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  • Humana Lifts Prior Authorization Requirements for Physical Therapist Services

    Physical therapists (PTs) and patients may face plenty of challenges when it comes to dealing with private insurers, but for those who participate in the Humana system, preauthorization for physical therapy is no longer one of them. In a move strongly supported by APTA, the insurer lifted the prior authorization requirement for outpatient physical therapy, occupational therapy, and speech-language pathology.

    Humana made the announcement earlier this month, stating that the change was effective December 18, and applies to both commercial and Medicare Advantage policies. Other elements of the Humana benefit package remain unchanged, including visit limits, referral requirements for some plans, and medical necessity requirements. Prior to the change, PTs, occupational therapists, and speech-language pathologists were required to obtain preapproval from a utilization management/review vendor.

    APTA has long advocated for the elimination of prior approval as a much-needed change for patients and providers, but also as a way for the association and the insurer to demonstrate how more collaborative relationships can improve the health care landscape.

    "This is great news for patients and PTs," said Elise Latawiec, PT, MPH, APTA senior practice management specialist. "But this change also presents an even bigger opportunity. When we demonstrate how the elimination of prior authorization can reduce administrative burdens on PTs, decrease overall costs, and improve outcomes in the Humana system, we build an even stronger case that we can make to other insurers with prior authorization requirements. As a profession, we are committed to being responsible stewards of limited health care resources, and can show that we can be held accountable without the use of an intermediary gatekeeper."

    Providers working with Humana can get more detailed information on the change by contacting the Humana telephone number listed on a patient's member identification card.

    The Humana decision represents a reversal in a trend toward greater use of utilization management (UM) vendors among insurers. APTA works to keep its members informed on the UM environment through an online toolkit that debuted in 2017. The association is also bringing the profession's voice to the table by participating in various payer and utilization management advisory groups.

    From PTJ: New Health Promotion Model May Equip PTs to Address Wellness and Prevention

    Despite organizations such as the Centers for Disease Control and Prevention and the World Health Organization urging health care providers to address modifiable risk factors and risky health behaviors in patients, physical therapists (PTs) are not “routinely” doing so, say authors of a recent study. The researchers believe a new clinical model could help bridge the gap between knowing and doing.

    The model, known as the Health-Focused Physical Therapy Model (HFPTM), was developed by researchers at the University of Alabama at Birmingham (UAB), and is focused on encouraging smoking cessation and regular physical activity among PTs’ patients and clients. Results of their validation efforts were recently published in Physical Therapy (PTJ).

    The HFPTM was developed as a preliminary model based on health promotion and education research. The model integrates community wellness programs with the PT's insight in anticipating health promotion needs for the population at large. From there, the PT screens for health promotion needs among patients and clients and then develops a health-focused management plan for those in need—a plan that could include referrals to other providers, treatment by the PT, or a combination. If the patient’s or client's care is not referred out completely, the PT then delivers "health-focused interventions" and analyzes outcomes. That outcome analysis creates a feedback loop that helps PTs further refine their understanding of health promotion needs at the community level.

    To gather more insight and validate the model, the researchers convened a “Health Promotion and Education Initiative: UAB Summit,” in which a group of 21 health care researchers, educators, and practitioners from backgrounds as diverse as nutrition, medicine, public health, and physical therapy helped to flesh out the model by offering feedback and identifying which lifestyle behaviors are within the PT's scope of practice and which require referral to another discipline.

    Summit participants viewed the interdisciplinary model as appropriate for the physical therapy profession and potentially useful for other professions. However, while participants perceived PTs as “well positioned” to provide health education and promotion services, they also suggested that PTs need to further develop “credibility” in areas such as stress management. Other areas were also identified as being in need of further attention by the physical therapy profession. These included handling payment and liability issues, developing screening tools and education materials, enhancing communication skills, and "building consultancy and referral systems to provide health-focused care for some unhealthy behaviors” outside of PTs’ scope of practice, authors write.

    While the authors assessed the model’s content validity only for smoking cessation and regular physical activity, they hope the model will “prove particularly useful for physical therapists who do not feel equipped to provide health-focused care.” Researchers suggest that this model “could serve as a framework upon which educators may teach the integration of health promotion into customary clinical care to educate physical therapist students and clinicians.”

    Authors of the study include APTA members Donald Lein, PT, PhD; Diane Clark, PT, DSc, MBA; Patricia Perez, PT, DScPT; David Morris, PT, PhD, FAPTA; and the late Cecilia Graham, PT, PhD.

     Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Foundation Awards Research Grants, Kendall Scholarships

    The Foundation for Physical Therapy (Foundation) recently awarded Florence P. Kendall Doctoral Scholarships for 2017 to Rachel Bican, PT, DPT, The Ohio State University; Kristina M. Kelly, PT, DPT, EdM, Ohio State; Jesse L. Kowalski, PT, DPT, University of Minnesota; Dana R. Mathews, PT, DPT, MS, University of Delaware; and Lauren M. Pacho, PT, DPT, board-certified neurologic clinical specialist, Ohio State.

    The $5,000 Kendall Doctoral Scholarship is awarded annually to outstanding physical therapists as they begin their first year of graduate studies toward a postprofessional doctoral degree.

    Four researchers also were awarded a total of $230,000 in research grants from the Foundation in support of their projects to evaluate the effectiveness of physical therapist interventions. Awardees and grants are:

    Stephanie Di Stasi, PT, MSPT, PhD, board-certified orthopaedic clinical specialist—Mercer-Marquette Challenge Research Grant. Di Stasi was awarded a $40,000 grant for a study on load modification vs standard exercise for individuals with greater trochanteric pain.

    Kenneth J. Harwood, PT, PhD—Health Services Pipeline Grant. Harwood was awarded a $50,000 grant to pursue a 1-year research project titled "The Effects of Timing of Physical Therapy on Health Care Costs, Utilization, and Opioid Use." The grant was made possible through a donation from APTA.

    Victoria G. Marchese, PT, PhD—Snyder Research Grant. Marchese was awarded the $40,000 Snyder grant for a 1-year research project focused on a strengthening intervention for childhood cancer survivors of lower-extremity sarcoma.

    Charles A. Thigpen, PT, PhD, MS—Magistro Family Foundation Research Grant. Thigpen was awarded $100,000 for a 2-year project titled "Effectiveness of a Physical Therapy First Musculoskeletal Pathway."

    "As the Foundation continues to open doors to deserving physical therapist researchers, we are certain that the emerging generation of investigators will change the face of rehabilitation research and physical therapeutic interventions," said Foundation Board of Trustees President Edelle Field-Fote, PT, PhD, FAPTA, in a Foundation press release. “We look forward to seeing the growth of our funding recipients as they go on to develop innovations that will transform the field.”

    Inaction by Congress Triggers No-Exceptions Therapy Cap in 2018

    In a development that leaves patients and providers in the lurch, Congress has recessed without addressing the Medicare therapy cap in any meaningful way. The inaction is particularly disappointing for APTA and other stakeholders given that a bipartisan agreement had been reached to permanently end the hard cap.

    The bottom line: beginning on January 1, 2018, the $2,010 hard cap on physical therapy and speech-language pathology services combined will be instituted, and the exceptions process that currently permits medically necessary services above the cap through use of the KX modifier will no longer apply.

    In late October, Congress seemed poised to enact a permanent repeal of the hard cap and included that change in a package of Medicare "extenders." Had those extenders been approved, it would have ended Congress' continual tradition of late-year scrambling to come up with a short-term exceptions process. Instead, Congress recessed without approving the extenders or enacting a temporary exceptions process.

    Over the past several months, thousands of APTA members called and tweeted their members of Congress, and generated over 20,790 emails to Capitol Hill urging Congress to pass the permanent fix for the therapy cap

    "Congress’ inaction creates the worst-case scenario for patients and providers," said APTA President Sharon Dunn, PT, PhD. "Medicare patients will start the new year unsure if they will receive medically necessary care. This inaction by Congress means arbitrary barriers, stress for patients and their families, and disruptions for providers."

    The therapy cap is just 1 of several issues left unresolved by Congress. A number of other critical Medicare extender policies that needed action, but also will now expire on December 31, include everything from special payments for ground ambulances, to reauthorization of special needs plans, to an extension of the State Health Insurance Health Programs.

    There is a chance the cap could be short-lived. Congress returns from its recess on January 19, and APTA’s congressional advocates and other patient and provider groups that are part of the Repeal the Therapy Cap Coalition will work to get the bipartisan agreement included in the next "must-do" bill to be taken up.

    "Congress is well aware of the negative ramifications of the therapy cap, which is why there is bipartisan support to repeal it," said Justin Elliott, APTA's vice president of government affairs. "It is imperative that Congress take action as soon as possible in January, and we will keep up the fight."

    APTA also will provide additional information and resources to help practitioners prepare for the application of the hard cap on January 1.

    APTA Urges CMS to Consider Ripple Effects of Medicare Advantage Changes for 2019

    Efforts by the US Centers for Medicare and Medicaid Services (CMS) to make Medicare Advantage (MA) plans more accessible to more vulnerable beneficiaries are laudable, and provisions that would steer patients away from overuse of drugs are understandable, but CMS needs to be mindful of the unintended consequences of these and other changes, says APTA in its comments on proposed MA rules changes for 2019.

    At the center of APTA's comments are proposed changes to so-called "uniformity requirements," out-of-pocket limits, and frequently abused drugs. Essentially CMS would like to make it easier for more vulnerable individuals to participate in MA plans by reducing cost-sharing requirements, and harder for providers and patients to overutilize certain drugs, including opioids. Both efforts are worth pursuing, APTA says in its comments to CMS.

    However, the association adds, those efforts need to be balanced against other concepts in MA plans.

    Specifically, APTA warns CMS that healthier members of the MA population shouldn't shoulder the expense of increasing access for more vulnerable individuals who want to participate through increased cost-sharing on services such as those provided by a physical therapist. The association also encourages CMS to require Medicare Part D sponsors to provide beneficiaries with more information on nondrug treatment options, increase access to those options, and support interdisciplinary care for treatment of chronic pain and opioid addiction. APTA's comments can be accessed on the association's Medicare Advantage webpage.

    The call for comments on proposed MA changes is an annual event, explained Kara Gainer, APTA's director of regulatory affairs, but as the program grows with every passing year, the provisions are beginning to play a bigger part in the overall health care landscape.

    "More and more Medicare-age beneficiaries are enrolling in Advantage plans, so now is the time for CMS to implement policies that ensure access to physical therapy," Gainer said. "But in addition to making changes that improve that access, CMS needs to make sure it maintains the gains we've already made."

    Study: High-Intensity Exercise Shows Promise for Patients With PD

    Could high-intensity treadmill exercise slow the progression of symptoms among individuals with Parkinson disease (PD)? Authors of a new study say that while more research needs to be done, their randomized clinical trial has proven the intervention to be safe, with indications that sufficiently vigorous treadmill work 3 times a week slowed severity at 6 months.

    Their findings, published in JAMA Neurology (abstract only available for free), are based on a study of 128 patients with stage 1 or 2 PD who were within 5 years of diagnosis. Authors wanted to find out whether endurance exercise—particularly the high-intensity variety—had any effect on PD severity over time. Authors say the study is the first to evaluate the effects of exercise at 80% to 85% of maximum heart rate among patients with PD, and 1 of only a handful that focused on disease severity as an outcome, rather than fitness or functional measures.

    Researchers divided the participants into 3 groups: a high-intensity group that received a prescription for 30 minutes of target heart rate (80% to 85% of maximum heart rate) treadmill work 4 times a week, a moderate-intensity group that received a prescription for 30 minutes of treadmill work that reached 60% to 65% of maximum heart rate 4 times a week, and a usual-care group that was told to continue with their current rates of physical activity. Sessions during the first 2 weeks were conducted that the study site; after that participants engaged in the treadmill work at local gyms or health centers. Patients wore heart rate monitors for all sessions and participated in monthly calls with study coordinators.

    At the end of 6 months, participants completed the Unified Parkinson Disease Rating Scale (UPDRS), and researchers compared those scores with UPDRS scores at baseline.

    Authors of the study found that individuals in the usual-care group recorded an average 3.2 point increase in PD severity in the UPDRS motor score component after 6 months, while the high-intensity treadmill group averaged a 0.3 increase—a difference significant enough to warrant further investigation, they believe. But the same couldn't be said for the moderate-intensity group, which averaged a 2 point increase in UPDRS motor scores, representing no significant difference between that group and the usual care group.

    Additionally, researchers found few adverse events associated with the high-intensity group, "demonstrating that patients with [PD] can exercise safely without direct supervision when guided by exercise specialists," they write.

    "In light of a recent report that low-dose, patient-centered, goal-directed physiotherapy and occupational therapy in patients in the early stages of [PD] is not effective, a demonstration of the nonfutility of high-intensity treadmill exercise in patients with mild [PD] is particularly important," authors write.

    Authors acknowledge limitations to their study, noting that only treadmill work was studied (as opposed to other forms of endurance training); that intensities were reached by manipulating both treadmill speed and incline (as opposed to isolating the effects of each); and that the study did not address other types of exercise that are also important in addressing PD, such as strength training.

    The bottom line, however, remains, as far as the authors are concerned: not only is high-intensity treadmill exercise safe for patients with PD, it shows promise as an approach to lessen disease severity. More research should be done, they write, but "meanwhile, clinicians may safely prescribe exercise at this intensity level for this population."

    Authors of the study include APTA members Margaret Schenkman, PT, PhD, FAPTA; Anthony Delitto, PT, PhD, FAPTA; Deborah Josbeno, PT, PhD; and Cory Christiansen, PT, PhD.

    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.

    PTJ: Research on Computer Gaming's Effectiveness in Physical Therapy Needs to Level Up

    Playing active computer games (ACGs) may increase older adults’ physical activity, but authors of a recent article published in Physical Therapy (PTJ) say that current data provide "little confidence" that such activity improves physical health or cognition. And it’s not yet clear whether it is safe for older adults to play ACGs unsupervised.

    Active computer gaming such as Nintendo Wii or Microsoft’s Xbox is being used in rehabilitation based in part on an assumption that sounds reasonable enough: because the games are fun and motivating, adherence to physical therapist interventions will improve, which will in turn have an impact on health outcomes such as falls. Authors of the PTJ review wanted to know if that assumption was supported by data.

    Authors analyzed 35 randomized controlled trials with 1,838 total participants to determine whether ACG improved balance, functional exercise capacity, functional mobility, fear of falling, and cognition. They also examined participant adherence to interventions and factors such as dose, frequency, setting, and whether interventions were supervised.

    What they found: playing ACGs had a "significant moderate effect" on cognition and balance, and on functional exercise capacity when participants played more than 120 minutes per week. But ACG had no effect on functional mobility or fear of falling. Researchers interpret the findings with caution, as all of the studies were low or very low quality.

    The fact that ACG had a moderate effect "on one outcome associated with falls risk yet no effect on another…highlights the importance of tailoring ACG interventions to older adults’ specific needs for daily function," authors write. The ACG interventions employed a variety of mechanisms to improve function, they explain, and facing forward while standing in one spot may have helped participants improve balance but not functional mobility.

    Authors also raise safety as an issue for ACGs, which they say hold "promise for self-led exercise interventions for even the most frail." But determining which ACGs are safe to use unsupervised was impossible to determine, as only 3 studies used unsupervised interventions. Further, only 9 studies included individuals with balance impairments—making them less likely to be unable to engage in traditional exercise. This makes it difficult to evaluate effects of ACG for this population, authors say.

    "Findings of this review suggest that ACG may provide positive physical and cognitive health benefits greater than those observed following no treatment, traditional exercise, or rehabilitation interventions for balance, functional exercise capacity, and cognitive function," authors conclude, but higher-quality, "robust" randomized controlled trials are needed "in order to state with confidence" that ACG is effective.

    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.

    Government Affairs and Public Service Awards Nominations Due January 12, 2018

    Do you know of an APTA member who in 2017 has gone above and beyond to advocate on behalf of the physical therapy profession at the federal level? Is there a member of Congress, staffer, or public figure who has championed physical therapy causes this year? Nominate them for APTA’s Federal Government Affairs Leadership Award or the Public Service Award.

    The Federal Government Affairs Leadership Award is presented annually to an active APTA member who has made significant contributions to the association’s federal government affairs efforts and shown exemplary leadership in furthering the association's objectives in the federal arena.

    The Public Service Award is presented annually to an individual who has demonstrated distinctive support for the physical therapy profession at a national level. Individuals from the following categories are eligible for nomination: members of Congress, congressional staff, federal agency officials, health and legislative association staff, and celebrities or other public figures.

    Recipients will be selected in February by the APTA Board of Directors, and the awards will be presented during APTA's Federal Advocacy Forum set for April 29–May 1 in Washington, DC. Winners' expenses to attend the award event will be paid by APTA.

    Nominations must be submitted by Friday, January 12, to Jennica Sims at jennicasims@apta.org.

    The Good Stuff: Members and the Profession in Local News, December 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!

    Is squatting the new standing? Jasmine Marcus, PT, points out some of the advantages. (mother nature network)

    Rachel Tavel, PT, DPT, writes for Huffington Post on the importance of seeing a pelvic health PT. (Huffington Post)

    A concussion forced Sarah Urke, SPT, to set aside her hopes of being an Olympic athlete; now she's preparing for a career as a physical therapist. (USC News)

    Rebecca Kilgore, PT, combines her knowledge of physical therapy with her training as a behavioral therapist to serve children with disabilities. (Jacksonville, Florida, Welcome to Sacksonville)

    Michaela Main, PT, DPT, is a cheerleader for the New England Patriots. (Boston University Today)

    Casie Danenhauer, PT, DPT, explains vaginismus and physical therapy's role in treatment. (Self magazine)

    Tracy Smith, PT, discusses the importance of prehab. (Palm Beach, Florida, Post)

    HIIT is hot. But is high-intensity interval training also dangerous? Aaron Hackett, PT, DPT, explains how to minimize the risks. (Shape)

    Fortino Gonzalez, PT, provides tips on training for a marathon. (McAllen, Texas, Monitor)

    “I owe my ability to walk to the physical therapy team I had. I saw them five or six days a week for six months. They had a lot of patience and pushed me a lot,” -Lee Springer, stroke survivor who has returned to competitive running. (Fremont, Ohio, News-Messenger)

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

    Analysis: The 'Big 5' Insurers Are Increasingly Dependent on Medicare and Medicaid for Revenue

    The degree to which the "big 5" private health insurers have come to rely on Medicare and Medicaid for their revenues may surprise you—but that reliance may be the key to increasing their involvement in the Affordable Care Act's individual marketplaces, according to authors of a new analysis in Health Affairs.

    The analysis looked at annual corporate filings with the Securities and Exchange Commission between 2010 and 2016 for the nation's 5 largest insurers—UnitedHealthcare, Anthem, Aetna, Cigna, and Humana—to analyze how revenue streams have shifted, and whether the ACA's marketplaces have had an impact on that shift. Combined, the insurers cover 43% of the total US insured population, or about 125 million people.

    Authors of the study focused on where revenues were coming from: the private group market (including administrative services-only arrangements); the individual market; and federal programs including Medicare Advantage, Medigap supplemental plans, Part D drug plans, and claims payment and network management in Medicaid programs. Here's what the study found:

    Growth was significant—especially in Medicare and Medicaid.
    Overall, membership in the companies' offerings grew by 23% from 2010 to 2016—twice the increase from 2005 to 2010. Between 2010 and 2016, the number of Medicare and Medicaid-related members nearly doubled, from 12.8 million to 25.5 million.

    The revenue landscape has shifted.
    In 2010, total revenue for the 5 insurers was $209 billion, with 44% of those revenues from government-related offerings. By 2016, revenues had increased to $360 billion, with 60% coming from Medicare and Medicaid.

    The individual market—including ACA marketplaces—account for a fraction of membership.
    Between 2010 and 2016, the number of members in individual plans experienced a 72% increase, from 2.3 million people to 3.8 million. But those numbers represent a small segment of the big 5's overall membership numbers—just 2% of the overall members in 2010, and 3% in 2016.

    Medicare and Medicaid programs seem to yield better benefit ratios for the companies.
    Among the 3 companies that reported on medical benefit ratios—the average revenue retained by the company per member given claims that are made—the government-related programs were more lucrative. The companies reported that they retained between 13% and 19% of Medicare and Medicaid premiums for administrative expenses, overhead, and profits, or about $1,500 to $2,000 per year, per member. The rate for commercially insured members was $624 to $912 per year per member. Overhead expenses were higher for Medicare Advantage operations than for the commercially insured, however.

    "In effect, these national insurers have become significant agents of publicly sponsored programs, acting on behalf of the federal government and states to purchase and arrange medical care on behalf of beneficiaries," authors write. Whether that's a good or bad thing by itself they don't say, but what they do believe is that there's a flipside to the situation: a private insurance industry so deeply dependent on public programs for revenue may offer an opportunity to shore up the ACA marketplaces.

    According to the authors, that opportunity is "tying," which would require any large insurance carrier wishing to do business with Medicare or state Medicaid programs to sponsor individual-market plans in those areas as well. "Requiring insurers that participate in Medicare Advantage in a given area to also serve the area's Marketplaces would strengthen state-level efforts to grapple with market stability and enhance the viability of the insurance Marketplaces," they write.

    Authors note that the idea comes with a certain amount of risk. After all, the companies' participation in Medicare and Medicaid is voluntary in the first place, and it's entirely possible that some insurers would back out of government-related programs altogether. Given that the insurance marketplace is increasingly consolidated, such a move by a dominant insurance company could have significant effects. "Without viable alternative insurance choices or a publicly sponsored insurance program, such as traditional Medicare, the threat of exiting could hold public programs hostage to increasing plan payments to retain insurer participation," authors write.

    The analysis was supported by a grant from the Commonwealth Fund.

    APTA offers a wide range of resources for members who want to learn more about the workings of private insurance at the association's Private Insurance webpage

    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.

    President Signs Law Allowing PTAs in TRICARE; Implementation May Not Be Immediate

    Physical therapist assistants (PTAs) are on their way to officially joining the TRICARE payment program used throughout the Department of Defense (DoD) health care system. President Donald Trump's signature on the National Defense Authorization Act enacts a change long advocated by APTA, but what happens next isn't entirely clear.

    One thing that's certain: the change won't take effect immediately. APTA Senior Congressional Affairs Specialist Michael Hurlbut says PTAs should keep themselves updated on the progress of implementation.

    "This is a huge step forward for PTAs, but the law itself simply directs DoD to make the change—it will take some time for actual regulations to be created and put in place," Hurlbut said. "APTA staff are monitoring progress, and will keep members informed of the timeline for the changeover to the expanded TRICARE system."

    The first glimmers of a possible change in TRICARE came in June 2017, when a US House of Representatives committee requested that the Secretary of Defense come up with a plan for bringing PTAs, occupational therapy assistants, and other support personnel into the TRICARE system. From there, action on the idea moved relatively rapidly from the House to a Senate committee, and then on to a vote in the full Senate in November.

    "We're very pleased that this APTA-backed change has been achieved," Hurlbut said. "This addition will make a difference for patients in TRICARE who deserve access to the valuable services provided by PTAs."

    APTA Board Recommends Further Exploration of Education Reform Through Education Leadership Partnership

    Mandatory residency that integrates specialty certification? Staged licensure? Someday, physical therapist (PT) education could include any or all of those things, as education inevitably evolves to meet the needs of society, the profession, and the health care system.

    But APTA will not be pursuing any of those paradigm-changing options right now.

    That much is clear after APTA’s Board of Directors (Board) adopted multiple motions related to the pursuit of best practice in clinical education at their November meeting. The motions were the result of recommendations from a task force appointed to respond to a 2014 charge from APTA’s House of Delegates (House) to investigate the future of physical therapist education (RC 12-14 and RC 13-14).

    The Board’s actions in November, which included amendments to the task force’s original recommendations, were the byproduct of months of extensive stakeholder engagement opportunities designed to generate feedback, including multiple in-person and virtual town halls, an online survey, and a collection of resources at APTA.org about the task force recommendations.

    “What we heard loud and clear from our stakeholder engagement is that the profession isn’t convinced that a highly integrated system of staged licensure and clinical-and-residency education, as originally recommended by the task force, is in the profession’s and ultimately our patients’ best interest right now, and we responded to that feedback,” said APTA President Sharon Dunn, PT, PhD, board-certified orthopaedic clinical specialist.

    “The task force recognized that some of their recommendations would mean massive changes that would take many years to implement, and it was always a priority to ensure that student debt wouldn’t increase as a result," Dunn explained. "Even so, there are too many unknowns in need of further investigation, and too many factors beyond APTA’s direct control, to commit right now to that kind of massive reform. But these conversations on advancing practice and education must continue in order to continue to meet our professional obligations to society.”

    So what happens now?

    Several things, but most simply and most significantly: the Board recommended that the Education Leadership Partnership (ELP) continue to explore the issues and concepts that were proposed as part of this multiyear exploration of PT education.

    The ELP comprises representatives from APTA, the Education Section of APTA, and the American Council of Academic Physical Therapy (ACAPT). It was formed in 2016 to help reduce unwarranted variation in practice by focusing on best practices in education.

    The Board recognized that the ELP is best positioned to pursue concepts identified by the task force, including:

    • Inclusion of clinical education inquiry into the profession’s data management plan and prioritized education research agenda
    • Development of a framework for formal partnerships between academic programs and clinical sites to include defined accountabilities for all parties
    • Development of a structured PT clinical education curriculum that could include elements such as universal definitions for entry-level competencies, the enhancement of the residency and certification process to better complement the standard clinical education experience, and the development of standardized measurement tools to evaluate student competencies at all phases of education
    • Creation of a long-term strategic plan for professional and postprofessional education informed by engagement with relevant stakeholders

    The Board does not have authority over the ELP and thus cannot formally charge the ELP to take specific actions. But by adopting motions to forward various recommendations to the ELP, the Board is demonstrating its trust in that partnership.

    “This whole process is a wonderful illustration of APTA’s ability to bring stakeholders together to examine our present and imagine our future,” Dunn said. “From the original member-generated motions in the House to the outstanding engagement around the task force recommendations, thousands of APTA members and nonmembers provided input that will inform the ELP’s ongoing efforts to achieve best practice in physical therapist education.”

    Move Forward Radio: Former NBA All-Star Grant Hill Discusses Pain Management and Alternatives to Opioids

    As a 19-year player in the National Basketball Association (NBA), Grant Hill was no stranger to injury, both major and minor. Experiencing "aches and pains, bumps and bruises is kind of par for the course," he says.

    Now available from APTA's Move Forward Radio: a conversation with Hill, who describes his experience with injury, managing pain, and what he would do differently today. "We all have pain in some fashion. The most important thing is to educate yourself…about pain—how do you handle postsurgery? What are your rights as a patient?" With regard to opioids, he explains, "You have options."

    The 7-time all-star retired in 2013 after numerous ankle injuries and surgeries—and painful recoveries—over the course of his career. Hill is a strong proponent of nonopioid alternatives to pain management and is a spokesperson for Plan Against Pain, a national campaign that educates the public on the availability of nondrug approaches to pain treatment postsurgery. As a player, he was prescribed opioids after surgery and for very painful injuries but says, "I didn’t like the way I felt." Hill tried to find alternative ways to treat his pain, including physical therapy. "Physical therapy has been an integral part of my career and my longevity" as a player, he says.

    He tells listeners: "Listen to your body. This is your body. This is your health. You don’t have to rely on opioids to deal with pain."

    Like Hill, APTA is raising public awareness about the risks of opioids and the benefits of physical therapy via its #ChoosePT campaign, which includes TV and radio public service announcements, national advertising, and free resources at MoveForwardPT.com/ChoosePT.

    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:

    Recovery From Debilitating Abdominal Pain Inspires a New Career Path
    Michelle Griffith had severe abdominal pain that was undiagnosed—until she saw a PT, who discovered her nerve damage and guided her recovery. Now she is an aspiring PT student.

    Pain Does Not Discriminate, Even in Hollywood
    Karen Joubert, PT, DPT, shares some insights into the needs of her famous clients, how they benefit from physical therapy, and her universal, back-to-basics approach in treating all of her clients.

    Neonatal Abstinence Syndrome
    Bertie Gatlin, PT, DSc, Divya Rana, MD, 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, including misconceptions about the condition and her perspective on 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.

    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.

    APTA Fellowship Opportunities Focus on Education Research

    APTA has opened its search to fill a fellowship position that will help to define the body of knowledge that drives physical therapist education.

    The APTA Visiting Scholar Research Fellowships program is looking to fill a position for either an early-investigator research fellowship or a postdoctoral research fellowship. The early-investigator fellowship will be awarded to the most highly qualified applicant who currently holds a faculty appointment at an accredited US academic institution and is embarking on his or her sabbatical year, while the postdoctoral research fellowship is targeted at the most highly qualified postdoctoral physical therapist applicant who intends to pursue a career in education research.

    A complete description of the fellowships, including responsibilities, requirements, terms, and application instructions, can be found on the APTA website (postdoctoral fellowship here, early-investigator fellowship here). The deadline for submission of applications is January 12, 2018, with in-person and virtual interviews conducted on a rolling basis with an opportunity for in-person interviews to occur in February 2018, during the APTA Combined Sections Meeting in New Orleans. A final decision on the position will be announced in April.

    Questions about the fellowship should be directed to the APTA Research Department.

    Study: Even Small Amounts of PA Can Reduce CVD Risk Among the Elderly

    It's no secret that physical activity (PA) can decrease the risk of cardiovascular disease (CVD) in middle-aged adults, but researchers in England have found that the relationship also applies to the elderly, and that even small amounts of PA can markedly lower the chances of CVD hospitalization and death in this age group.

    Researchers used data from the EPIC study, a 10-country prospective population study, to track CVD-related hospitalizations and deaths among 24,502 participants, aged 39-79 years, and compare those with participants' self-reported PA. This isn't the first study of its kind, but authors believe it is notable because of its focus on participants 65 and older, and its 18-year median follow-up duration—a relatively long time span that allowed researchers to follow some participants into old age. Findings were published in the European Journal of Preventive Cardiology.

    Participants were divided into 3 age groups: 54 and younger, 55-65, and over 65. Individuals were then placed into a category of "inactive," "moderately inactive," "moderately active," and "active" based on self-reported levels of PA. Researchers tracked the participants for CVD-related hospitalizations and deaths that included events related to coronary heart disease (CHD) as well as stroke.

    A CVD event occurred in 5,240 of the 24,502 participants, with 4,450 events related to CHD and 1,231 events related to stroke. Among age groupings, the under-55 group experienced 874 CVD events, the 55-65 group experienced 1,650 events, and the over-65 group experienced 2,716 events.

    When researchers compared the data with reported levels of PA, they found that among the over-65 group, the chances of experiencing a CVD event were reduced by 12% for the active participants, 13% for the moderately active individuals, and 14% among the moderately inactive, compared with the inactive group. The 55-65 group showed reductions of 16% for the active, 1% for the moderately active, and 11% for the moderately inactive. In the youngest group, active, moderately active, and moderately inactive resulted in a reduction of 5%, 15%, and no reduction, respectively. The results were adjusted for socioeconomic status, age, sex, smoking status, blood pressure, diabetes, BMI, and cholesterol levels.

    "Elderly people appeared to benefit at least comparably from PA compared to middle-aged individuals regarding the risk of CVD," authors write, adding that "even those participants who were moderately inactive had a substantially lower CVD risk than those who were completely inactive." They believe the findings point to the possibility that "even modest engagement in PA may be associated with a substantially lower CVD risk in the elderly."

    The researchers believe the data support World Health Organization recommendations for at least 150 minutes of moderate-intensity PA per week, or 75 minutes of vigorous-intensity PA per week, but add that the nature of the self-reports used in their study widens the lens through which PA is viewed. Because the EPIC study asks about PA during leisure, work, and transportation, authors were able to obtain a more comprehensive perspective and, from that perspective, were able to see the effects of even small levels of PA.

    "These observations suggest that in order to achieve cardiovascular health benefits from PA, elderly people should be encouraged to engage in at least some PA of low level," authors write. "These findings indicate that health benefits are not restricted to those engaging in vigorous intensity PA."

     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 Webpage Maps APTA's Coalition Connections

    "Better together"—the idea that more gets done when everyone's pulling in the same direction—has been a key theme within APTA for a few years now. But the association extends that idea far beyond its own members and components, and now you need look no further than a new APTA webpage for proof.

    Now available at APTA.org: a new resource that lists the coalitions, alliances, and other shared interest groups in which the association participates to help highlight important issues and bring the profession's voice to the table. The listings are grouped as "advocacy," "payment," and "practice," and include links to the coalitions themselves whenever possible.

    It's not a short list. As of the publication of the page, APTA lists no fewer than 30 groups in which it has involvement, including the Therapy Cap Coalition, the Coalition to Preserve Rehabilitation, the Disability and Research Rehabilitation Coalition, the Joint Commission, and the Academy of Nutrition and Dietetics, to name a few.

    The association's involvement in shared interest groups has played a significant role in some clear gains for patients and the physical therapy profession, including the Alliance for Integrity in Medicare Coalition's work in debunking of the "improvement standard" myth brought to light through the Jimmo v Sibelius settlement agreement, and the National Physical Activity Plan Alliance efforts to focus attention on the importance of physical activity as a way to improve public health.

    Want more information on APTA's involvement in other groups? Email advocacy@apta.org or practice@apta.org.

    Study: Physical Therapy May Be Underused Among Patients With OA

    Aside from taking oral analgesics, patients with osteoarthritis (OA) may be underusing nonsurgical therapies such as physical therapy, say authors of a recent study published ahead of print in Arthritis Care & Research (abstract only available for free). The use of physical therapy, a guideline-recommended first-line treatment, is “a key area for improvement,” researchers write.

    While 70%–82% of participants in 3 clinical trials had used oral analgesics to treat OA symptoms, only 39%–52% had used physical therapy. Other treatments included knee injections (55%-60%) and topical creams (25%–39%). Most participants had used more than 1 type of treatment.

    Yet clinical practice guidelines for OA, authors note, first recommend nondrug interventions such as “self-management education, weight-loss, and physical activity, along with pharmacologic therapy when tolerated and safe.”

    In the study, researchers sought to identify what, if any, patient demographic and clinical factors were associated with use of these guideline-based nonsurgical interventions, as well as how frequently interventions were used. They analyzed data from 3 clinical trials affiliated with Duke University Medical Center primary care practices (PRIMO-Duke), Durham Veterans Affairs Health Care System (PRIMO-VA), and University of North Carolina–Chapel Hill (PATH-IN).

    While physical therapy use was only moderately used, it was still higher than in previous studies, researchers write. They suggest that this difference could be due to older studies being based on referral data from single providers, as opposed to self-report data from patients, who may have been referred by more than 1 provider. Still, authors observe, with just 39%–52% of participants receiving a therapy that is recommended as a first-line treatment, this is “a key area for improvement in OA treatment.”

    Among pharmacologic treatments, the use of NSAIDs, other nonopioids, and opioids aligned with clinical practice guidelines. Opioids are recommended as the last resort for managing OA symptoms; however, opioid use was higher among veterans than in the other 2 clinical trials, “suggesting a gap in OA treatment guidelines and opioid use for OA among veterans,” say authors. However, researchers were unable to determine whether veterans who used opioids did so because NSAIDs either had failed to relieve pain or led to side effects.

    Across all 3 studies, nonwhite participants, on average, were more than twice as likely as white patients to have used topical creams. But authors found that no other “single clinical or socio-demographic participant characteristic was consistently associated with any specific OA treatment.” They also note that other characteristics were associated with use of multiple treatments, including being female, being nonwhite, having higher BMI, and having pain scores. Other patient demographics analyzed include income level, age, “fair/poor self-rated health,” years with symptoms, knee OA, and hip OA.

    The results of the study, say researchers, suggest “potential adherence to OA treatment guidelines for oral analgesics” but also indicate “areas for improvement in opioid use, [physical therapy], and joint injections.”

    “It is imperative that we understand not only how to best manage OA but also how to implement evidence-based guidelines for OA management in the community considering individual demographic and clinical characteristics to reduce the burden of OA pain and disability,” authors write.

    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.

    2018 Slate of Candidates Posted

    The 2018 Slate of Candidates for APTA national office is now posted on the APTA website. The candidate webpage, including candidate pictures, statements, and biographical information, will be posted on March 26, 2018.

    Elections for national office will be held at the 2018 House of Delegates on June 25, 2018. Please contact Justin A. Lini in APTA’s Governance and Leadership Department for additional information.

    Final CMS Bundling Rule Reduces Number of Mandated Participants, Expands Possibilities for PTs

    The US Centers for Medicare and Medicaid Services (CMS) has issued a final rule on bundled care that largely mirrors what the agency proposed in August: a scaled back knee and hip joint replacement bundled care model—albeit with more opportunities for participation by individual providers—and cancellation of a plan to expand bundled care models to cardiac care and hip and femur fractures.

    Known as the Comprehensive Care for Joint Replacement (CJR) model, the hip and knee bundle program launched in 2016 was the first-ever attempt by CMS to mandate bundled care. The rule as it now stands applies to 67 different geographic areas covering some 800 hospitals: beginning in 2018, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas. CMS estimates that 430-450 facilities will participate in the CJR next year, a number that includes facilities participating voluntarily.

    In addition to reducing the number of geographic areas required to participate in the CJR, the final rule also follows through on a CMS proposal to switch low-volume and rural hospitals in the remaining 34 areas from mandatory to voluntary participation. A CMS fact sheet summarizes the changes in store for 2018.

    At the same time CMS pulls back on the reach of the CJR, it is making it easier for clinicians, including physical therapists (PTs), to be included as qualifying alternative payment model (APM) participants (QPs) under the Quality Payment Program’s Advanced APM track. By expanding the ways providers can make it onto a CMS "affiliated practitioner list" to include clinicians whose contractual relationship with a facility supports a hospital's CJR goals, the new rule would deepen the pool of providers eligible to receive the Advanced APM 5% incentive payment. CMS will continue to maintain ultimate authority for who does and doesn't qualify as a QP, based on Medicare Part B claims data, but says it won't establish a specific threshold a clinician must meet to be considered supportive of a facility's CJR goals.

    The expansion of the requirements to be considered a QP is good news for physical therapists but is tempered by other factors. The reduction of the number of hospitals in the mandatory program will dampen the effects of the change, as will the fact that the increased participation options apply only to facilities participating in "Track 1" of the CJR program—a version with more stringent requirements that also puts facilities at more financial risk.

    As for expansion of mandatory bundling programs into other areas, that's no longer in the works. Just as proposed, the final rule halts a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to begin in February of this year but were delayed until October 1, and then pushed back again to a January 2018 startup date. The rule effectively cancels those programs altogether.

    From PT in Motion: Walking Away From the PT Designation

    Fed up with all the paperwork? Tired of the hassles? Want to focus on all the good you can do for people without the burden of having that "PT" designation after your name? How about just dropping the title and calling yourself something else?

    Simple answer: it doesn't work that way. Less simple answer: doing so could put you in ethical and legal jeopardy.

    This month's "Ethics in Practice" column in PT in Motion magazine tells the story of "Tina," a physical therapist (PT) who was drawn to the profession by way of her love for athletics, and who found her true professional niche as a PT running a cash-based practice, primarily treating already-active clients seeking to boost their athletic performance.

    Tina loves the work, but hates the documentation, which she sees as required only as a way to receive reimbursement. Since her business is cash-based, she decides to forget the standard documentation procedures in favor of her own far less rigorous approach. When Tina asks a fellow PT to fill in for her while on a trip, the substitute is unnerved by the lack of proper documentation, and warns Tina that she could be in trouble if faced with an audit.

    Tina understands the point, but comes up with what she thinks is a clever solution: she'll just stop referring to herself as a PT, removing the designation from her business cards, taking down framed licenses and diplomas, and explaining to clients that she has evolved into a "wellness expert

    Simple, right? Wrong, writes column author Nancy Kirsch, PT, DPT, PhD. Tina's actions call issues of professional responsibility into question. The idea of voluntarily surrendering a PT credential clearly poses legal issues, but it also presents ethical challenges should the practitioner in question continue to rely on knowledge and skills acquired through her or his training and professional development as a PT. As Kirsch writes, "Does Tina's desire to avoid documentation obviate her responsibility to tap the full extent of her abilities on behalf of her clients?" Check out this month's PT in Motion to learn more.

    "Name Game" is included in the December issue of PT in Motion . Hard copy versions of the magazine are mailed to all members who have not opted out; digital versions are available online to members. Know a nonmember PT or PTA? Invite them to read “What to Expect When They’re Expecting,” the issue’s cover feature that’s open to the public. Then invite them to join APTA to take advantage of all the association’s member benefits.