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  • Study: Even in States That Limit Direct Access, Getting PT First for LBP Makes a Big Difference

    A recent analysis of private insurance data adds more weight to the argument that seeing a physical therapist (PT) first for low back pain (LBP) produces a host of positive results, including lower costs, reduced probability of an emergency department (ED) visit, and lower rates of opioid prescription. But according to the study's authors, definitive answers can still be difficult to come by when it comes to the question of whether those positives further increase when a state eliminates all restrictions on direct access.

    In a study sponsored through a grant from the Health Care Cost Institute (.pdf), researchers from the University of Washington and George Washington University looked at private insurance claims data of 159,777 beneficiaries with LBP between 2009 and 2013. Researchers focused on beneficiaries from 6 western states—Alaska, Idaho, Montana, Oregon, Washington, and Wyoming.

    The study divided patients between states that offer unrestricted direct access (the law in Alaska, Idaho, and Montana) and states that impose certain restrictions on treatment—specifically, special training requirements for the PT (Washington), "degree and referral requirements" (Wyoming), and a 60-day restriction on treatment time (Oregon, although this restriction was eliminated in 2013, after the study period). Patient groups were further divided into 3 categories: those who saw a PT on the initial date of diagnosis of LBP ("PT first"), those who saw another provider initially but accessed a PT at a later date ("PT later"), and patients who saw another provider initially and never saw a PT ("no PT").

    Consistent with previous studies, authors found that regardless of the type of direct access provision, patients who saw a PT first for LBP experienced significantly lower total costs for care compared with both the no-PT and PT-later groups, including lower out-of-pocket expenditures. The PT-first cost differences were most dramatic in relation to outpatient costs and to a lesser extent to physician costs. Also unsurprising were the authors' findings that the PT-first patients had significantly lower rates for ED visits, imaging, and opioid prescriptions compared with the other groups.

    But the particular focus of the research—the differences in costs and other factors depending on the level of restriction to direct access—yielded some more complicated results. Among them:

    • In restricted states, 20.8% of all patients eventually saw a PT, compared with 13.5% in unrestricted states.
    • Among PT-later patients, those who eventually saw a PT in a restricted state averaged 69 days before seeing the PT, compared with 75 days in unrestricted states.
    • Among the no-PT groups, imaging and opioid prescriptions tended to be higher in restricted states than in unrestricted states—but ED visits were lower.
    • Across all groups, overall costs of care were lower for patients in restricted states compared with unrestricted states, a difference that authors tied to lower outpatient and hospital costs.

    Authors write that while more research is needed, there are possible explanations for the seemingly lower costs associated with restricted direct access, some of which might have something to do with the states used in the study.

    "The lower cost could be associated with prescribing restrictions and/or greater use of lower cost providers in restricted states," authors write. "Alternatively, the lower cost could be associated with access to care differences such that restricted states are more urban than unrestricted states, which are more rural."

    Also worth further exploration, according to authors, are the advantages of unrestricted direct access when it comes to rates for imaging services and opioid prescriptions, which were lower when a state had no restrictions on access. "These results suggest that removing restrictions on access to [physical therapy] may result in better imaging outcomes among select populations, but may not benefit ED visit rates," they write.

    Authors of the study include Kenneth Harwood, PT, PhD, CIE.

    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.

    Research Reaffirms Pelvic Floor Physical Therapy's Effectiveness for UI in Women After Menopause

    For women with urinary incontinence (UI), physical therapy that includes pelvic floor muscle training (PFMT) can offer long-lasting relief in a relatively short period of time, according to a new study. It's a finding that could be especially important for older women with osteoporosis and UI, whose urgency can both increase their risk for falls and interfere with the physical activity needed to battle loss of bone density.

    In an article e-published ahead of print in Menopause (abstract only available for free) researchers share data from a randomized controlled trial of 48 postmenopausal women at British Columbia Women's Hospital and Health Centre in Vancouver, Canada. The women, aged 55 and older, all had osteoporosis or low bone mineral density as well as stress, urge, or mixed UI for which they had not previously been treated. The incidence of UI is higher than average among women with osteoporosis.

    Half of the women received group osteoporosis education (taught by a physical therapist, dietician, and nurse clinician) on physical activity, diet, and medications, as well as a follow-up phone call. The other half underwent 12 individual physical therapy sessions over 3 months. The sessions included education on UI, pelvic floor muscle retraining using electromyography biofeedback, motor control exercises, functional pelvic floor muscle exercises, bladder habit retraining, dietary recommendations, and audio recordings for use at home. All participants maintained "bladder diaries" during the study to track UI episodes.

    After 3 months, the women who had completed physical therapy experienced 75% fewer leakage episodes compared with baseline, and had significantly improved scores on the Urogenital Distress Inventory (UDI), the Incontinence Impact Questionnaire (IIQ), and the perceived efficacy scale (both the UDI and the IIQ are available for download at PTNow). At 1 year, the physical therapy group maintained their previous improvement in leakage episodes and had significantly better results on the 24-hour pad test and the UDI compared with the osteoporosis education group.

    In contrast, the education group showed no improvement in UI episodes at 3 months, and the number of leakage episodes actually increased after 1 year.

    Prior studies also have found pelvic floor physical therapy effective for treating UI in women. What's unique about this study, according to the researchers, is the inclusion of "multiple, validated, and reliable UI outcome measures" that examine not just the number of leakage episodes, but the participants’ quality of life. Also different is the "individualized progression in exercise training" according to ability of each woman, rather than at the group level.

    "Many women believe there is nothing they can do, that UI is a normal part of aging for which the only options are costly drugs or invasive surgeries," authors write. "Given the negative impact of UI on physical activity levels and the importance of physical activity to improving bone density, our results should be used by physicians and other healthcare providers to educate clients with osteoporosis and UI: they can effectively reduce or cure their incontinence with this PFMT."

    APTA is a strong advocate for the role that physical therapy can play in transforming the lives of women experiencing UI, and has provided guidance to the Federal Agency for Healthcare Research and Quality (.pdf) in its research efforts around the condition. The association offers several relevant resources to members and the public, including the APTA Section on Women's Health and the PT's Guide to Incontinence, as well as a clinical summary on urinary incontinence in women. The effectiveness of physical therapy in the treatment of pelvic floor weakness—and the strides being made by members of the women's health section—was also the subject of a 2014 feature article in PT in Motion magazine.

    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.

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    Physician Self-Referrals for TKA Physical Therapy: Twice as Many Visits, but Lower Intensity

    In the end, the self-referral issue could be boiled down to a quantity vs quality debate, at least for patients who receive total knee arthroplasty (TKA).

    The "quantity" part of the debate: patients who undergo TKA and are referred to physician-owned physical therapist services average about twice as many visits as patients who receive physical therapy from an independent provider. The quality part? Despite the higher number of visits, the self-referred patients receive less "intensive" physical therapy, with far fewer individualized therapeutic exercises than their non-self-referred counterparts. Both conclusions were reached in a new study published in Health Services Research (abstract only available for free).

    Researchers looked not only at the differences in treatment among physician-owners and physicians with no financial ties to physical therapist services, but also at what happens when patients of a physician-owner don't end up going to that physician's facility. In those instances, researchers found that much like the patients whose physician doesn't have a financial stake in physical therapy, these patients also receive fewer visits but more intensive treatments.

    To get at these conclusions, researchers analyzed Medicare data from 3,771 TKA episodes between 2007 and 2009. Of those, 709 were designated as self-referrals, in which there was a financial connection between the physician and a patient's physical therapist services. The remaining non-self-referring cases were further divided into 2 categories—2,215 episodes in which the referring physician did not have any financial interest in physical therapist services, and 847 episodes in which the referring physician did have a financial interest, but the patient received physical therapy from an independent provider.

    Authors of the study were hoping to test 3 main hypotheses: that self-referrers would prescribe more visits than non-self-referrers; that the self-referred episodes would generate more service units; and that a physician-owner "might shirk on quality and substitute lower-cost unlicensed medical assistants to perform physical therapy."

    Researchers were able to achieve what they considered conclusive results for 2 of the 3 hypotheses. They found that the self-referral group averaged 15.51 visits per patient, compared with 7.19 visits for the non-self-referrals. Yet when it came to service units, the self-referred episodes generated an average of 3.03 fewer relative value units than the non-self-referred cases. Authors write that when taken together, the findings indicate that PTs who were not involved in a self-referral setting "saw patients for fewer visits, but the composition of services received was more intense."

    The third hypothesis—that the self-referred episodes were of lower quality due to the more prevalent use of unlicensed medical assistants and not PTs—was impossible for the authors to directly test, given that the Medicare data did not identify exactly what type of health care personnel provided the physical therapist treatments. But what the data did reveal is that regardless of who was providing the treatments for self-referred patients, patients in this group were receiving a larger proportion of services "not requiring the training or expertise of physical therapists," rather than "hands-on or patient-engaged physical therapy."

    The study found that based on coding records, more than 72% of the physical therapy delivered in the non-self-referral group consisted of "individualized therapeutic exercise to develop strength, endurance, range of motion, and flexibility," compared with a 64% rate among the self-referrals, a difference authors say is "highly significant." Researchers also found that non-self-referral patients received a higher proportion of services aimed at improving functional performance—7.5% compared with 5% for the self-referral group. The self-referral cohort also received more group therapy (and thus less 1-on-1 interaction) than the non-self-referral patients.

    Making the issue even more intriguing were the researchers' finding that these differences—number of visits, service units delivered, intensity of treatment, group therapy—existed in roughly the same proportions among patients whose physician had a financial interest in physical therapist services, but who received treatment elsewhere. "It appears that when orthopedic surgeon owners do not benefit financially from referring [TKA] patients for physical therapy, their patients received essentially the same bundle of physical therapy services as patients treated by surgeon nonowners," authors write.

    Beyond the clinical implications, authors believe their study adds more weight to the argument against the in-office ancillary services (IOAS) exception to the Stark laws—federal legislation that prohibits most self-referral practices in Medicare. IOAS allows physicians to self-refer for several "common sense" or same-day treatments; unfortunately, it also creates loopholes for services that are rarely provided on the same day, including physical therapy, anatomic pathology, advanced imaging, and radiation therapy. Authors write that most research on these exceptions has reached the same conclusion as their own study: "that self-referral results in increased use of services and higher health care expenditures."

    Like an earlier study that questioned the quality of care provided by self-referrals for physical therapy for LBP, the TKA study lends further support to the APTA’s efforts to advocate for the elimination of the exceptions, a position also supported in current and past federal budget proposals from the Obama administration.

    Those efforts are also ongoing at the state level, where Missouri and South Carolina are dealing directly with the issue of physician self-referral (sometimes called physician-owned physical therapy services, or POPTS). In Missouri, 1 of only 4 states with anti-self-referral laws on the books, legislation has been introduced to nullify the prohibition. The Missouri Chapter of APTA is fighting the legislation. In South Carolina, the state's Supreme Court is expected to issue a long-awaited ruling on the constitutionality of that state's anti-POPTS law later this year.

    Authors of the study write that while the debate about elimination of the loopholes continues on Capitol Hill and in statehouses, facts on the ground could change self-referral practices regardless of any action taken by lawmakers; namely by way of alternative payment arrangements, such as bundled care, that emphasize cost-effective, outcomes-based care, with payment made for an entire episode of care. The first such mandatory bundled care provision for Medicare and Medicaid—for TKA and total hip arthroplasty—is set to debut in multiple areas across the country in April.

    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.

    Health Apps Get a Checkup: Report Rates iOS and Android Offerings in Fitness, Nutrition, More

    If the multitude of health and fitness apps were lumped together and assigned an overall letter grade based on quality ratings from their customers, they'd be pulling an uninspiring "D," according to a new analysis. But that doesn't mean there aren't some individual standouts among the nearly 8,000 apps and 4 million reviews included in the study.

    The review (free for download after sign-in), conducted by the ARC research group, began with thousands of apps, but focused closely on the 65 most popular Android and iOS app brands in 5 categories: fitness, medical, nutrition, stress relief, and women's health. Final ratings were based on app store feedback during 2015, and while the overall average was a fairly undazzling 66 out of 100, it's a number that obscures what ARC describes as some of the "amazing" satisfaction ratings of a few individual offerings.

    Here is ARC's list of the top 3 performers in each category:

    Fitness
    1. StrongLifts (muscle-building workouts) - average score: 88
    2. Sworkit Lite ("personalized video workouts") - average score: 84.5
    3. Sports Tracker (activity tracker) - average score: 80

    Medical
    1. GoodRx (prescription drug pricing and information) - average score: 84.5
    2. iTriage (medical information, symptom-based information) - average score: 82.5
    3. iPharmacy (drug and pill identifier) - average score: 82.5

    Nutrition
    1. Water Drink Reminder ("stay healthy and hydrated all day") - average score: 85
    2. Calorie Counter by MyFitnessPal: - average score: 83
    3. LoseIt! (weight loss app) - average score: 82.5

    Stress Relief
    1. Relax Melodies - average score: 88.5
    2. White Noise - average score: 83.5
    3. White Noise (free version) - average score: 82

    Women's Health
    1. Period Calendar/Tracker by Abishkking - average score: 94.5
    2. Period Tracker by GP Apps - average score: 88.5
    3. Period Tracker by SevenLogics - average score: 87

    Surprisingly, some of the biggest names in health and fitness apps were among those with "room to improve," according to the ARC report, with quality scores that averaged below 50. Those lower-rated apps included FitBit (49.5), Weight Watchers Mobile (47), Google Fit (37 – Android only app), and Garmin Connect Mobile (21).

    However, low-scoring apps aren't necessarily destined to stay that way, the report notes. One example: Jawbone's UP fitness tracker improved its 2015 average to 54, a 12.5 point gain over 2014's rating average. The report links the improvement to the inclusion of a "Smart Coach" feature and a new line of bands that are more durable and ergonomic.

    CMS, Private Insurers Agree on Health Care Outcome Measures

    Everyone agrees that the future of health care will be driven by outcomes. But which outcomes will be doing the driving? A major-player collaborative that includes the Centers for Medicare and Medicaid Services (CMS) and the country's leading private insurers' organization has unveiled its first answers to that question.

    In mid-February, the Core Quality Measures Collaborative released its first-ever consensus document to "identify core sets of quality measures that payers have committed to using for reporting as soon as feasible," according to CMS, which joined with America's Health Insurance Plans (AHIP), purchasers, consumers, and physician and other care provider organizations to develop lists of standard outcome measures in 7 clinical areas. Besides CMS and AHIP, participants included the American Medical Association and the American Academy of Family Physicians.

    The inaugural 7 areas addressed by the measures are cardiology; gastroenterology; HIV and hepatitis C; medical oncology; obstetrics and gynecology; orthopedics; and accountable care organizations (ACOs), patient centered medical homes (PCMHs), and primary care. According to AHIP, these will be the first in a series of "broadly agreed upon core measure sets that are aligned and harmonized across public and private payers."

    Measures listed in the orthopedic category may be of particular relevance to physical therapists and physical therapist assistants, and include risk-standardized complication rates after total knee arthroplasty (TKA) or total hip arthroplasty (TKA), and hospital-level 30-day readmission rates after TKA or THA. Also worth noting: measures in the ACO/PCMH/primary care category that include body mass index (BMI) screening and follow-up rates, and use of imaging studies for low back pain.

    In addition to the core measure sets, the aollaborative also identified future areas for measure development. These include "goals of patient care and education," "shared decision-making," "pain management measures," and "preventive diabetes measures" in the ACO/PCMH/primary care grouping. In the orthopedics category, "patient reported outcomes," "functional status measures for patients undergoing orthopedic surgery," and "transitions of care" are among the areas targeted for future measure development.

    CMS states that it is already using measures from each of the core sets, and that it also "intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set." AHIP says that private insurers will use a "phased-in approach."

    While the collaborative unveiled its work on outcomes, APTA continued its own efforts to ensure that the physical therapy profession will be prepared to thrive in the coming health care landscape: earlier this month, the association announced the members of the scientific advisory panel that will guide the APTA Physical Therapy Outcomes Registry, a project that is anticipated to be the single largest repository of physical therapy outcomes data.

    News of the collaborative's measures was covered in the Huffington Post, The New York Times, and Medpage Today, among other outlets.

    As the need for outcomes data builds, so does the need for health care delivery systems that can strengthen those outcomes. In addition to its work on the Registry, APTA continues its Innovation 2.0 program, an initiative supporting research that bolsters the role of physical therapy in emerging health care models. Innovation 2.0 projects under way address pay-for-quality models, ACOs, PCMHs, and adding value in postacute care settings.

    Move Forward Radio: Lakers' PT Talks About Keeping Elite Athletes Healthy, Offers Advice for the Less-Elite Among Us

    Must be the PT.

    Los Angeles Lakers superstar Kobe Bryant says that he has a "secret weapon" on the court: the team's physical therapist (PT).

    The most recent episode of APTA's Move Forward Radio focuses on a discussion with Judy Seto, PT, DPT, OCS, SCS, MBA, CSCS, PES, CES, who has served as head physical therapist for the Lakers for the past 5 years. Seto is responsible not only for meeting Bryant's physical therapy needs but for keeping an entire professional basketball team healthy through an 82-game regular season, plus preseason, postseason, and the offseason.

    Seto gives listeners an insider's perspective on how these elite athletes maintain their levels of performance through a demanding schedule, but she also provides tips for amateur basketball players who want to stay on the court.

    Other recent Move Forward Radio episodes include:

    Acute Care Physical Therapy
    People find themselves in an acute care hospital for many reasons, but no matter what brings them to the facility, they're likely to encounter a physical therapist while they're there. Sharon Gorman PT, DPTSc, GCS, FNAP, discusses the PT's role, including rehabilitation, prehabilitation, and more.

    Blood Flow Restriction Training and Physical Therapy
    Johnny Owens, PT, MPT, discusses blood flow restriction training, a relatively new approach that involves applying a tourniquet to an injured limb to allow patients to make greater strength gains while lifting lighter loads (and reducing overall stress).

    Success Story: A Knee Injury Ends Basketball Dreams, Inspires Career Path
    What happens when an injury forces you to reevaluate your dreams? For Jonathan, whose basketball hopes were permanently sidelined, it meant finding meaning in helping others return to doing what they love through physical therapy.

    Success Story: A Young Dancer Recovers From Hip Injury to Return to Her Passion for Performing
    Isabella had been passionate about dance for as long as she could remember. After a hip injury threatened to prevent her from pursuing that passion, a PT helped her get back to doing what she loves.

    Success Story: Paralyzed After Giving Birth, This Mom Is Moving Again
    For Laura, an emergency C-section led to a spinal cord infection that left her unable to feel or move her legs. Though she was told she would need a wheelchair for the rest of her life, Laura and her PTs have defied expectations. Now, 3 years after the infection, she has made it to her feet.

    Success Story: Man Loses 300 Pounds and Improves Quality of Life
    At age 50, Scott weighed more than 500 pounds and suffered from chronic venous wounds on his legs. Now he's healthy and happily less than half the man he was (weight-wise), thanks to a PT who treated his immediate conditions and gave him the encouragement and confidence he needed to make life-saving lifestyle changes.

    Innovative Device Encourages Movement in Children With Cerebral Palsy
    Thubi Kolobe, PT, PhD, FAPTA, and Peter Pidcoe, PT, PhD, DPT, discuss their collaboration on a device that provides crucial movement assistance for children with cerebral palsy and other developmental delays. The device was 1 of only 13 featured in a recent "Innovation Festival" sponsored by the Smithsonian Institution.

    Aging Healthy by Decade
    Yes, our bodies change as we age, but we can stay healthy and active by understanding and responding to those changes in effective ways. Robert Gillanders, PT, DPT, OCS, talks about trends he sees in the clinic and provides age-specific advice for healthy aging.

    Physical Therapist Tips to Help You #AgeWell
    As part of National Physical Therapy Month, APTA published a list of PT tips to help individuals #AgeWell. In this episode, Alice Bell, PT, DPT, GCS, discusses some of the themes from that list, which includes information on chronic pain, diabetes, falls, Alzheimer’s disease, heart disease, and several other conditions.

    Muscle Soreness: What's Normal, What's Not?
    You've likely experienced it: you exercise hard after not exercising for a while, and later, your muscles ache—something called delayed onset muscle soreness, or DOMS. Malachy McHugh, director of research at the Nicholas Institute of Sports Medicine and Athletic Trauma in New York, shares his perspective on the effectiveness of many current treatments for DOMS and his predictions for possible prevention methods in the future.

    Chronic Disease and Prevention
    The bad news: chronic disease is widespread in the US. The good news: chronic disease is preventable. Mike Eisenhart, PT, talks about chronic disease prevention, both in terms of a physical therapist's role in preventing chronic disease, and in terms of our own role taking responsibility for our long-term health.

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

    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 e-mailed to consumer@apta.org.

    National Physical Activity Plan Seeks Input on Revisions—Due February 26

    APTA members have an opportunity to comment on the latest revision of the National Physical Activity Plan (NPAP), a high-profile effort to create a comprehensive set of policies, programs, and initiatives to increase physical activity in all segments of the American population. But hurry—the deadline is February 26.

    The NPAP Alliance has released an online survey to help evaluate proposed revisions to the plan, which was originally released in 2010. Respondents can comment on and rate strategies in 9 areas: business and industry; community, recreation, fitness, and parks; education; faith-based; health care; mass media; public health; sport; and transportation, land use, and community design. The Alliance estimates that each section should take approximately 10 minutes to complete.

    APTA is a member of the NPAP Alliance board of directors and offers several resources on physical activity, including a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity.

    Study: To Help Reduce Sedentary Behavior in Schools, Students Need to Think on Their Feet

    What's good for the office may be good for the classroom, according to some researchers who think the standing desk trend should be extended to schools as a way to help reduce obesity and improve overall health among children.

    A team of researchers published a systematic review in Pediatrics [log-in may be required] examining the effects of standing desks on students’ sedentary behavior, physical activity level, health outcomes, and academic outcomes. After analyzing the results of 8 studies conducted in elementary school settings, they found that the decreased sitting time, besides doing the obvious good, may also have a null effect on learning. "In essence, it can be hypothesized that students could effectively learn while simultaneously reducing the high volumes of sedentary time accumulated through passive and static sitting in the classroom," authors write.

    The effects on actual physical activity were mixed, with some studies finding no change and others reporting an increase in activity. The evidence on caloric expenditure and BMI was inconclusive.

    Authors write that the reduced sitting and increased standing times suggest that standing desks could serve as one tool in the fight against childhood obesity. Citing one study’s results of children burning an extra 32 calories per hour, authors estimate that standing desks could lead to a net reduction of 12 pounds per year in weight gain.

    Interestingly, some studies that measured neck, back, and/or joint pain showed increase in pain for children using standing desks. Future research, the authors urge, should consider “the frequency of sit-to-stand transitions, how to stand (eg, shifting weight from one foot to the other), and having a resting bar or pendulum for the foot.” Also needed are studies with larger sample sizes and higher-quality methodology.

    Even with its limitations, the review lends support to the view that environmental interventions can be as beneficial to health promotion as education on healthy eating and increased physical activity.

    According to the Centers for Disease Control and Prevention (CDC), over one third of children and adolescents in the United States are overweight or obese, placing them at higher risk for diabetes, cardiovascular disease, joint problems, and a host of other health problems.

    APTA is a strong advocate in the battle against obesity, and offers extensive resources on the PT's role in prevention and wellness, as well as on behavior change in the patient and client.

    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.

    2016 MPPR Calculator Now Available

    The 2016 multiple procedure payment reduction (MPPR) calculator is now live on APTA's Medicare webpage. PTs must follow an MPPR policy that implements a 50% payment reduction to the practice expense value of certain "always therapy services" CPT codes.

    This year's calculator illustrates both the 50% reduction as well as the overall 2% cut to Medicare payments implemented through sequestration. The calculator, delivered by way of an Excel spreadsheet, calculates Medicare physician fee schedule payment for procedures provided to a beneficiary on a given day.

    The 2016 payment landscape: While the sustainable growth rate was repealed last year, the therapy cap for physical therapy and other services remains in place, and is scheduled to be revisited by Congress in 2017. APTA continues to advocate for elimination of the cap. Interested in joining those efforts? Sign up for PTeam.

    CMS Sheds Light on '60-Day Rule' on Overpayment

    The US Centers for Medicare and Medicaid Services (CMS) issued a final rule that attempts to clarify just how providers are supposed to handle self-identified overpayments, and while some of the changes have been characterized as generally favorable to providers, the bottom line remains the same: don't ignore payments that seem too high.

    In a rule announced earlier in February, CMS established its expectations around the "60-day rule," a provision that addresses when an "identified" overpayment must be repaid before it becomes subject to federal False Claims Act (FCA) liability. The new provisions provide details on when the 60-day clock starts ticking, and how far back providers must review—the so-called "lookback" period—for overpayments they may have received.

    The rule adopted by CMS (.pdf) sets the lookback period at 6 years—a shorter time period than the 10-year window specified in the proposed rule. According to CMS, the 6 year lookback rule will begin on March 14, 2016, and will not be retroactive.

    As for the 60-day rule, CMS specified that the countdown does not begin until after a provider has identified an overpayment "through the exercise of reasonable diligence" and quantified the amount of the overpayment.

    The notion of what does and doesn't constitute "the exercise of reasonable diligence," and just how long that should take, is left somewhat open to interpretation. But in its commentary on the rule, CMS writes that "we adopt the standard of reasonable diligence and establish that this is demonstrated through the timely, good faith investigation of credible information, which is at most 6 months from receipt of the credible information, except in extraordinary circumstances."

    And simply ignoring a potential overpayment is definitely not a good option. CMS states that just as providers face FCA liability for not reporting and returning identified overpayments within the 60-day deadline, providers who fail to exercise "reasonable diligence" in the first place could wind up in a similar situation due to their "reckless disregard or deliberate ignorance."

    Providers who report a self-identified overpayment to either the Self-Referral Disclosure Protocol managed by CMS or the Self-Discloser Protocol managed by the Office of the Inspector General will be considered to be in compliance with the rule "as long as they are actively engaged in the respective protocol," according to a fact sheet from CMS.

    The final rule also lays out the ways providers and suppliers may return overpayments, through what CMS describes as "an array of familiar options from which providers and suppliers may select."

    APTA regulatory affairs staff will conduct an analysis of the rule and post a summary and other information in the coming weeks.

    Rates of EMS Transports for Falls Can Be Related to Factors Beyond Injury Severity

    Falls among people 65 and older make up a significant portion of the 911 calls to emergency medical services (EMS) providers—but the likelihood of the event resulting in transport to a trauma facility can depend on the location of the fall, sex of the injured individual, and even geographic setting, according to an analysis of events recorded in 2012.

    In an article published in the American Journal of Preventive Medicine(pdf), researchers looked at data from 903,588 calls made to EMS providers related to falls by individuals 65 and older, including age and location of the victim, as well as the initial clinical impressions of the EMS provider and final dispensation of the call.

    Here's a sampling of what they found:

    1 in 5 calls did not result in transport.
    Overall, 20.7% of patients 65 and older who fell were not transported to an emergency department, trauma center, or other facility. That's a higher percentage than among patients in the same age group who are seen by EMS personnel for no-fall events (10.9% not transported). Most of those who were not transported after a fall—57%—were not transported because they refused care.

    Sex and age seem to be related to transport rates.
    Women were 30% more like to be transported than men overall, and among both sexes, individuals 85 and older were 14% more likely to be transported than patients 65-84.

    Falls in facilities are more likely to result in transport.
    Researchers found that people who fell in institutional settings such as nursing homes were 3.5 times more likely to be transported. "Nursing home residents are older and frailer than community-dwelling older adults," authors write. "As such, they are at much greater risk of falling and more likely to suffer a serious injury, such as a fracture or head injury." Falls in "business locations" such as stores or restaurants were the settings least likely to result in a transport.

    Geography seems to matter—a bit.
    Beyond the home vs facility vs business setting, transport rates also varied according to what researchers describe as the "scene location"—that is, the geographic location of the call. Falls in rural areas were 1.15 times more likely to result in a transport, followed by falls in "wilderness environments." Falls in suburban areas resulted in slightly below-average transport rates, and urban areas fell in line with the average rate.

    Training of the emergency medical technician (EMT) comes into play, too.
    Researchers found that compared with EMT-Basic providers, EMT-Intermediates were less likely to transport patients. Nurse providers were most likely—about 1.47 times the average.

    Authors of the study write that the patients who are not transported—20% of all calls—represent a significant opportunity for education on falls prevention.

    "Many older adults do not want to be identified as a person who is likely to fall, because they fear losing their ability to live independently and remain in their own home," authors write. "When an EMS call for a fall does not require transport, the older adult may be more receptive to information about steps they can take to reduce their chances of falling again by eliminating home hazards or undertaking a strengthening and balance training program."

    APTA offers multiple falls prevention-related resources, such as how to develop consumer events on balance, falls, and exercise, and information on evidence-based falls programs. Members can also access an APTA pocket guide on falls risk reduction (.pdf) and a clinical summary on falls available through PTNow.

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

    The Good Stuff: Members and the Profession in Local News, February 2016

    "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!

    Daniel Dale, PT, DPT, plays a central role in the rehabilitation of severely injured Georgia Bulldogs wide receiver Devon Gales. (Fox 5, Atlanta)

    "I discovered that physical therapy would make all the difference between a failed replacement and a totally successful one." – Reporter Doris Welle on her recovery from TKA (Dickinson County, Iowa, News)

    Juliana Ament, PT, DPT, MOMT, OCS, on the growth of dry needling in Fairbanks, Alaska. (Fairbanks, Alaska, Newsminer)

    Dayton Children's Hospital offers kids martial arts training as part of their physical therapy. (ABC 22 Now, Dayton, Ohio)

    Ryan DeWitt, PT, MPT, CSCS, CES, OCS, and Ron Kaminski, PT, ATC, talk about overuse injuries. (San Jose, California, Mercury-News)

    PT Students from Central Michigan University help give race a "family feel." (MLive.com)

    Nancy Byl, PT, MPH, PhD, FAPTA, comments on how new lower-cost, lightweight robotics are changing the world of assistive robotics. (Sacramento Bee)

    Stephen Rapposelli, PT, OCS, provides a PT's top 10 tips for safe snow shoveling. (Delaware Online)

    "[Urogynecologist Linda] Kiley says physical therapy is normally 80 percent effective in helping women overcome the problem and lead healthy lives." – "Breaking the Stigma of Pelvic Health Issues Among Women" (CBS 12, West Palm Beach, Florida)

    Dan DeLozier, PT, DPT, ATC, PES, featured as an example of a "kicka** cycling-specific physical therapist" (Bicycling.com)

    Lynn Steenberg, PT, offers tips on leadership that creates growth opportunities. (Syracuse.com)

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

    CMS Announces New Approach to Manual Medical Reviews

    To the surprise of APTA and other organizations that were expecting to get more information and provide input on the plan, the US Centers for Medicare and Medicaid Services (CMS) has moved ahead with a system for manual medical reviews for physical therapy and other services that exceed the therapy cap.

    Last week, CMS announced that it has contracted with Strategic Health Solutions to serve as a supplemental medical review contractor (SMRC) to conduct a "targeted review process" for claims that exceed the $3,700 cap for physical therapy and speech-language pathology combined, and $3,700 for occupational therapy services. Unlike previous years, in which reviews were conducted for all claims exceeding the thresholds, the new approach allows Strategic Health to select only certain claims for review.

    According to CMS, Strategic Health will pay particular attention to 2 main areas: providers with "a high percentage" of patients receiving therapy beyond the thresholds compared with peers; and "therapy provided in skilled nursing facilities, therapists in private practice, and outpatient physical therapy or speech-language pathology providers … or other rehabilitation providers." CMS writes that an evaluation of the number of units or hours of therapy provided in a day will be "of particular interest."

    The new approach is required as part of changes adopted in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

    The announcement was made with little warning from CMS, and was apparently developed without input of any stakeholders, including APTA, which made numerous requests to meet with CMS on the subject. The association has requested more information on the new process, and will provide members with details as they become available.

    Study: Return-to-Play Predictions for Hamstring Injuries Hamstrung by Variability

    Think you can predict how long it will take an athlete with a hamstring injury to return to play based on the athlete's history and an initial clinical examination? Some researchers say you probably can't—and magnetic resonance imaging (MRI) probably won't help.

    In a study published in the British Journal of Sports Medicine(pdf) researchers followed the progress of 180 male athletes with acute hamstring injury in an effort to analyze the predictive value of patient history and initial clinical examination, as well as any additional insight added by MRI. All of the athletes participated in a supervised physical therapy program, and were cleared for return to sport by either a physician or a physical therapist (PT).

    Using a more in-depth statistical analysis than in previous studies, the investigators calculated that patient history and clinical examination explained only 29% of the total variance in time to return to sport among the participants. Adding MRI increased that variance by just 2.8%—for a total of 31.8%.

    Based on their findings, the authors write, “Clinicians cannot provide an accurate time to return to sport” based on patient history, initial examination, or MRI. However, they add, “this is not a call to abandon MRI in clinical practice,” a resource that could be valuable for confirming the diagnosis and informing patients about their injuries.

    The initial examination included pain experienced during range-of-motion testing, manual muscle testing, the active slump test, and measuring length and width of the injury through tenderness to palpation. The variables that were correlated with length of time before return to sport included pain score at the time of injury, being forced to stop within 5 minutes of the onset of pain, painful resisted knee flexion, and length of injury.

    One of the limitations of the study is that the criteria for determining return to sport were determined by the individual physicians and PTs. But, the investigators note, while scientifically not optimal, this may better reflect the reality of patient care.

    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.

    Obama Budget, APTA Comments to Congress Converge on Elimination of Self-Referral Loophole

    For the fourth year in a row, the federal budget plan announced by President Barack Obama proposes that the so-called Stark law be tightened up to eliminate exceptions that allow physicians to self-refer for certain services, including physical therapy. And should Congress need an additional reminder of the importance of this change, it need look no further than APTA, which recently supplied Senate and House committees with comments outlining exactly why the loopholes should be closed.

    The $4.1 trillion FY 2017 budget plan is unlikely to be enacted by Congress, where Republican leaders have stated that they would break with tradition and not hold a hearing on the budget with the administration's budget chief. Still, Obama's budget has helped to emphasize issues that the administration believes are worth attention—and action.

    According to administration budget estimates, elimination of exceptions to the prohibition on referral to in-office ancillary services (IOAS) in Medicare would result in $4.98 billion in savings over 10 years. The current IOAS exception allows for self-referral for physical therapy, anatomic pathology, advanced diagnostic imaging, and radiation therapy.

    As in past years, the Obama proposal around IOAS was applauded by the Alliance for Integrity in Medicare (AIM) a coalition of organizations, including APTA, that has been advocating for removal of physical therapy and other services from the exception.

    "Since fee-for-service continues … the financial incentive remains for clinicians to exploit the IOAS exception[s]," AIM writes in a news release on the budget. "Alternative payment models … will not be successful if arrangements that allow overutilization continue to be incentivized in the Medicare program."

    Obama's emphasis on elimination of the IOAS exception was recently echoed by APTA, which supplied comments to the Senate Finance and House Ways and Means committees.

    In those comments, APTA writes that "care furnished under the IOAS exception is often degraded, raising serious quality concerns" and that legislators should support the "original intent of the IOAS exception," which was centered on same-day services.

    "This reform is in the best interests of taxpayers, patients, and the American health care system overall," APTA writes.

    Elimination of the IOAS exceptions remains one of APTA's public policy priorities, and has gained support from the American Association of Retired Persons (AARP), which announced its position against the exceptions late in 2014.

    APTA Names Physical Therapy Outcomes Registry Scientific Advisory Panel

    A game-changer in the physical therapy profession's efforts to document outcomes now has its scientific leadership in place.

    APTA recently announced the members of the Scientific Advisory Panel (SAP) to the Physical Therapy Outcomes Registry (Registry), the major APTA initiative to create the most comprehensive database of physical therapy outcomes in the country.

    The panelists include: James Irrgang, PT, PhD, ATC, FAPTA (Director); Kristin Archer, PT, DPT, PhD; Linda Arslanian, PT, DPT, MS; Janet Freburger, PT, PhD; Christopher Hoekstra, PT, DPT, OCS, FAAOMPT; Stephen Hunter, PT, DPT, OCS; Michael Johnson, PT, PhD, OCS; Christine McDonough, PT, PhD; and Linda Woodhouse, PT, PhD.

    The SAP will provide direction for the Registry on scientific integrity, clinical application, quality, public policy, and research.

    “The Scientific Advisory Panel represents excellence and a wide range of expertise — research scientists, front-line clinicians and managers, and administrators from the physical therapy business community,” said APTA President Sharon Dunn, PT, PhD, OCS in a news release.

    As one of the association’s top strategic priorities, the Registry will use the data contributed to show how physical therapy can transform the lives of patients through positive outcomes. Physical therapy practices and facilities can also use the Registry to benchmark their performance and justify services to payers, as well as meet quality reporting requirements.

    Data from the Registry is published in the Logical Observation Identifiers Names and Codes (LOINC) database, a worldwide universal coding system that provides standardized codes and names for more than 73,000 data elements.

    Why is the Registry such a big deal? Check out "The Physical Therapy Outcomes Registry Is Totally Into You," part of last year's "Transformation" series to learn more.

    Article Looks at Stem Cell Clinic Debate

    As the prominence of stem cell clinics has increased, so has attention from the US Food and Drug Administration (FDA)—along with more public debate on whether the techniques are useful interventions or a new form of "quackery."

    In a recent article in STAT, an online health care and science magazine, reporter Usha Lee McFarling looks at the arguments for and against therapies that involve injecting stem cells processed from the patient into an injured area. Proponents say it speeds healing and can help patients avoid surgery, while detractors question its effectiveness and legality.

    According to the STAT article, "federal regulators are preparing to crack down on scores of clinics" that perform the therapies, based in part on new FDA guidelines (.pdf) that define the stem cells used in most clinics as drugs that require "a rigorous approval process."

    The article includes interviews with critics who describe the stem cell approach as a "huge unproven human experiment," as well as with providers who perform the therapies and claim that the injections are not drugs but "simple outpatient surgeries that should not be regulated."

    This isn't the first time the rise of stem cell clinics has gained wider media attention: in September 2015, USA Today focused on the topic in a feature article. The topic of regenerative medicine in general, and the physical therapist's relationship to it, will also be the subject of a cover story in the March issue of APTA’s PT in Motion magazine.

    Rehab Research Bill Passes Major Hurdle in Senate

    APTA's efforts to support improvements in rehabilitation research just received a major boost by way of a US Senate Committee, which has completed the "markup" phase of a bill that would bolster research efforts at the National Institutes of Health (NIH).

    Next stop: the Senate floor.

    Titled the "Enhancing the Stature and Visibility of Medical Rehabilitation Research at NIH Act," (S. 800), the bill passed through markup by the Senate Committee on Health, Education, Labor, and Pensions (HELP) with only minor changes. The Disability Rehabilitation and Research Coalition (DRRC) worked with NIH and the office of Sen Mark Kirk (R-IL), the bill's sponsor, to develop the necessary compromises. APTA is on the steering committee of DRRC, which is composed of over 40 organizations committed to promoting rehabilitation research.

    If signed into law, the bill would help better coordinate rehabilitation research across all institutes at NIH in several ways, including statutorily defining medical rehabilitation research to ensure continuity in the use of the word, and standardizing reporting mechanisms to enhance the coordination of research.

    The bill is based in part on recommendations from an NIH blue ribbon panel that was co-chaired by Rebecca Craik, PT, PhD, with members that included Anthony Delitto, PT, PhD, and Alan M. Jette, PT, PhD. The panel's recommendations, issued in 2013, were supported by APTA, with then-APTA President Paul A. Rockar Jr, PT, DPT, MS, characterizing the findings as ones that reflect APTA's "core principles," and are "critical to meeting the NIH's mission and impacting society in a positive manner."

    The bill will join a package of Senate legislation that serves as a companion of the 21st Century Cures legislation (H.R. 6) on the House side that passed last year.

    Improvements to rehabilitation research and support of NIH work in this area are among APTA's public policy priorities.

    Jimmo Message Hasn't Sunk In; CMS Needs to Do More

    When theJimmo v Sebelius settlement was announced in 2013, patient advocates applauded what they saw as a landmark change for individuals who need care to maintain their medical conditions or slow their declining health. However, 3 years later, many providers and payment adjudicators are still making coverage decisions as if they're living in a pre-Jimmo world—mostly because the US Centers for Medicare and Medicaid Services (CMS) hasn't done enough to bring them up to speed, according to an advocacy group supported by APTA.

    Recently, APTA provided a supporting declaration to the Center for Medicare Advocacy's (CMA) efforts to get CMS to do a better job of making it clear that the "Improvement Standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy, and that skilled maintenance care can qualify for payment.

    "There are still many providers and contractors who do not know about, understand, or trust the change in the improvement policy," CMA wrote in a December 2015 letter to APTA and other stakeholders. "We believe this is largely due to the fact that CMS' Education Campaign was insufficient to make up for the rigor with which Medicare enforced the Improvement Standard—for decades." According to CMA, CMS conducted only 1 briefing for providers and adjudicators, in early December of 2013. Since that time, CMS "has refused to do more," CMA writes.

    APTA agreed with CMA's take on the situation and submitted a declaration of support, writing that the information provided by CMS is "introductory in nature and [has] not been sufficient in educating our members."

    "Approximately 2 years after the CMS National Education Campaign, APTA is still receiving inquiries from physical therapists regarding the coverage of skilled maintenance therapy under Medicare," APTA writes. "We have found that many providers have not received any information regarding the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit." The association suggests posting answers to frequently asked questions, sharing information briefs on what to do in case of denials, hosting national calls, and sponsoring regional town halls.

    Patients and physical therapists do have recourse: CMA has created a "self-help packet" for appealing denials of outpatient therapy that may have been made based on a pre-Jimmo understanding of payment policy. The webpage featuring the packet also contains background information on Medicare coverage and the "improvement myth," therapy cap exceptions, and appeals processes.

    APTA engaged in an extensive effort to educate its members on the Jimmo settlement, and maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.

    Botox Approved for Lower Limb Spasticity

    Six years after gaining FDA approval for the treatment of upper limb spasticity, onabotulinumtoxinA—commonly known as Botox—has now been OK'ed for the same use in lower limbs.

    According to Medscape (free sign-in required) the FDA approval was based on a clinical trial of more than 400 individuals who were experiencing lower limb spasticity poststroke. Participants treated with Botox showed statistically significant improvements at weeks 4 and 6 in muscle tone and clinical patient benefit.

    The trials were focused on the ankle and toes, and didn’t confirm use in other areas of the lower extremities.

    In 2010, FDA approved the use of Botox for upper limb spasticity, but effectiveness was only confirmed for the elbow, wrist, and fingers. Five years later, effectiveness was confirmed for use in 2 thumb muscles.

    Zika Outbreak a 'Public Health Emergency,' Could be Linked to Guillain-Barré, Other Disorders

    The Zika outbreak has been elevated to a "public health emergency of international concern" by the World Health Organization (WHO) while health officials scramble to understand the disease, including its possible relationship to Guillain-Barré Syndrome (GBS) and other disorders that affect the nervous system.

    As of January 30, 26 countries had reported locally transmitted Zika infections across Central America, South America, the Caribbean, and the Pacific Islands. The list of countries treating these infections continues to grow. Travel-related cases have been identified in the continental United States. Puerto Rico, American Samoa, and the US Virgin Islands already are experiencing ongoing transmission of the virus.

    The new status from WHO may help affected countries better respond to the virus through stepped up research, surveillance, care, and follow-up.

    The virus largely has been transmitted via mosquito bites, but a US Centers for Disease Control and Prevention (CDC) report notes that infections have occurred through mother-to-fetus transmission, sexual transmission, blood transfusion, and lab exposure. This week, the first human-to-human transmission of the virus within US borders was reported in Texas, where a woman contracted the disease through sexual contact with her husband.

    Signs of Zika infection include fever, skin rash, conjunctivitis, muscle and joint pain, malaise, and headache, but health officials are also concerned about the infection's possible relationship to disorders of the nervous system. In addition to a rise in microcephaly recorded in Brazil since October 2015, both Brazil and El Salvador have observed a dramatic increase in cases of GBS coinciding with the 2015 Zika outbreak.

    In a January 18 statement, the Pan American Health Organization (PAHO) recommended that “countries in the Americas prepare their healthcare facilities to respond to a potential increase in demand for specialized care for neurological syndromes.”

    WHO does not recommend a travel ban to infected countries, and while health officials anticipate clusters of outbreaks in the United States due to infected travelers, CDC says that widespread transmission “appears to be unlikely.” The CDC has issued a set of travel tips for anyone visiting areas affected by the Zika outbreak.

    The CDC asks providers to report any suspected cases to their state health department to enable laboratory diagnostic testing and avoid further transmission.

    White House Proposes $1.1 Billion to Reduce Opioid Abuse

    In a proposal aimed in part at building on an initiative that includes APTA, President Barack Obama has designated $1.1 billion in new funding over 2 years to intensify the fight against the country's opioid use and heroin abuse epidemic.

    According to a White House fact sheet, Obama's proposal takes a "2-pronged approach" to address the drug problem: $1 billion in new mandatory funding for expanding treatment for individuals with an opioid use disorder, and $500 million to increase prescription drug overdose prevention strategies, including more funding for medication-assisted treatment. Some of the funds will be directed specifically to rural areas of the country, which have seen disproportionately high levels of abuse and overdose.

    The proposal, which requires congressional approval, further intensifies the administration's focus on the opioid abuse epidemic. That focus received national attention in October 2015, when Obama announced the creation of a public- private partnership to combat opioid abuse and heroin use. APTA is participating in the initiative along with 39 other health care provider groups that include the American Medical Association, the American Academy of Family Physicians, and the American Nurses Association.

    APTA has long advocated for the role of the physical therapist (PT) in pain management, using its MoveForwardPT.com website to educate the public, and featuring new approaches to pain treatment being used by PTs in a 2014 feature story in PT in Motion magazine. More recently, the August 2015 issue of Physical Therapy (PTJ), APTA's peer-reviewed journal, included a discussion of how to interpret the burgeoning effectiveness evidence from recent clinical trials and systematic reviews on pain treatment.

    APTA Adds Physical Therapy Perspective to Senate Work Group Report on Chronic Health Conditions

    The challenges of providing care to individuals with chronic health conditions are now the focus of a bipartisan working group in the US Senate, and APTA is helping to shape the group's policy proposals.

    In December 2015, the Senate Finance Committee's Bipartisan Chronic Care Working Group issued a 30-page "policy options document," the product of a 6-month investigation of possible ways to improve care delivered to Medicare beneficiaries with chronic health conditions. The information-gathering process included over 80 stakeholder meetings and 530 recommendations, with the final document including 24 policy proposals ranging from the changes to the Medicare Advantage (MA) program to expanded education and research initiatives.

    According to the work group, the policy changes listed in the document are aimed at increasing care coordination, streamlining Medicare payment systems "to incentivize the appropriate level of care," and establishing a chronic care system that "facilitates the delivery of high quality care, improves care transitions, produces stronger patient outcomes, increases program efficiency, and contributes to an overall effort that will reduce the growth in Medicare spending."

    On the whole, APTA's comments to the proposals were supportive, with the association focusing on 12 proposals that would most directly affect physical therapy. Among them:

    Expansion of the Independence at Home demonstration project into a "permanent, nationwide program." APTA supported the idea, but advocated for a careful approach.

    Continued access to MA special needs plans. APTA asserted that "all plans have access to physical therapy services."

    Provisions that would allow MA plans to vary benefit structures to meet the needs of chronically ill enrollees. APTA supported this idea, but called for care in the definition of "non clinical" professionals.

    Telehealth provisions that would expand opportunities for use in MA, accountable care organizations (ACOs), and for beneficiaries poststroke (3 separate policy proposals). APTA supported all 3 proposals, particularly in relation to physical therapy, writing that "telehealth will not replace traditional client care, but it will give [physical therapists] and [physical therapist assistants] the flexibility to provide services in a greater capacity."

    Ensuring accurate payment for individuals who are chronically ill. APTA wrote that it was "generally supportive" of the proposal, but suggested that to truly achieve a more effective payment system, additional regulatory changes need to happen—including a full repeal of the Medicare therapy cap.

    The association also commented on proposals to increase care coordination among ACOs, the development of quality measures for chronic conditions, and a suggestion to increase transparency at the CMS Center for Medicare and Medicaid Innovation (CMMI), a center that should create more grant funding opportunities "aimed at providers such as physical therapists," according to APTA.

    APTA highlights the role of the physical therapist and physical therapist assistant in the treatment of chronic conditions through its prevention, wellness, and disease management webpage. In addition, the 2015 House of Delegates adopted the position Health Priorities for Populations and Individuals (RC 11-15) "to guide [APTA's] work in the areas of prevention, wellness, fitness, health promotion, and management of disease and disability." The priorities include active living, injury prevention, and secondary prevention in chronic disease and disability management. The topic was also the subject of a popular presentation at the 2015 NEXT Conference and Exposition.

    Also available from the APTA Learning Center: "Disease Management Models for Physical Therapists: Focus on Diabetes and Cardiovascular Disease."

    CMS Looks at Cultural Components of Hospital Readmission Rates

    It's established fact that minorities and other vulnerable populations face a higher risk of hospital readmissions for conditions such as chronic heart failure or procedures such as total knee or hip arthroplasty. But that could change if hospitals and other health care providers started to comprehensively address the matrix of cultural, economic, and comorbidity issues faced by racially and ethnically diverse patients, according to a new publication from the US Centers for Medicare and Medicaid Services (CMS).

    "While not all readmissions are entirely preventable, it is widely understood that a portion of unplanned readmissions could be avoided by addressing a series of barriers patients face prior to, during, and after admission and discharge," write authors of a recently release CMS guideline. The publication, titled "Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries," lays out key issues related to the higher readmission rates, and accompanies those issues with a set of ambitious strategies for reducing those rates.

    The issues that contribute to higher readmission rates among racially and ethnically diverse patients, as identified by CMS, include lower rates of follow-up after discharge, fewer linkages to primary care providers, limited English proficiency in certain cases, degree of health literacy, cultural beliefs or customs that may influence health behaviors, socioeconomic barriers to resources, higher rates of anxiety and depression, and the effect of comorbidities.

    The strategies suggested by CMS for addressing these disparities are wide-ranging, and depend in large part on increased levels of interdisciplinary collaboration, greater attention to patient education, and stronger connections with communities and resources outside the health care facility.

    According to the guide, any effort to close the readmission gap must include strong patient data collection efforts to better understand the particular barriers each individual faces; readmission reduction strategies that begin even before admission; and the creation of true multidisciplinary, culturally competent teams to help coordinate care and educate the patient. Additionally, the CMS guide encourages the creation of better partnerships throughout the community "to ensure that the next care provider is aware of the patient's status and care information, and to direct at-risk patients to needed care following hospitalizations."

    "CMS has an important opportunity and a critical role in preventing hospital readmissions while promoting health equity among diverse Medicare beneficiaries," said Cara James, director of CMS’s Office of Minority Health in a CMS news release. "This guide encourages action-oriented steps and solutions in achieving health equity, addresses reducing readmissions and focuses on our initiative of achieving better care, smarter spending, and healthier people throughout our health care system."

    The guide also includes 3 case studies that CMS believes demonstrate efforts to reduce the readmission gap: a "re-engineered" discharge process; a system that incorporates telehealth into home health; and a "health connections" program that identified area "hot spots" of "super utilizers" and then delivered education and other programs to that population.

    APTA highlights cultural competence as a crucial part of evidence-based practice on its Cultural Competence in Physical Therapy webpage, and offers additional online resources on the ways racial and ethnic disparities affect health care.racial and ethnic disparities affect health care.

    Learn about how physical therapy can affect readmissions: check out "The Value of Physical Therapy in Reducing Avoidable Hospital Readmissions," offered through the APTA Learning Center, and “There's No Place Like Home: Reducing Hospital Readmission Rates,” a feature article in the November 2015 PT in Motion magazine.