physical therapists (PTs) by 8% in 2021, as well as a system that will eventually pay less for services delivered "in whole or in part" by the physical therapist assistant (PTA) or occupational therapy assistant (OTA).

    In short, the 2020 PFS is a big deal. And at more than 2,400 pages, it's also just plain big, with several major components that affect PTs and PTAs in both good and bad ways, and plenty of context behind the details.

    You can read the entire rule to see for yourself, but before you do, here are 6 concepts that can help you understand what the profession is facing when it comes to the PTA modifier and estimated reimbursement cut in 2021.

    1. The application of the PTA and OTA modifiers were required by law—and will be broadly applied.
    The seeds that grew into the CMS rule requiring the use of modifiers were planted in 2018, when Congress passed (and the President signed) the Bipartisan Budget Act. The law required CMS to establish a system to denote when outpatient physical or occupational therapy services were furnished "in whole or in part" by a PTA or OTA, and beginning in 2022, to use that system to reimburse services at 85% when that "in whole or in part" line was crossed. The requirement applies to payments for physical therapy in private practice, outpatient hospitals, rehab agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehab facilities.

    2. The modifier system could have been a lot worse than what's in the final rule. APTA members were a big reason for the improvement.
    When CMS proposed how the modifiers would be used—"CO" for OTAs and "CQ" for PTAs—it forwarded an needlessly complicated system that threatened patient care and ignored the realities of PT practice (this PT in Motion News story outlines the problems with the proposed rule from APTA's perspective).

    APTA members, association staff, and other organizations pushed back hard by way of thousands of responses to the agency. CMS took notice, and while it hung on to its "de minimis" standard that the codes must be used when 10% or more of the service is delivered by a PTA or OTA, it backed away from many of the more problematic elements of its proposed plan. This is how the modifier process will work:

    • The CQ or CO modifier is required to be affixed to the claim line of the service alongside the respective GP or GO therapy modifier. Claims that aren't paired appropriately will be rejected.
    • The CQ/CO modifier doesn't apply if all units of a procedure code were furnished entirely by the therapist. The modifier requirement does apply when all units of the procedures code were furnished entirely by the PTA or OTA.
    • Only the minutes that the PTA spends independent of the PT count toward the 10% standard.
    • The 10% standard is applied to each billed unit of a timed code (as opposed to all billed units of a timed code as CMS originally proposed), and the system allows for 2 separate claim lines to identify where the CQ/CO modifier does and does not apply.

    Need more information? Join APTA for a live Q and A session on the modifier system on December 3, and prep for the event by reviewing a pre-recorded presentation now available. And keep an eye out for a quick guide to the CQ modifier coming soon to apta.org.

    3. The 8% cut is an estimate based on an attempt to maintain "budget neutrality” and is proposed for January 1, 2021.
    There are 2 main concepts at the heart of the planned 8% cut: the complex nature of relative value units (RVU), and the idea that in order to provide additional money to 1 area in the fee schedule, CMS must pull money from other areas (budget neutrality).

    RVUs are the basic unit of payment in the feel schedule, and they're established by way of a formula that involves values for work, practice expense (PE), and malpractice (MP), adjusted for geographic costs variations and multiplied by a conversion factor (CF). In the final 2020 fee schedule, CMS sets out a plan to increase work values for office and outpatient evaluation and management (E/M) codes, mostly used by physicians. That adjustment would raise overall RVUs for E/M services.

    The problem is that as far as CMS is concerned, giving several codes more money means giving other codes less. CMS' approach—strongly opposed by APTA and organizations representing 35 other professions facing cuts—is to simply devalue elements that are used to calculate RVUs in other areas. The agency asserts that it can't say with certainty that the estimated cuts will be the reality of payment in 2021 because it's waiting to see how other budget adjustments might affect the fee schedule's overall bottom line in 2021.

    4. Opposition to the RVU plan was far-ranging, strong—and largely ignored by CMS.
    The physical therapy profession wasn't singled out for a cut to pay for increased E/M reimbursement. Among the 36 professions affected, estimated cuts include a 7% decrease for emergency medicine, a 7% cut to anesthesiology, a 6% reduction for audiology, and 9% and 6% drops in payment for chiropractors and clinical social workers, respectively. CMS was flooded with messages opposing the cuts, including a letter initiated by APTA that was signed by 55 members of Congress. In its final rule, CMS briefly acknowledged the opposition and said it will address the criticisms in future rulemaking.

    5. APTA is aggressively fighting the cut, and all options are on the table.
    APTA is evaluating its advocacy options and refining its strategy for addressing the cut. We already know that any approach must involve working with other affected professions as well as mobilizing individual APTA members to add their voices to a grassroots campaign to let CMS know how the cuts could decimate care and put patients at risk.

    In fact, the effort has already begun. Visit the APTA action center to send a message opposing the 8% cut to your representatives on Capitol Hill—it only takes 2 minutes.

    6. APTA wants you to be prepared for what's coming soon.
    While the 8% cut remains an unsettled issue, there are plenty of elements of the 2020 fee schedule that will begin in January. The association and its regulatory affairs staff have already created several resources, with more on the way. Available now:

    APTA Regulatory Review: Final Physician Fee Schedule for 2020. The big picture, more on the CQ modifier and estimated cut, plus an overview of other elements in the PFS, including the Merit-based Incentive Payment System (MIPS), KX modifiers, remote monitoring, dry needling, and more.

    Live Q and A on CQ modifier, December 3, 12 Noon (ET). Download a pre-recorded presentation and submit your questions in advance for a detailed discussion focused on the new PTA code modifier.

    Live Q and A: The Changing Landscape of Federal Payment, Coverage, and Coding Policies, December 10, 1:00 pm – 2:00 pm. Download a pre-recorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the PFS, MIPS, TRICARE, and more.

    Insider Intel: PFS, MIPS, and more. A recording of a November 20 phone-in session with APTA regulatory affairs staff that touched on a wide range of payment topics, many related to the PFS.

    Information on the updated KX modifier thresholds and exceptions. The 2020 PFS includes a slight increase in the limits on therapy provided before the KX modifier is applied. Learn more here.

    Coming soon: a written guide on how to apply the CQ modifier, a webpage devoted to the 2020 Medicare changes, a 2020 multiple procedure payment reduction (MPPR) and sequestration fee schedule calculator, advocacy information on fighting the 8% cut, and more.

    CMS Rule on Hospital Price Transparency Sets the Stage for Major Shift in Public Access to Charges for Services

    In this review: Medicare and Medicaid Programs: Price Transparency Requirements for Hospitals to Make Standard Charges Public (final rule)
    Effective date: January 1, 2021
    CMS fact sheet

    The big picture: Hospitals will face more stringent requirements to disclose charges for items and services—including physical therapy—in a consumer-friendly, online form. Hospitals aren't happy about it.
    A final rule from the US Centers for Medicare and Medicaid Services (CMS) makes it clear that the agency will move ahead in its efforts to make hospital cost data more accessible to consumers. Beginning January 1, 2021, hospitals will be required to share a much more detailed range of charges, including gross charges, charges negotiated with a third-party payer, charges for cash payment from individuals, and minimum and maximum negotiated charges. The publicly accessible data must cover at least 300 services that patients can schedule in advance—known as "shoppable" services—and while hospitals have some leeway as to which service charges are included, they are required to lists charges for a core set of 70 services, including physical therapy, specifically therapeutic exercise (CPT 97110).

    The American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, and the Children's Hospital Association announced that they will challenge the final rule in court, writing in a joint statement that the rule "will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations in value-based care delivery."

    Notable in the final rule

    The total number of disclosed services must be at least 300. If a hospital doesn't offer 1 or more of the 70 required services, it must substitute an additional shoppable service so that the total list equals at least 300 services.

    Listings must be easy-to-understand, presented in a "machine readable" format, and updated annually. In addition to the charge data being available for free on a public website, the lists must be in formats that can be "read" by computers (as opposed to pdf files, for example), and must use clear language in descriptions of services, including information that makes it easy to identify the particular hospital location associated with each listed service.

    The definition of "standard charge" is broad. Under the new rule, the "standard charges" that must be shared include cash prices, charges negotiated with individual payers, and de-identified minimum and maximum charges.

    Billing codes must be included. Listings must include relevant codes such as Current Procedural Terminology codes, Healthcare Common Procedure Coding System codes, and diagnostic-related group codes, among others.

    The rule will require health insurers to be more transparent, too. The rule extends to group health plans and health insurers, which will be required to allow public access to out-of-pocket cost information for all covered items and services, as well as to payment rates for both in and out-of-network providers.

    Does Everyone Have a Unique Muscle Activation 'Fingerprint?' Researchers Say Yes

    In this review: Individuals have unique muscle activation signatures as revealed during gait and pedaling
    (Journal of Applied Physiology, October 2019 )

    The message
    It's no secret that people move differently, but researchers who carefully tracked muscle movements of study participants during exercise think the differences may go even deeper than variation in movement styles. Their conclusion: humans possess muscle activation "signatures" that are as unique to each individual as fingerprints or iris structure. Not only could these patterns be used to identify an individual, they write, but finding a person's activation strategies could help to identify the potential for future musculoskeletal problems, and better tailor treatments to individual patient needs.

    The study
    Researchers analyzed movement patterns of 53 individuals using surface electromyography (EMG) on their legs as they pedaled on a stationary bicycle and walked on a treadmill. Using a machine learning protocol, authors of the study tracked activation patterns from 8 muscles of the right leg: the vastus lateralis (VL), rectus femoris (RF), vastus medialis (VM), gastrocnemius lateralis (GL), gastrocnemius medialis (GM), soleus (SOL), tibialis anterior (TA), and biceps femoris-long head (BF). They used the data to establish unique muscle activation signatures recorded during an initial session. Participants then returned for a second round of the same activities between 1 and 41 days after the first (average, 13 days), allowing researchers to evaluate the similarities between activation patterns observed at each session.

    Participants were in good health. Most were male (77%), with an average age of 23.1 years and average BMI of 23.2 for males and 21 for females.

    Findings

    • Researchers found "substantial" variability in activation patterns among individuals, especially in the RF, GL, BF, and SOL muscles, with the same types of variability recorded on both days of activity.
    • The machine learning system was able to identify individual muscle activation patterns during the first session with a high degree of accuracy, particularly when more of the tracked muscles were factored into the mix. The classification rate was just over 99% for pedaling and 98.86% for treadmill gait.
    • Recognition rates were nearly as accurate when focused on the second session, where accuracy was 89.80% for 7 muscles in pedaling, and 86.20% for 7 muscles during walking. Authors of the study think the differences between the first and second sessions are due to variations in placement of the EMG sensors, but they believe that given the highly similar results, the differences in placement only strengthen their conclusions.
    • The RF, GM, GL and SOL muscles provided the best recognition data for pedaling, while the TA and BF muscles were tied strongly to better recognition data related to gait.

    Why it matters
    Earlier studies have established that movement patterns such as gait can be consistently linked with individuals—a kind of signature—but those studies stopped short of an examination of identifying the muscle activation strategies that may (or may not) influence the movement pattern. Authors of the EMG study believe theirs is the first to look into activation itself as a biomarker.

    Although they call for further study, authors believe that individual muscle activation signatures may have "specific mechanical effects on the musculoskeletal system" and could help identify individuals who are at greater risk of musculoskeletal disorders. For example, they write, the activation patterns of the GM, GL, and SOL muscles tended to vary significantly between individuals; because these muscles are attached to the Achilles tendon in different fascicle bundles, "different activation strategies might induce unique load patterns of load distribution within the Achilles tendon, with some strategies being more likely to lead to tendon problems."

    More from the study
    Authors didn't land on a single explanation for why muscle activation patterns might be individualized, but they write that both "optimal feedback control" and "good enough" theories of motor control could be at play in activation signatures.

    Activation patterns may be consistent with the optimal feedback control theory in that "it is possible that each individual optimizes their movement with the muscle activation strategies that are best, given that individual's mechanical and/or neural restraints," they write. On the other hand, they add, it's also possible that the signatures develop according to the "good-enough" concept, "through motor exploration, experience, and training, leading to habitual rather than optimal strategies." It's a debate that likely won't be settled without "retrospective studies on large cohorts or longitudinal studies performed at different lifespans," authors note.

    Keep in mind…
    The study population was small, and homogenous. While the homogeneity was intentional to tease out the accuracy of the machine learning process, the approach limited researchers' ability to identify potential motor control theories at play, and whether at least some of the activation strategies are innate.

    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.

    New APTA Campaign Makes Membership Personal—And Offers Prizes

    At APTA, it's always been about individual members working together to support shared values. That's the concept at the heart of a new membership campaign that builds on connections—and offers rewards to members who make them.

    APTA's "ONE by ONE" campaign, launched in October, makes membership personal by encouraging current members to recruit their fellow physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy students to join the association. Every time they recruit a new or returning member, they're entered into a monthly drawing for a free year of APTA membership. And if a member is able to recruit 5 or more new members by the campaign's end on September 30, 2020, she or he is entered to win 1 of 5 iPads that will be given away in October 2020.

    But that's not all: If a new member also joins an APTA section, the recruiting member receives an additional entry in the monthly free membership drawing, and all new members recruited through ONE by ONE are entered into a monthly drawing for APTA’s Passport to Learning, which provides access to the association's continuing education offerings in the APTA Learning Center. There's even a prize for the participating section that experiences the largest year-over-year growth rate during the campaign. All the details can be found on the ONE by ONE webpage, including a toolkit that gives you everything you need to join the campaign.

    APTA member Christel Johnson, PT, MPT, from Texas, was among the first to win free APTA membership. She's thrilled to get a break on dues, of course, but is quick to point to the bigger picture.

    "I believe in APTA and what it stands for, and I appreciate how it works to support this profession that I love," Johnson said. "I speak with all of my colleagues, residents, and students, to make sure they understand all that APTA does for us and the importance of supporting the organization through membership."

    The APTA ONE by ONE campaign runs through September 30, 2020.

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

    Getting soldiers back in shape: Kevin Houck, PT, DPT, recounts his experiences providing physical therapy to soldiers in the Middle East and the US. (Sharon, Pennsylvania Herald)

    Don't get uptight (quads): Rachel Tavel PT, DPT, offers stretching and relief techniques to help counter tight quadriceps. (Men's Health)

    Home is where the PT is: Jay Shaver, PT, makes house calls. (Kalispell, Montana, Daily Inter Lake)

    Falls prevention: Alex Anderson, SPT, discusses the importance of falls screening for adults 55 and older. (WHSV3 News, Harrisonburg, Virginia)

    Hospital-YMCA partnership: Becky Geren, PT, explains the physical therapy benefits of a new partnership between a local hospital and YMCA. (Chattanooga, Tennessee, Times Free Press)

    Thumb thing to think about: John Gallucci, PT, DPT, affirms that yes, "text thumb" is an actual injury, and provides tips on easing the discomfort.(Yahoo! Lifestyle)

    Making exercise habit-forming: Catherine Hoell, PT, DPT, shares her approach to helping her patients make exercise a part of their routines. (CapeCod.com)

    Quotable: "I want to be a patient advocate. I try to provide my patients with opportunities to improve their quality of life." -Ian Lonich, PT, DPT, who specializes in neurologic physical therapy. (Washington, Pennsylvania Observer-Reporter)

    Taping it for granted? Nick DiSarro, PT, DPT, peels back the real from the hype when it comes to kinesiology tape. (Parade)

    Spina bifida and e-stim: Gerti Motavalli, PT, outlines the benefits she has observed in using electrical stimulation therapy in treating children with spina bifida. (13 KRCG News, Columbia, Missouri)

    Advice for the hot-to-trot: Michael Conlon, PT, shares a few pointers to help get people ready to participate in post-Thanksgiving "Turkey Trot" runs. (NBC Better)

    Quotable: "I’m still interested in physical therapy. I get the magazines – it’s part of my life. You never get out of it!" Gertrude Schwarz, PT, who at 100 is the oldest living graduate of New York University's physical therapy program, on her love for her profession. (NYU News)

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

    APTA Cosponsored Study: Direct Access to Physical Therapy for LBP Saves Money, Lowers Utilization Better When It’s Unrestricted

    In this review: Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain
    (e-published ahead of print in PTJ, November 2019 )

    The message
    Does unrestricted direct access to a physical therapist (PT) make a difference compared with "provisional" direct access systems that include restrictions such as visit limits and referral requirements for specific interventions? A new analysis of insurance claims records from nearly 60,000 adults across the US says yes.

    The study, cosponsored by APTA, reveals that for patients with new-onset low back pain (LBP), seeing a PT first in states with unrestricted direct access resulted in lower health care costs and use compared with patients seeking care in provisional access states. And the differences don't end there: researchers found that patients in provisional access states who saw a PT first tended to incur higher costs than those who saw a primary care provider (PCP) first, while data from unrestricted direct access states showed relatively equal, if not slightly lower, costs for seeing a PT first compared with PCPs.

    The study
    Researchers reviewed private and Medicare Advantage insurance claims from 59,670 adults with new-onset LBP between 2008 and 2013 to explore health care cost and utilization from 2 perspectives: first, in terms of differences between patients who saw a PT first for LBP in states with unrestricted direct access versus those who sought PT care in states with provisional direct access provisions; and, second, in terms of differences between patients who saw a PT first versus those whose first meeting was with a PCP.

    The deidentified data was provided by OptumLabs®, which worked collaboratively with APTA and UnitedHealthcare to produce this and 2 other research articles related to access to PTs first for LBP. Authors of this study included APTA member Christine McDonough, PT, PhD.

    Findings

    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, no patients diagnosed with neoplasm 12 months prior and 3 months after the first visit, and insurance enrollment for at least 12 months before and after the index date), nearly 98% initially met with a PCP. Overall, more women than men sought care for LBP, with around 21% of all patients reporting prior physical therapy use. Among patients who sought treatment from a PCP, experience with physical therapy was much lower—about 2.1%.
    • Among patients who saw a PT first, those in provisional-access states recorded 31% more physician visits and had 58% higher odds of having imaging in the first 30 days of the index visit, compared with patients from unrestricted states.
    • Average 30-day costs were lowest for patients in unrestricted states who saw a PT first for LBP, at $511. The next-to-lowest costs were associated with patients who saw a PCP first in unrestricted-access states ($556), followed by patients in provisional-access states whose first visit was with a PCP ($632). The highest costs were for patients in provisional-access states whose index visit was with a PT, at $726. After 90 days, the rankings shifted, but only slightly: seeing a PT first in a provisional-access state was associated with the highest costs ($1,269), followed by index visits with a PCP in provisional-access states ($1,046), PT-first visits in unrestricted states ($1,032), and PCP-first visits in unrestricted states ($948).
    • Patients in provisional-access states who saw a PT first averaged LBP-related costs that were 19% higher than PCP-first patients at 30 days. It was a different story in unrestricted-access states, where patients who visited a PT first averaged costs that were 4% lower than PCP-first patient costs, a difference that authors call "insignificant."

    Why it matters
    This large-scale retrospective study—authors believe it's the first to analyze how state limits on PT access affect utilization and costs—adds to the evidence that direct access to a PT for LBP (and seeing a PT first) achieves effective results. The cost differences alone are potentially significant, given the estimate that as many as 70% of people will experience LBP in their lifetimes, making it "the third most costly medical condition in the United States," according to authors.

    More from the study
    Authors were particularly interested in the findings that patients in provisional-access states who saw a PT first tended to incur higher cost and utilization than those whose index visit was with a PCP. Authors believe the explanation for the difference may have something to do with the way the restrictions tend to increase the need to visit physicians following the initial PT visit to comply with requirements around, for example, imaging or specific procedures.

    Similarly, authors theorize that the cost ratio—in other words, the magnitude of the differences—may also be due to the pressures provisional-access systems bring to bear on LBP treatment.

    "Given that patients in provisional-access states often are required to see a PCP after a certain number of physical therapist visits or required a PCP shortly after the initial physical therapist visit, these additional visits likely increase the cost of care in provisional-access states," authors write. "Since physician gatekeeping does not occur in unrestricted-access states, which would increase the cost of care, we would postulate that this restriction accounts for the differences in 30-day costs between provisional-access states and unrestricted-access states."

    APTA's role
    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP as well as the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and the investigation included in this review. APTA cosponsored all 3 studies

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients and were limited to evaluation of only "certain variables." Additionally, data from patients in states that changed their access regulations between 2008 and 2016 were excluded, reducing sample size.

    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.

    [Editor's note: McDonough is the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant and of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    Technology's Brave New World of Ethical Challenges Explored in PT in Motion Magazine

    That latest piece of technology you're thinking about weaving into your practice? Maybe it should come with a warning label.

    This month, PT in Motion magazine takes a look at the ethical issues that new technologies can introduce in physical therapist practice. From seemingly offhand social media posts to the use of voice assistant devices (VADs) such as Alexa to mounting cameras in clinics, experts interviewed for the story explain the ethical considerations that need to be weighed before powering up.

    "New Technology: Keeping It Ethical, Keeping It Legal" focuses on 7 general areas of technology: providing online advice, posting photos, VADs, wearable technology, use of cameras, electronic health records, and telehealth. PTs interviewed for the article include APTA Ethics and Judicial Committee Chair Bruce Greenfield, PT PhD, FAPTA; APTA Section of Health Policy and Administration member Robert Latz, PT, DPT, who's also the section's representative on the association's Frontiers in Rehabilitation, Science, and Technology Council; and Nancy Kirsch, PT, DPT, PhD, FAPTA, president of the Federation of State Boards of Physical Therapy and author of PT in Motion's "Ethics in Practice" column.

    As it turns out, although the technologies themselves may be new, the potential ethical pitfalls may sound familiar: issues that can be associated with new technology—such as jurisdictional permission to practice, patient privacy, records confidentiality, and honest patient communications—didn't arrive with the first computer. Longtime ethical standards still apply: the danger lies in the ways rapidly advancing technology can overshadow those standards, potentially harming patients—and ruining careers.

    "New Technology: Keeping It Ethical, Keeping It Legal" is featured in the November issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Also among the content available to all viewers: "Serving Veterans Through Community Programs," a primer on care options available to military veterans.

    Final Outpatient Payment Rule From CMS Eases Supervision, Moves Ahead With 'Site Neutral' Payment Despite Lawsuit

    In this review: Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs (final rule)
    Effective date: January 1, 2020
    CMS Fact Sheet

    The big picture: Continued trends toward easing supervision burdens, and a contested effort to reduce payment variation (that doesn't really affect PTs)
    The US Centers for Medicare and Medicaid Services (CMS) is pushing for an outpatient environment in which overall payments vary less according to who owns a facility, according to the final Medicare outpatient payment system rule set to go into effect on January 1, 2020.

    The rule moves ahead with CMS efforts to establish a "site neutral" payment model in its payment for physician services, doing away with a system that pays so-called "off campus" hospital-owned facilities more than it does their independent equivalents. The plan hit a recent snag when a federal judge refused to impose a stay on a court ruling in September in favor of plaintiffs, including the American Hospital Association, that sought to block the rollout of the site-neutral plan. CMS stated in the final rule’s fact sheet that they do not believe “it is appropriate at this time to make a change to the second year of the two-year phase-in of the clinic visit policy. The government has appeal rights, and is still evaluating the rules and considering, at the time of this writing, whether to appeal from the final judgment.” Because physical therapy services in outpatient settings are paid under the CMS physician fee schedule, PTs aren't affected by CMS' hoped-for change.

    The final rule also includes an APTA-supported move toward easing supervision burdens placed on hospitals by way of changed supervision requirements for outpatient therapeutic services in all hospitals. Beginning January 1, the requirements will move from "direct" supervision to "general" supervision, meaning that while a given procedure may be furnished under a physician's overall direction and control, the physician's physical presence no longer will be required during the performance of the procedure. The change is viewed as a particularly positive one for critical-access hospitals and other facilities in underserved areas.

    Also notable in the final rule

    • Payment rates for outpatient hospitals and ambulatory surgical centers (ASCs) will increase by 2.7%.
    • CMS said it will consider the stakeholder feedback it received on its proposal to add 4 safety measures to the Outpatient Quality Reporting Program (Hospital OQR Program) in the future. These measures already are required of ASCs: patient falls, patient burns, wrong site/side/procedure/implant, and all-cause hospital transfers/admissions.
    • CMS recognized that it received over 1,400 comments regarding its proposal to require hospitals to make their standard charges public for all items and services, and stated that it would summarize and respond to these comments in a future final rule.

    Worth watching: prior authorization
    Prior authorization also figures into the new rule, which requires preapproval for 5 cosmetic procedures including vein ablation. While this doesn't directly affect services associated with physical therapy, APTA advocates in general against prior authorization requirements that slow the delivery of care and limit patient access to appropriate interventions. APTA regulatory affairs staff will continue to pay particular attention to future rulemaking in this area.

    Final DMEPOS Rule Attempts to Shape a Clearer, More Predictable System

    In this review: Medicare Program: Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements for DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements (final rule)
    Effective date: January 1, 2020
    CMS Fact Sheet

    The big picture: A rule that attempts to keep up with the rapid development of new and different DMEPOS
    The US Centers for Medicare and Medicaid Services (CMS) aims to make payments for devices a little more predictable in light of the ever-increasing—and ever-advancing—range of options available to providers and patients. CMS intends to accomplish this goal by way of a "comparable item analysis" system that the agency thinks will help make it easier to nail down exactly what Medicare will pay for those devices. The new rule takes effect January 1, 2020.

    The idea is that when old and new items are comparable, CMS will use the fee schedule amounts for the existing older item to determine payment amounts for the new one. If there are no comparable older items, CMS says it will base payment on commercial pricing data such as internet pricing and supplier invoices. Those prices for the noncomparable items won't necessarily stay fixed: if commercial pricing drops, so will CMS rates. CMS identified 5 main categories upon which new DMEPOS items can be compared with older ones: physical components, mechanical components, electrical components (if applicable), function and intended use, and additional attributes and features.

    Also notable in the final rule

    • CMS is revamping requirements around face-to-face meetings between providers and patients in need of DMEPOS that "may have created unintended confusion for stakeholders." The current requirements—essentially a collection of ad-hoc provisions that have accrued over the past 13 years—will be replaced with what CMS describes as a "single list of DMEPOS items potentially subject to a face-to-face encounter and written orders prior to delivery, and/or prior authorization requirements."
    • CMS will no longer require contract suppliers to notify CMS 60 days in advance of a change of ownership (CHOW). Instead, CMS will require notification no later than 10 days after the effective date of the CHOW. Additionally, CMS is removing the distinction of a “new entity,” but the rule retains the successor entity requirements.

    Final 2020 Fee Schedule: CMS Relents on PTA Differential System for 2020; Presses on With Planned 8% Cut to Physical Therapy in 2021

    A major win, and a major challenge: that's what APTA and the physical therapy profession are facing now that the US Centers for Medicare and Medicaid Services (CMS) has released the final 2020 Medicare physician fee schedule. While the agency seems to have listened to critics and made significant positive changes to the way it will calculate payment when therapy services are delivered "in part" by a physical therapist assistant (PTA), it inexplicably ignored thousands of comments, including a letter from members of Congress, calling for reconsideration of a proposed 8% cut for physical therapy payment and host of other disciplines in 2021. The planned cuts set the stage for intense advocacy efforts by APTA and other professional organizations representing a wide range of health professions including psychologists, occupational therapists, ophthalmologists, chiropractors, and clinical social workers. [CMS has also issued a fact sheet and press release on the final rule.]

      

    The win: CMS backed off from an ill-advised system to calculate when therapy services delivered "in part" by a PTA would trigger 15% lower Medicare Part B payments beginning in 2022.

    Background: It wasn't CMS' idea to create a code modifier (CQ or CO) to denote services delivered "in part" by a PTA or occupational therapy assistant (OTA)—that was something introduced by federal law—but the way CMS proposed to roll out the system lacked understanding for the real world of physical therapy care delivery. In addition to the proposal being misinformed, it was overly burdensome, and would've likely reduced patient access to needed care.

    What was proposed: CMS forwarded the idea of a "de minimis" 10% standard that would trigger use of the modifier whenever a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service. The proposal stipulated, among other things, that the modifiers be applied to the claim when services were delivered concurrently with a physical therapist (PT), and required all codes to be accompanied by a written explanation of why the modifier was or wasn't used.

    What's in the final rule: APTA and its members engaged in an intensive advocacy effort around these provisions, and CMS reconsidered its approach, adopting a system that's consistent with many of the association's recommendations. Among the wins in the new rule:

    • When the PT is involved for the entire duration of the service and the PTA provides skilled therapy alongside the PT, the CQ modifier isn't required.
    • When the same service (code) is furnished separately by the PT and PTA, CMS will apply the de minimis standard to each 15-minute unit of codes—not on the total PT and PTA time of the service, allowing the separate reporting, on 2 different claim lines, of the number of units to which the new modifiers apply and the number of units to which the modifiers do not apply.
    • The proposed documentation requirements are scrapped.

    "This is a huge win for physical therapy under Medicare," said Kara Gainer, APTA director of regulatory affairs. "When we speak with a unified voice, make a clear case for our position, and offer viable options, we can make a difference with CMS. In this case, the difference our members made was huge."

     

    The challenge: For now, CMS is sticking to its proposal to cut payment for physical therapy providers by an estimated 8% beginning in 2021.

    Background: CMS thinks that values for office/outpatient evaluation and management (E/M) codes are too low—an opinion that APTA doesn't necessarily oppose.

    What was proposed: The Medicare physician fee schedule is budget-neutral. To increase values for the E/M codes while maintaining budget neutrality under the fee schedule, CMS proposed cuts to other codes to make up the difference beginning in 2021. Under the plan, physical therapy could see code reductions that may result in an estimated 8% decrease in payment. Other professions stand to lose as well: for example, ophthalmology would see a 10% cut, audiology would face a 6% reduction, chiropractic care would drop by 9%, and clinical social workers would see payment decline by 6%. In total, 36 specialties are facing reimbursement reductions in 2021. However, CMS has not yet determined the actual cuts to each code.

    What's in the final rule: Despite a flood of comments into CMS—more than 10,000 from APTA members alone—and a collaborative advocacy effort among professional organizations that included a letter signed by 55 members of Congress opposing the cuts and a provider sign-on letter signed by 10 associations, CMS left the proposal untouched in the final rule.

    CMS briefly acknowledges the reaction it received, writing that "we understand commenters' concerns with the magnitude of the redistributive adjustment necessary." The agency explains that it was reluctant to make any changes to the plan given that "we do not know the magnitude of redistribution resulting from other policies we may adopt through rulemaking before then," and characterizes a table of proposed 2021 code valuation adjustments included in the final fee schedule as being "for illustrative purposes only."

    "APTA made it very clear to CMS that the association and its members oppose the cuts proposal for 2021, and Congress reinforced APTA’s message," said Katy Neas, APTA executive vice president of public affairs. "APTA and its members, along with literally thousands of other health care providers, made compelling arguments and offered thoughtful alternatives that were seemingly completely ignored as the final rule was drafted. We are taking CMS very seriously when it says that this plan is subject to change. We've brought the association's voice to bear on the PTA modifier issue, and CMS listened. Over the next 12 months, we will leverage every possible opportunity – working with Congress and CMS --to change this flawed policy."

     

    More from the fee schedule: MIPS continues to expand, and CMS continues to move toward a more streamlined system.

    The final rule also makes changes to the Merit-based Incentive Payment System (MIPS). Starting in 2020, CMS will add measures for diabetic foot and ankle care; peripheral neuropathy: neurological evaluation and prevention evaluation of footwear; screening for clinical depression and follow-up plan; falls screening and plan of care, elder maltreatment screen and follow-up plan; preventive care and screening: tobacco use: screening and cessation intervention; dementia: cognitive assessment, functional status assessment, and education and support of caregivers for patients with dementia; falls: screening for future fall risk; and functional status change for patients with neck impairment. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.

    Other changes to MIPS include the following:

    • Data completeness for the 2020 performance year will be set at a 70% sample for both Medicare Part B claims-based reporting and clinician or group reporting via a registry.
    • Groups will be able to attest to an improvement activity when at least 50% of the MIPS-eligible clinicians perform the activity, at a rate of at least 50% of the group's providers with a National Provider Identifier (NPI) performing the same activity for the same 90 continuous days in the performance period.
    • The Promoting Interoperability category will continue to be reweighted for PTs by CMS in 2020, meaning that PTs won't be scored in this category.
    • MIPS-eligible clinicians with a final score of 45 will receive a neutral payment adjustment in 2020, with the score rising to 60 points for the 2021 payment year. The exceptional performance bonus will be triggered with a score of 85 points in both 2020 and 2021.
    • CMS will also continue its shift to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond.
    •  

    Also notable in the 2020 PFS: KX modifier thresholds, dry needling, biofeedback codes, negative pressure wound therapy, and more.

    As always, the fee schedule rule is expansive. Here are some quick takes on other 2020 PFS provisions of interest to the physical therapy community.

    The KX modifier gets a slight bump. The threshold amount for use of the KX modifier will rise from $2,040 to $2,080 for physical therapy and speech-language pathology services combined, and by the same amount for occupational therapy services. The targeted medical review threshold remains at $3,000. These changes will be incorporated into APTA's multiple procedure payment reduction (MPPR) calculator, which will be live before January 1, 2020.

    Dry needling codes have been added—but CMS won't be covering them. The final rule adds 2 dry needling codes (1 for insertions in 1-2 muscles, and another for insertions in 3 or more), but the codes will remain unpaid unless a national coverage determination says otherwise. If the codes were covered, CMS believes they should be considered as "sometimes therapy" procedures rather than "always therapy."

    Biofeedback codes are now available as "sometimes therapy." Codes related to biofeedback training of perineal muscles or anorectal or urethral sphincters have been added to the biofeedback family, and valued at .90 work RVU for the initial 15 minutes of treatment and .50 work RVU for each additional 15 minutes of one-on-one contact.

    Negative wound pressure gets coding values. After some 3 years of work, CMS has established relative value units (RVU) and direct practice expense inputs for codes associated with negative wound pressure therapy, with a .41 work RVU for code 97607 (vacuum-assisted drainage collection for total wound surface area of 50 square centimeters or fewer) and .46 work RVU for 97608 (vacuum-assisted drainage collection for total wound surface area of 51 square centimeters or more).

    CMS remains unclear when it comes to PTs' use of remote physiologic monitoring codes. Last year, CMS said qualified health care professionals can furnish and bill for these services, as long as it’s within their scope of practice. APTA interprets this to include PTs, who are included in the American Medical Association’s definition of "qualified health professionals." In response to APTA’s continued request for clarity from the agency, CMS advised that PTs with billing questions related to these codes contact their Medicare administrative contractor(s). In the final rule, CMS says it will "consider these and other questions." Once again, the issue seems to be up in the air.

    Final Home Health Rule Cements PDGM, Allows PTAs to Perform Maintenance Therapy

    When it comes to its most talked-about provisions, the US Centers for Medicare and Medicaid Services' (CMS) final rule for home health payment under Medicare isn't much of a change from the proposed version released earlier this year, meaning that an entirely new payment system will indeed be rolled out beginning January 1. But other parts of the rule have been tweaked—and in several areas, those tweaks represent wins for the physical therapy profession and the patients it serves in home health settings. [In addition to the lengthy final rule, CMS also offers a fact sheet summary.]

    It's official: PDGM is on for 2020.
    There wasn't much debate about whether this would happen, but the final rule eliminates any doubt: the Patient-Driven Groupings Model (PDGM) will be the system under which CMS pays home health agencies (HHAs). It's a big change, and APTA offers extensive information on the details of the model, but the bottom line is that the PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The system classifies episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. CMS says it will monitor how HHAs are operating under the PDGM, including the provision of therapy services.

    Overall payments will increase by 1.3%.
    CMS projects an annual increase of about $250 million in payments related to home health.

    "Behavioral adjustments" will still be used—but they won't be as large as proposed.
    In anticipation of the possibility that HHAs will alter their practices to maximize payment under the PDGM, CMS had proposed a "behavioral adjustment" that reduced payments by 8.01%. The final rule lowers the negative adjustment to 4.36%.

    PTAs will be able to perform maintenance therapy under the home health benefit.
    The final rule follows through on an APTA-supported proposal to allow physical therapists assistants (PTAs) and occupational therapy assistants (OTAs) to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the PTA or OTA, the qualified therapist still would be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days.

    A question about pain still will be available to patients.
    In addition to removing a quality-reporting measure on to pain interfering with activity from the Quality Reporting Program, CMS also proposed eliminating a home health consumer survey question about whether the patient and provider had discussed pain in the past 2 months. APTA and other organizations pressed for that question to remain, and CMS relented. The pain interfering with activity quality measure has been removed, however.

    Split payments are going away, and Requests for Anticipated Payment (RAPs) will be gone by 2022—but a modified RAP process will be in place beginning in 2021.
    CMS is phasing out the split percentage payment approach beginning in 2020. The split percentage payment amount, paid in response to a RAP, will shift from an upfront 60%-initial, 50%-subsequent payment for each 60-day period to 20% for both initial and subsequent 30-day periods of care. Then, beginning in 2021, there will be no upfront payment made in response to a RAP; however, all HHAs will be required to submit a "no-pay” RAP every 30 days to alert the claims processing system that the beneficiary is under a home health period of care. HHAs must submit the “no-pay” RAP within 5 calendar days of each 30-day period or be subject to a late penalty. Beginning in 2022, CMS will eliminate RAPs and instead require HHAs to submit a Notice of Admission (NOA) every 30 days; agencies must do so within 5 calendar days of each 30-day period or be subject to a payment penalty. CMS says that because they are removing upfront payment associated with the RAP, the agency is relaxing the information needed to submit the “no-pay” RAP and subsequent NOA.

    Want more on PDGM? Sign up for the November 20 APTA "Insider Intel" phone-in session, where the home health system will be discussed along with the final Medicare physician fee schedule.

    UnitedHealthcare to Expand Program Waiving Copays, Deductibles for Physical Therapy for LBP

    Momentum around better insurer coverage of physical therapy continues to build at UnitedHealthcare (UHC), which announced that it's moving ahead to expand a pilot project that waives copays and deductibles for 3 physical therapy sessions for patients with new-onset low back pain (LBP). The pilot follows a multiyear collaboration between APTA, OptumLabs®, and UHC.

    The program is targeted at UHC enrollees in employer-sponsored plans who experience new-onset LBP and seek care from an outpatient in-network provider. The program fully covers up to 3 visits to a physical therapist (PT) or chiropractor in addition to visits normally covered. When the program was rolled out in June, it was limited to plans sponsored by employers of more than 50 employees in Florida, George, Connecticut, North Carolina, and New York. The expanded pilot, which begins January 1, 2020, will extend to self-funded plans with 2 to 50 employees in Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia.

    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP and the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and an investigation that linked unrestricted direct access to a PT for LBP to lower health care utilization and costs than would occur with provisional access to physical therapy. APTA cosponsored all 3 studies.

    "The evidence supporting the use of physical therapy as a first-line, widely accessible treatment for low back pain continues to grow, and insurers like UnitedHealthcare are paying attention and moving from analysis into action," said Carmen Elliott, APTA's vice president of payment and practice management. "APTA's collaboration with UHC and Optum has helped UHC establish some on-the-ground changes that we hope will pave the way for a true sea change in the way insurers think about the value of physical therapy."

    House, Senate Legislation Could Lead to Major PT Telehealth Opportunities in Medicare

    Physical therapists (PTs) have tended to be largely left out of opportunities to provide telehealth services through Medicare, but that could change significantly if federal lawmakers support APTA-supported legislation recently introduced in the US Congress.

    This week, legislators on Capitol Hill announced the introduction of companion bills in the US Senate and House of Representatives that could open the doors to wider use of telehealth in Medicare, including use by PTs. Known as the "CONNECT for Health Act of 2019" (CONNECT), the bills now in the House (HR 4932) and Senate (S 2741) would remove many current restrictions on telehealth in Medicare and give the Secretary of Health and Human Services (HHS) broad authority to waive others. The legislation was introduced by members of the Senate and House telehealth caucuses, with Sen Brian Schatz (D-HI) and Rep Mike Thompson (D-CA) leading the efforts in their respective chambers.

    While the bill covers a lot of ground, it's the provisions allowing the HHS Secretary waiver power that should be of particular interest to PTs, according to Baruch Humble, APTA senior specialist for congressional affairs.

    "If this bill is successful, starting on January 1, 2021, the HHS Secretary could waive telehealth restrictions and open up opportunities for therapists to be reimbursed for telehealth services as long as those services don't limit or deny coverage and can reduce spending without sacrificing quality of care," Humble said. " That's a big step forward for Medicare."

    Baruch added that the waiver rules even have exceptions—namely, that even if a service doesn't reduce spending and maintain quality, a waiver could still be granted if the service was targeted at a high-need health professional shortage area. The waiver process would also be subject to an annual public comment process, and include regular data collection and reviews of waivers conducted no more frequently than every 3 years.

    The CONNECT Act includes another potential opportunity for PTs to participate in telehealth by way of programs created through the Center for Medicare and Medicare Innovation (CMMI).

    Provisions in the bill would direct CMMI to identify services that could deliver both outcome- and cost-effectiveness through telehealth. Physical therapy is among the services that could be reviewed by CMMI, which could design and test delivery models that could be adopted by Medicare, Medicaid, or the Children's Health Insurance Program.

    According to a summary created by the bills' sponsors, current Medicare restrictions that limit telehealth to certain rural areas, clinical sites, and types of providers create "barriers" to a service delivery method that "increases access to care in areas with workforce shortages and for individuals who have barriers to accessing care."

    The legislation is endorsed by more than 120 organizations, including AARP, the American Medical Association, and Kaiser Permanente. APTA not only endorsed the legislation but worked in collaboration with the American Occupational Therapy Association and the American Speech-Language-Hearing Association to advocate for their respective professions as the legislation was being drafted.

    "The CONNECT act is a win for the profession, not just because it opens the opportunity for telehealth by PTs beginning as early as 2021, but because it establishes a way for the profession to demonstrate, through data and outcomes, how a PT's use of telehealth could make a very real contribution to improved health," Humble said. "PTs using telehealth can play an important role on several health care fronts, particularly in terms of efforts to combat the opioid epidemic by reaching rural and underserved communities with nonpharmacological options to chronic pain."

    APTA government affairs staff will continue to track the progress of the legislation. Stay tuned for opportunities to advocate in support of the bills.

    APTA offers a summary of research on telerehabilitation's effectiveness and a collection of PT testimonials supporting the use of telehealth. 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), the Medicare fee schedule, self-referral, and more.

    Telehealth

    Senate sponsors of the CONNECT Health Act, led by Sen Brian Schatz (HI, at microphone) have introduced a bill that could provide opportunities for greater use of telehealth by PTs.