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  • Study: As Youth Sports Intensity Grows, So Does Prevalence of Little League Shoulder

    Authors of new study say that Little League shoulder (LLS) is an underresearched condition—something that needs to change soon, because prevalence is up as more, and more intense, youth sports programs continue to proliferate.

    For the study, published in the American Journal of Sports Medicine (abstract only available for free), researchers looked at Boston Children's Hospital treatment records of 95 8- 16-year-olds diagnosed with LLS between 1999 and 2013. Although the numbers aren't large, authors claim that it's an improvement over what had been "the most instructive previous study to date," which only investigated 23 patients.

    To qualify for the study, patients had to have a diagnosis of LLS, also known as proximal humeral epiphysiolysis, with an open physis. Patients were further divided into groups with and without glenohumeral internal rotation deficits (GIRD). In addition to noting overall prevalence, researchers tracked demographics, treatment duration, recurrence rates, and possible risk factors associated with GIRD.

    The mean age of the patients in the study was 13.1 years, with 50% of all participants either 12 or 13 years old. The patient population was 98% male, and 97% of all patients were baseball players (3 patients were tennis players). Of the baseball players, 79 were pitchers, 7 were catchers, and the remaining 6 played other positions. The 2 females in the study—ages 10 and 11—were both baseball pitchers.

    Among the findings:

    • The incidence of LLS increased by an average of 8% per year, a rate of increase that was larger than growth in overall departmental and divisional patient volume.
    • Among all patients, 12 (13%) reported concurrent elbow pain, with 6 diagnosed with medial epicondyle apophysitis ("Little League elbow").
    • GIRD was diagnosed in 28 patients (30%), though authors feel prevalence may be underrepresented in their study. Ultimately they found that patients with previously-diagnosed GIRD were at higher risk for LLS, but the difference was deemed insignificant.
    • Cessation of throwing was part of the treatment recommendation for 94 of the 95 patients in the study, with an average 4.2-month resting period prescribed.
    • Physical therapy was provided to 75 patients (79%) at some point during treatment, with all GIRD patients receiving physical therapy.
    • Though 33% of patients were lost to follow-up, among the patients with adequate follow-up information, it took an average of 2.6 months to achieve resolution of symptoms, with an average return-to-play time of 4.2 months.
    • Authors believe that the clustering of LLS at ages 12 and 13 isn't surprising, as it's around that age that players move to a larger diamond that requires longer throwing distances.

    "The current study demonstrated increasing numbers of cases over the study period … which speaks to the pressing need for improved evidence in response to the evolving epidemiology of the condition," authors write.

    Authors also believe that the presence of concomitant elbow pain in 13% of the patients points to problems with how—or how often—children are throwing. "Impressively, this suggests that some young pitchers are throwing with such excessive force and/or frequency or with such poor throwing mechanics that 2 of their upper extremity joints are developing overuse injuries," they write.

    Moving forward, authors call for more research—and more care of youth sports participants.

    "As GIRD and symptom recurrence may occur in patients with LLS more than previously believed, consideration should be given toward close monitoring of patients for at least 1 year after initiation of treatment," authors write. "Current guidelines regarding pitch counts, rest, and activity modification in the setting of shoulder/arm pain should continue to be emphasized."

    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.

    #PTTransforms (The Blog) Has Arrived

    Add 1 part hot physical therapy topic to 1 part APTA author. Mix well. What do you get?

    We're about to find out.

    This week, APTA launches the #PTTransforms blog, a new offering that will feature a range of association voices sharing their perspectives on some of the biggest topics shaping—and re-shaping—physical therapy. These quick takes are designed to get you thinking, get you talking, and maybe even get you more involved in the transformations taking place in nearly every corner of the profession.

    The debut installment is a 2-for-1: APTA President Sharon L. Dunn, PT, PhD, OCS, on impending payment reform and the "road less traveled," followed by James Irrgang, PT, PhD, ATC, FAPTA, chair of the APTA Physical Therapy Outcomes Registry Scientific Advisory Panel, on why the profession must waste no time in building its outcomes data.

    Read, think, comment, repeat.

    CJR Bundle Webpage Now Includes Free Download of Sold-Out Webinar

    As part of an enhanced collection of APTA resources on the Comprehensive Care for Joint Replacement (CJR) bundled care model, the association's sold-out webinar on the system is now available as a free download for members.

    The APTA CJR webpage contains extensive information on both the nuts-and-bolts of the program, and the considerations PTs should weigh when making practice decisions. The online resource also includes links to evidence-based clinical information and community programs.

    In the webinar available at the webpage, APTA staff presenters Roshunda Drummond Dye, JD, and Heather Smith, PT, MPH explain the model, how it will impact physical therapist (PT) practice, and the factors that could influence a PT's decision to become a collaborator in a bundled care program. The 90-minute program is also aimed at helping participants understand the changes in practice operations that will need to be made, and highlighting some of the APTA resources on the CJR.

    The new recording and updated resources arrive just in time for the April 1 debut of the first-ever mandatory bundled care program created by the Centers for Medicare and Medicaid Services (CMS). The program will require hospitals in 67 metropolitan areas to participate in bundled payment systems for Medicare patients undergoing total knee and total hip replacements. Physical therapists (PTs) may choose to collaborate with a facility in the program.

    Obama Says Change in Pain Treatment Must be Part of Fight Against Opioid, Heroin Addiction

    Recently released US Centers for Disease Control and Prevention (CDC) prescription guidelines supporting nondrug, nonopioid treatments for chronic pain are among the resources that could help physicians and drug companies be held "more accountable" in the battle against opioid abuse and heroin use, according to President Barack Obama.

    Obama made the comments during a meeting of the National Rx Drug Abuse and Heroin Summit held in Atlanta on March 29. The event, moderated by physician and media figure Sanjay Gupta, featured a panel of former addicts, physicians, and public health experts, and was aimed in part at highlighting White House efforts to gain support for an additional $1.1 billion requested this year to fight the abuse epidemic.

    The conversation at the summit touched on the need for more and better-funded addiction treatment resources, reduced restrictions on the use of buprenorphine to treat opioid addiction, and an overall shift toward the view of addiction as a treatment problem rather than a law enforcement issue. But the discussion also addressed the ways in which the medical community has approached the treatment of pain through the use of opioids, and how that approach needs to change.

    "It seemed like for a period of time … that pain relief was talked about only in the context of giving out drugs," Gupta said. "The CDC has released some of these new guidelines regarding opioid prescriptions … pretty plainly stated … saying that these opiates should not be a first-line treatment for chronic pain. And that’s not the way the medical culture has thought about this for some time."

    Obama agreed with Gupta's comments, as well as comments from Leana Wen, MD, Baltimore's commissioner of health, who said that physicians aren't trying to create addicts but do need resources, "whether they are the guidelines as issued by the CDC, or whether they are other efforts by our medical societies to assist us, to make better decisions for our patients."

    "And so the doctor is right," Obama said in response to Wen. "We have to have a chance in the medical profession and the drug companies, and we have to hold them more accountable. We, as consumers and as parents have to be more accountable, as well, in terms of how we approach keeping our families well, in order for us to be able to prevent this massive gateway into addiction that can cause real problems."

    In addition to requests for increased funding, the Obama administration's efforts to fight addiction include an initiative involving public and private entities engaged in educating their constituents and the public. APTA is among the participants in that initiative, and recently attended a working group meeting to discuss the CDC guidelines.

    First Innovation 2.0 Learning Lab Coming April 21

    Are you ready for a payment model based on performance and improved outcomes? More important—are you doing something new yourself, or about to take on a different approach? Set aside a little time later in April to take a deeper dive into innovative ways of delivering care.

    Coming April 21, 2:00 pm-5:00 pm ET: the first of 4 APTA Innovation 2.0 Learning Labs, an opportunity for members to hear firsthand from the physical therapist innovators who were selected to pursue new, creative models of care through APTA's Innovation 2.0 program. The inaugural online lab will focus on a pay-for-quality program for treatment of patients with LBP.

    The project, conducted through Intermountain Healthcare in Salt Lake City, Utah, and led by Gerard P. Brennan, PT, PhD, and Stephen Hunter, PT, DPT, OCS, focuses on low back pain treatment as the basis for a comprehensive incentive program that doesn't just tally outcomes, but looks at what prevents some patients from progressing. Among other components of the program, Brennan and colleagues intend to develop a "severity adjustment formula" that could predict when a patient has a low chance of achieving a minimally clinically important difference from physical therapy—before physical therapy begins.

    The Learning Lab is a free online event intended as an advanced experience for providers who are currently active in innovative programs or ready to explore them. Because the event has limited seating, members interested in participating are required to answer a series of questions on the registration form to help APTA select participants who can gain—and later share with others—the most benefit from the lab. To register, visit the Innovation 2.0 webpage and scroll to the "Learning Lab" section.

    Registered participants will receive a template that will help them replicate the model presented in the lab. APTA will post a free recording of the event afterwards.

    Visit the Innovation 2.0 background page for details on all of the projects selected for development, as well as projects that received honorable recognition. Profiles of each project were also featured in a 2015 article in PT in Motion magazine.

    New Round of HIPAA Audits Will Include Business Associates

    Get ready for a new round of Health Insurance Portability and Accountability Act (HIPAA) audits—and this time, they're going to be even broader in scope to include not just providers and other entities, but also the "business associates" that handle patient data. And just like the first phase of audits completed in 2012, the process includes onsite visits.

    The new round of audits, conducted by the Department of Health and Human Services' (HHS) Office of Civil Rights (OCR), is aimed at a "wide range of health care providers, health plans, health care clearinghouses, and business associates," according to information from HHS. The audits will not include entities currently under investigation or under compliance review.

    The audit process will begin with entity desk audits, conducted electronically, followed by a second round of desk audits of that entity's business associates. OCR hopes to complete this phase of the process by the end of December 2016.

    After that, OCR will shift to onsite audits intended to cover "a broader scope of requirements from the HIPAA Rules than desk audits." Afterwards, auditors will provide draft findings to the entities with the opportunity to respond. Those responses will be included in a final report.

    HHS describes the audits as "primarily a compliance improvement activity" after which aggregated results will allow OCR to "better understand compliance efforts with particular aspects of the HIPAA Rules." Still, HHS says, "should an audit report indicate a serious compliance issue, OCR may initiate a compliance review to further investigate."

    The latest audit is the second phase of a review program required by the 2009 American Recovery and Reinvestment Act, which also increased HIPAA security requirements and stipulated that a HIPAA-covered entity's business associates—companies that process, analyze, or handle data—are also subject to HIPAA rules. The first phase ended in 2012. OCR has already begun emailing providers and other entities about the startup of phase 2.

    APTA offers a HIPAA webpage with resources to help physical therapists and physical therapist assistants understand the requirements. In addition, HHS has published a helpful guide to security of health information, and recently posted an announcement about the newest round of audits, including a list of frequently asked questions.

    Think you know your HIPAA? Take this quick 5-question quiz.

    CMS Will Test Payment Increases to Selected SNFs

    In its continuing search for ways to reduce avoidable hospitalizations among skilled nursing facility (SNF) patients, the Centers for Medicare and Medicaid Services (CMS) will test a new payment system that would increase some payments and reward multidisciplinary care planning.

    The test, set to launch in the fall of 2016, would increase payments to physicians conducting a comprehensive assessment in an SNF to the same amount they receive for providing the assessment in a hospital, according to a CMS news release. The new model would also provide new payments to practitioners "for engagement in multidisciplinary care planning activities," and for treatment of 6 conditions that CMS says are linked to 80% of avoidable hospital admissions: pneumonia, dehydration, congestive heart failure, urinary tract infections, skin ulcers, and asthma.

    CMS plans to select approximately 250 SNFs to participate in the model, which will apply to both Medicare and Medicaid beneficiaries.

    The test system will be coordinated through Enhanced Care and Coordination Providers (ECCPs), CMS-funded groups that have been working with the agency since 2012 to reduce avoidable hospitalizations for SNF patients. A total of 7 ECCPs have been collaborating with SNFs to provide training and preventive services; now 6 of those 7 will serve as hubs for the new payment model.

    The 6 participating ECCPs are the Alabama Quality Assurance Foundation, HealthInsight of Nevada, Indiana University, the Curators of the University of Missouri, The Greater New York Hospital Foundation, and Pennsylvania-based UPMC Community Provider Services.

    Foundation Receives $100k Gift From Tri W-G

    One of the Foundation for Physical Therapy’s (Foundation) most supportive companies has once again stepped up for physical therapy research by presenting the Foundation with a gift of $100,000.

    The latest contribution from Tri W-G is in addition to donations of over $450,000 the company has made to the Foundation over the years, according to Foundation Board of Trustees President Barbara Connolly, PT, DPT, EdD, FAPTA. In accepting the most recent gift, Connolly remarked, "It is with the support and commitment of Partners like Tri W-G that the Foundation is able to continue funding physical therapy research and developing the next generation of researchers."

    Tri W-G has supported the Foundation for more than 30 years, and in 2008 was the first-ever recipient of the Foundation's Premier Partner in Research Award.

    "Tri W-G is proud to renew and grow its relationship with the Foundation," said Tri W-G Vice Present Duane Fast in a Foundation news release. "Our long-time investment in the Foundation not only highlights our commitment to research but also represents the role the physical therapy industry should play."

    Women Losing Ground in Disability-Free Life Expectancy

    While women live longer than men on average, more women than men experience activity limitations after age 65, says a recent study—reversing a 22-year trend in which disability prevalence was declining in women. Men, however, are now living and staying active for longer than before.

    The retrospective study, published in American Journal of Public Health and Practice (abstract only available for free) examined 30 years of interview data from the 1982 and 2004 National Long Term Care Survey, as well as the 2011 National Health and Aging Trends Study, to estimate mortality and disability rates. The 43,888 respondents represented “all settings, including institutions.” The authors categorized individuals as having "moderate disability," which they defined as a problem performing 1 or 2 personal care activities independently; or "severe disability"—inability to perform 3 or more personal care activities.

    What they found was that after 2 decades of decline from nearly 26% to just over 20%, the percentage of older women with any activity limitations began heading in the opposite direction starting in 2004, rising from 20.2% to 24.2% by 2011.

    As with women, disability rates among men also decreased over the course of the 22 years from 1982 to 2004, dropping from approximately 23.5% to about 16.5%. But unlike women, that's more or less where the rates stayed between 2004 and 2011, rising only slightly, to 16.6% by 2011.

    The numbers show a stark disparity between the sexes, and virtually erase earlier differences, authors note, writing that "the advantage over men in disability-free life expectancy that women experienced at age 65 in 1982 was no longer present in 2011."

    And the changes become even more dramatic later in life. Authors note that “At older ages, the improvement for men is even more marked: 43% of remaining years at age 85 years were expected to be active in 1982 compared with 60% in 2011. For women, the proportion of remaining years at age 85 years expected to be active was stable at about 35%.”

    Researchers didn't find any significant increase in severe disability rates among women, and attribute this “growing gap” to increases in less-severe disability, such as limitations in performing household chores or shopping for groceries. They advise directing public health interventions at older women to postpone disability as long as possible, in part “to offset impending long-term care pressures” associated with aging Baby Boomers.

    Maintaining physical activity and mobility throughout life is the focus of APTA's #AgeWell campaign, launched during National Physical Therapy Month in 2015. The association created several tools and resources to help members spread the word, including information for consumers at MoveForward.com on healthy aging by decade, and "9 Physical Therapist Tips to Help You #AgeWell." APTA also commissioned a survey on public perceptions of aging and activity, and shared the results in an infographic.

    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.

    VA Choice System Not Working, Say VA Officials, Legislators

    A program meant to fix a broken Veterans Affairs (VA) health system is itself broken, according to lawmakers working to overhaul the Veterans Choice program. Critics say that the program, intended to provide some veterans with the option to see a provider outside the VA system, has done little to help reduce wait times and gaps in care.

    According to reports in Stars and Stripes and the Military Times, legislators on the Senate Veterans Affairs Committee are working on an omnibus bill that would include reforms to Veterans Choice, a $10 billion program quickly assembled in 2014 in response to scandals at the VA involving lengthy waits for care—waits that some associated with the deaths of veterans.

    Veterans Choice was devised as a temporary program to allow veterans to receive medical care outside of the VA system under certain circumstances. Under the program, a veteran can work with a non-VA provider participating in the Choice system if the VA cannot schedule an appointment within 30 days of the veteran's preferred date, if the date has been deemed medically necessary by the veteran's provider, or if the veteran lives more than 40 miles from her or his closest VA medical facility.

    But the fix is in trouble. Stars and Stripes reports that David Shulkin, the undersecretary for health at the VA’s Veterans Health Administration, described the program as one that "has not worked." News outlets have picked up on the problems, first at the local level in places like North Carolina and Colorado, and more recently by way of a report on National Public Radio that recounted the months-long efforts of a veteran to schedule physical therapy and acupuncture treatments, only to have those treatments ended when the providers stopped participating in the Choice program due to slow reimbursements.

    Among the legislation considered at a March 15 Veterans Affairs Committee meeting were the "Improving Veterans Access to Care in the Community Act," introduced by Sen Jon Tester (D-MT), and Sen Richard Burr's (R-NC) "Veterans' Choice Improvement Act." Both bills would eliminate third-party administrators, with the VA coordinating care and providers billing the department directly. They also would require the VA to set reimbursement rates and pay providers within 30 days of electronic claim submission, and within 45 days for paper claims.

    Tester's bill specifically would mandate "the use of value-based reimbursement models" and establishment of a process for monitoring quality of care. Burr's bill would include "stringent requirements on reimbursement rates and a mandate that VA provide compensation to veterans within 90 days of determining that the former service member has a presumptive health condition," according to the Military Times.

    "Bottom line is the Choice program is broken," Tester is quoted as saying in the Stars and Stripes report. "We need to fix it and we need to fix it as soon as possible."

    Chronic LBP Correlated With 'Clustering' of Socioeconomic, Behavioral Factors

    While the disability and health care utilization burdens of chronic low back pain (cLBP) have been well-documented for some time, a new study finds that those burdens may fall unevenly, with poorer, less-educated, and less-healthy Americans most likely to experience the condition.

    Researchers analyzed demographic and health-related data from 5,103 Americans aged 20 to 69 years who participated in the National Health and Nutrition Examination Survey (NHANES) back pain questionnaire in the 2009-2010 survey cycle. Of those, 700 reported experiencing cLBP, which researchers defined as "current pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold at the time of the survey, with a history of pain lasting almost every day for 3 months."

    Authors of the study then cross-referenced individuals reporting cLBP with different demographic, health, and health care usage data to get a better picture of how factors like income and education correlate with the condition. The results, e-published ahead of print in Arthritis Care & Research (abstract only available for free), show what authors call a "clustering of behavioral, psychosocial, and medical issues." Among them:

    • Overall prevalence of cLPB was 13.1%, with adults between 50 and 69 years old 2 times more likely to experience the condition. Women were more likely to have cLPB, and Caucasian participants were 1.5 times more likely to report cLBP than African American or Hispanic respondents.
    • Adults with cLBP had generally received less education than those without cLBP—they were nearly 2 times less likely to have a college degree, and 2.2 times less likely to have a high school diploma or associate's degree.
    • The odds of unemployment were 1.79 times higher for the cLBP group. The cLBP group was also 2.2 times more likely to have an annual income of $20,000 or less.
    • The rate of income from disability was 12.8% in the cLPB group, compared with 4.6% among those without cLBP.
    • More than 1 in 3 adults with cLBP screened positive for depression; the rate was just over 1 in 5 among those without cLBP.
    • Adults with cLBP were 3.9 times more likely to have reported sleep disturbances than those without cLBP.
    • Nearly half (48%) of the cLBP group reported 3 or more comorbidities, compared with 17% of individuals without cLBP.

    In terms of health insurance and utilization, adults with cLBP were less likely to be covered by private insurance, and more likely to have Medicare (2.25 times) or Medicaid (3.23 times). They were also 1.9 times more likely to report an overnight hospitalization in the past year. When researchers analyzed health and demographic data among the adults with cLBP who reported 10 or more health care visits per year, they found increased likelihoods linked to unemployment, disability income, depression, and sleep disturbances.

    Authors cite several limitations to their study—including an absence of data on institutionalized adults and adults over 69 years of age—but argue that the nature of the NHANES survey makes their findings freer from bias than claims-based studies, and more likely to be accurate given NHANES' use of trained interviewers to administer the questionnaire.

    While authors also acknowledge that their findings don't establish causal links between various factors and cLBP, they assert that "the clustering of behavioral, psychosocial, and medical issues should be considered in the care and rehabilitation of Americans with cLBP."

    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.

    Extensive Overhaul of Pain Care Needed, According to HHS, NIH

    More indications that the US health care system soon could be looking at pain in a new way: just days after the release of national guidelines recommending nondrug and nonopioid approaches in the treatment of chronic pain, the US Department of Health and Human Services (HHS) unveiled a "National Pain Strategy" (NPS) that calls for extensive efforts to rethink the way pain is treated, improve access to that treatment, and strengthen research and education across health care disciplines.

    Development of the plan began in 2011, after an HHS-commissioned report from the National Institute of Health's Institute of Medicine called for nationwide improvements in data collection on pain and its treatment, evaluations of the availability and effectiveness of care, public and professional education on pain, and translational and clinical research. The NPS released March 18 attempts to serve as a roadmap for accomplishing those improvements.

    The strategy is organized around 6 areas:

    Population research. The NPS calls for more detailed information-gathering efforts to track data around prevalence of pain overall and specific types of pain, including information on the relationship between types of pain and various population groups over time.

    Prevention and care. The strategy encourages the development of a more comprehensive view on pain that includes better evidence on pain prevention, as well as assessment tools and outcome measures.

    Disparities. In recognition of the ways pain impacts vulnerable populations, the NPS urges more work around "increasing understanding of the impact of bias and supporting effective strategies to overcome it."

    Service delivery and payment. According to the NPS, "wide variations in clinical practice, inadequate tailoring of pain therapies to individuals, and reliance on relatively ineffective and potentially high-risk treatments such as inappropriate prescribing of opioid analgesics, or certain surgical interventions, not only contribute to poor quality care for people with pain, but also increase health care costs." The fix: an "integrated, multimodal, and interdisciplinary" approach—supported by payment systems that recognize the effectiveness of that approach.

    Professional education and training. The NPS calls for improvements to various health care disciplines' core competencies to include "basic knowledge, assessment, effective team-based care, empathy, and cultural competency."

    Public education and communication. The strategy advocates for a national public awareness campaign that would provide education on the impact of chronic pain "and its status as a disease that requires appropriate treatment." That campaign would also include better information on the use—and potential for misuse—of pain medications.

    According to a news release from HHS, the NPS dovetails with the department's efforts to address the epidemic of opioid abuse, launched in March 2015. Those efforts are related to a White House initiative to battle opioid abuse and heroin use launched in the fall of that same year. APTA is among the participants in that initiative, and recently participated in a working group meeting to discuss the new US Centers for Disease Control and Prevention recommendation that nondrug, nonopioid approaches be considered the first-line treatments for chronic pain.

    No Turning Back: 4 Ways Bundled Payments Will Change Rehab Care

    Maybe the biggest ICYMI issue in physical therapy so far this year is the impending implementation of Medicare's Comprehensive Care for Joint Replacement model (CJR), a program that will require hospitals in 67 metropolitan areas to use bundled payment systems for total knee arthroplasty (TKA) and total hip arthroplasty (THA). The system launches on April 1.

    You may have some familiarity with the immediate impacts of the CJR on physical therapists (PTs) and physical therapist assistants (PTAs), but the model, and others like it, also set the stage for even bigger shifts in how rehabilitation professionals interact with the health care system.

    In the February issue of Physical Therapy (PTJ), APTA's research journal, APTA Executive Vice President of Public Affairs Justin Moore, PT, DPT, laid out the top 4 long-term practice implications of payment bundles. The article, appearing in PTJ's new "Point of View" feature, provides much more detail (as well as an explanation of how we've arrived at this moment in health care), but here's a quick take on that list:

    1. Bundled care's 3 biggest components, in order: data, data, and data.
    Patient measurement tools will be standardized and integrated into practice, and PTs and PTAs will need to strengthen their profession by strengthening the data that support it. Bottom line: Expect to be participating in registry programs such as the upcoming APTA Physical Therapy Outcomes Registry.

    2. Practice guidelines will be even more important than they already are.
    It will be increasingly important that the entire care team understands the ways PTs and PTAs contribute to the overall treatment process. Everyone will need to know what to expect, which means practice guidelines will play a vital role. As Moore writes, "further development of clinical practice guidelines will only facilitate the inclusion of rehabilitation professionals in the development of the care pathways."

    3. It's not just about you; it's about the team.
    Interprofessional education and practice will become a crucial component of care. Every provider involved in a bundled system will need to understand how the various elements of care are supposed to work (see #2 above) and how they fit in to the system. "Knowing if, when, and in what role rehabilitation professionals are involved in the continuum of service comprising a bundle is essential for success at a patient, system, and provider level," Moore writes.

    4. Bring along your business acumen.
    "The management of resources is essential to best deploy limited access in the most efficient and effective fashion," is how Moore puts it. What that means is, the move to bundling and other value-based systems will require PTs and PTAs to be more savvy when it comes to analyzing what they're doing and at what cost—something that will require "measurement beyond a service-level mentality," Moore writes.

    Read the entire Point of View (a new commentary feature) in the February issue of PTJ, and check out an overview of the CJR featured in the March edition of PT in Motion magazine. Although APTA's March 24 webinar on the CJR is full, a recording of the event will be made available in the days that follow.

    Foundation Announces 2016 Award Recipients

    This year's recipients of the Foundation for Physical Therapy's (Foundation) service awards include 2 inspirational leaders in the profession and a medical products company that has been a consistent supporter of physical therapy research.

    The 2016 awards and winners are:

    • Spirit of Philanthropy Award: Marilyn Moffatt, PT, DPT, PhD, DSc (hon), GCS, CSCS, CEEAA, FAPTA
    • Charles M. Magistro Distinguished Service Award: Steven H. Tepper, PT, PhD
    • Premier Partner in Research Award: DJO Global

    "The vital work of the Foundation would not be possible without the dedication and commitment of each of our service award recipients," said Foundation Board of Trustees President Barbara Connolly, PT, DPT, EdD, FAPTA, in a Foundation news release. "They play such an important role in allowing us to further our mission to fund physical therapy research and develop the next generation of researchers. They continue to inspire and remind us of the impact our work has on the lives of many, and for this we are truly grateful."

    This year's recipients will be recognized during the Foundation's gala on June 9, 2016, during the NEXT conference in Nashville, Tennessee.

    Study Looks at Readmission Hazards, Offsets Among Adults With Debility

    Among individuals admitted for inpatient rehabilitation, patients who are admitted for debility—a significant decline in functional mobility and/or activities of daily living—are among the most likely to be readmitted within 30 days. Now a new study takes a closer look at just how those readmissions play out, and what factors are related to the greatest risk of readmission within that group.

    In the February issue of Physical Therapy (PTJ), APTA's research journal, researchers share their findings from an analysis of more than 45,000 records of Medicare beneficiaries who were admitted to a hospital for debility, and then later discharged to the community between 2006 and 2009. Authors of the study tracked these patients to uncover rates of readmission within 90 days, and any factors that would put some at higher risk for readmission than others. The records covered 1,199 facilities.

    What they found was that 1 in 3 patients were readmitted within 90 days, with more than half of those readmissions (56%) occurring in the first month after discharge—19% of the total. That 30-day readmission rate was not as high as the 23%-24% reported among Medicare beneficiaries in skilled nursing facilities, but authors point out that their study focuses on patients readmitted to the community after discharge from inpatient rehabilitation rather than after discharge from acute care.

    In terms of risks for a return to the hospital, researchers found that certain comorbidities—specifically congestive heart failure, renal failure, and chronic pulmonary disease—were among the top reasons associated with readmission. "These generally prevalent conditions have implications for developing and targeting hospital readmission reduction programs for patients with debility," authors write.

    There were positive signs when it came to the effect of inpatient rehabilitation. Researchers found that higher scores on the Functional Independence Measure (FIM) at discharge correlated to a decreased risk of readmission. That decrease amounted to a 2% lower risk of readmission within the first 2 weeks of discharge for every 1 point increase in FIM, with the rate dropping to a 1%-per-point relationship for readmission at 1 month. The protective effects of the higher FIM scores seemed to fall off at the 2 month mark, authors note. Of the FIM items associated with the greatest impact on readmission, walk/wheelchair and stair locomotion, lower body dressing, eating, and bowel and bladder control topped the list.

    The average age of patients in the study was 80.8 years. The study group was majority female (60.1%), non-Hispanic white (86.4%), not married (56.2%), and living with others prior to acute hospitalization (61.8%).

    Authors believe that while more study is needed, their findings around readmission hazards can inform health care providers, particularly in the ways patients with debility are evaluated and monitored after discharge.

    "These considerations are relevant to discharge planning and transition of care from inpatient rehabilitation to community," authors write. "Patients with debility who have lower motor function and comorbid conditions associated with increased readmission hazard should be monitored for functional trajectory and medical stability during inpatient rehabilitation and post-discharge. Optimizing independence levels for motor function during inpatient rehabilitation is an important consideration for reducing hospital readmissions."

    Lead author of the study was Rebecca Galloway, PT, PhD. The article appears in the concluding issue of a 3-issue PTJ series focusing on health services research. Current and past editions of PTJ are available for free to APTA members.

    CDC: Physical Therapy, Other Non-Drug, Non-Opioid Approaches Should be First-Line Treatment for Chronic Pain

    In its final version of guidelines for prescribing opioids for chronic pain, the US Centers for Disease Control and Prevention (CDC) minces no words about the importance of physical therapy and other nondrug/nonopioid approaches, and delivers a clear message that physical therapists (PTs) and physical therapist assistants (PTAs) have known for some time: there are better, safer ways to treat chronic pain than the use of opioids.

    Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain," the CDC states in its first recommendation. "The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as [cognitive behavioral therapy, or CBT], and certain interventional procedures can ameliorate chronic pain."

    The CDC guidelines were created in response to growing rates of opioid use disorder and opioid overdose, a problem fueled by ever-increasing rates of opioid prescriptions written by primary care providers—approximately 259 million prescriptions written in 2012 alone. In its introduction to the guideline, CDC cites from 1 study that among 15- 64-year-olds who received opioids for noncancer pain, 1 in 550 died from an opioid-related overdose at a median of 2.6 years from their first prescription.

    A draft version of the guidelines were published in late 2015 as part of a CDC call for comments. APTA responded with strong support for the recommendations, writing that approaches such as physical therapy "have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain."

    Other stakeholders were less enthusiastic. According to a report from National Public Radio, some critics questioned the CDC recommendation against using opioids as a first-line treatment for chronic pain.

    In that NPR report, Debra Houry, director of CDC's National Center for Injury Prevention and Control, responded by pointing to weak evidence supporting the benefits of opioids for chronic pain and growing evidence pointing to the risks. "We have decided that because of that, and the uncertain benefits of opioids, that continuing to prescribe them for chronic pain is not warranted," Houry said. "On the other end, nonopioids, there is evidence for their benefits."

    In addition to the statement around first-line treatment, the CDC guideline includes recommendations that address the importance of establishing treatment goals, discussing risks of opioids with patients, choosing appropriate dosage and release factors, and conducting thorough follow-up assessments once a patient has been prescribed an opioid. The guidelines are not intended to apply to opioid use related to patients with cancer, palliative, or end-of-life care.

    News of the CDC guidelines spread quickly, with major media outlets including Newsweek, USA Today, The Wall Street Journal, and others reporting on the recommendations that arrive amidst increased national attention on the epidemic of opioid abuse and heroin use across the country. APTA is participating in a White House initiative to address the problem through, among other things, increased public awareness.

    Those APTA public awareness efforts include a page on MoveForwardPT.com, the association's website for consumers looking for information on physical therapy, with information on the risks of opioids and physical therapy's role in the treatment of pain.

    In addition to the guideline, CDC also released a checklist and fact sheet that outline the basics of the larger document. Both stress that nonopioid therapies should be "tried and optimized" before considering an opioid prescription as well as during reassessment of a patient who has received a prescription for opioids.

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

    Kristin Bacon, PT, is competing in the Alaskan Iditarod. (KTVA11 Anchorage, Alaska)

    Physical therapist listed among "8 jobs for people who want jobs in fast-growing industries." (Buffalo, New York, News)

    Margaret O'Neil, PT, PhD, MPH, gives her thoughts on a new video game platform developed by Drexel University for children with cerebral palsy. (Technically/Philly)

    Amanda Hall, PT, MPT, PCS, creates cool imaginative casts for her patients. (WRC News4 Washington, DC)

    Charles A. Thigpen, PT, PhD, ATC, describes the effectiveness of injury prevention training for young pitchers. (Headlines and Global News)

    Dianna Rose-Gates, PT, DPT, PCS, discusses how physical therapists and school transportation services can work together to meet the needs of children. (School Transportation Services newsletter)

    "They had the patience of Job. Now I'm walking the way I did before." – Jean Bouy, TKA patient, whose gifted quilts for the PTs and PTAs at Cloud County Health Center have blossomed into a fundraising initiative. (Salina, Kansas, Journal)

    Brendan Sullivan, PT, CSCS, has been named Medical Honoree of the 2016 Albany, New York, Capital District Walk to Cure Arthritis. (Capital District Walk to Cure Arthritis newsletter)

    Susan Herdman, PT, PhD, FAPTA, and Courtney Hall, PT, PhD, share insights on benign paroxysmal positional vertigo with The New York Times.

    "Life is very much like physical therapy. With the help of others, we can strengthen, we can heal and we can understand that healing is a process. – Physical therapy patient Harris Murray in "Life lessons through physical therapy." (Orangeburg, South Carolina, Times and Democrat)

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

    Army Study on Minimalist Running Shoes Finds No Reduction in Injury Risk

    A new study from the US Army says that when it comes to choosing between minimalist running shoes (MRS) and traditional running shoes (TRS), there are plenty of differences to consider, but injury risk probably shouldn't be 1 of them.

    Army researchers analyzed injury rates, fitness performance, and other demographic variables among 1,332 men in an Army brigade, 83% of whom wore TRS with the remaining 17% wearing MRS. Authors of the study aimed to find out whether one type of shoe decreases injury risk (a claim that has been made by fans of MRS), but they also found out more about the characteristics of MRS wearers—or at least male MRS wearers in the Army. The study was e-published ahead of print in the American Journal of Sports Medicine (abstract only available for free).

    When it comes to injury, after adjusting for demographic and other variables, researchers found that "even though returning to a more natural gait through the use of MRS has been suggested to reduce running-related injuries, the current study found no differences in injury incidence among soldiers who wore MRS and soldiers who wore TRS."

    According to the study, the identifiable risk factors had more to do with the soldiers themselves than what they wore. Soldiers who were older, had a BMI of 30 or more, were previously injured, performed poorly on a 2-mile run test, and who were from support battalions (as opposed to infantry, cavalry, artillery, or special troop battalions) were more likely to experience a running-related injury.

    Not surprisingly, the soldiers who wore MRS tended to be younger and "performed significantly better on all physical fitness tests," according to the article. Authors write that the link is consistent with runners' surveys that reveal a higher rate of MRS use among individuals who considered themselves "elite" runners, and were younger. Similarly, they write, "soldiers motivated to enhance their performance may exercise at higher intensities … and may be more likely to try MRS due to anticipated theoretical performance advantages."

    Authors don't discuss whether those advantages actually exist, but are clear that their findings don't support the idea that one type of shoe has an advantage over another when it comes to injury. "Individuals can wear the shoes of their choice without adversely affecting their injury risks," they 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.

    A First: NFL Official Acknowledges Link Between Football-Related TBI and CTE

    In what The Washington Post described as "a stunning admission," a top official of the National Football League (NFL) has publicly conceded a link between head injuries in football and chronic traumatic encephalopathy (CTE)—a connection that the league has previously refused to clearly acknowledge.

    Jeff Miller, the NFL's senior vice president for health and safety, was participating in a roundtable discussion held by the US House of Representatives' Committee on Energy and Commerce when he was asked whether there was a link between diseases such as CTE and football-related head injuries. "The answer to that question is certainly yes," he said.

    Miller's statement, which some believe was unintentional, marks the first time an NFL official has acknowledged such a connection. According to a report from ESPN, Miller's acknowledgement came after Ann McKee, a neuropathologist, outlined her findings around the prevalence of CTE among former NFL players. When pressed for his opinion, Miller answered that McKee had established a connection, but added that "there's also a number of questions that come with that."

    Miller refused to answer reporters' questions after the meeting. In an interview with the Post, NFL spokesman Brian McCarthy stressed that while Miller did acknowledge the link in McKee's findings, he also said that "the experts should speak to the state of the science."

    "We want the facts, so we can develop solutions," McCarthy continued to the Post. "We know the answers will come as this field of study continues to advance."

    Critics of the NFL argue that the league has, at best, only vaguely nodded to a connection between head trauma and CTE in football.

    According to ESPN, Miller's comment is already being used by a lawyer representing former NFL players who are objecting to a proposed settlement of a concussion lawsuit filed against the NFL by players. In a letter to the Third Circuit Court of Appeals, attorney Steven Molo describes Miller's admission as a "stark turn" in the NFL's position, and one that "directly contradicted" what the league had earlier claimed.

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage, and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Continuing education offerings from APTA include the prerecorded webinar "Managing Concussions With an Interprofessional Team" and the online course "Concussion and the Postconcussive Syndrome,” both available through the APTA Learning Center.

    SNF Use of Highest Therapy Categories to be Investigated by RACs

    New data now available from the Centers for Medicare and Medicaid Services (CMS) seem to back up allegations that many skilled nursing facilities (SNFs) are inappropriately using "ultra-high" (RU) and "very high" (RV) rehabilitation categories to increase their payments—and improve their bottom lines. The findings have prompted CMS to turn over the issue to recovery audit contractors (RACs).

    On March 9, CMS released a new public use file on SNF utilization in 2013, representing more than $27 billion in Medicare payments and approximately 2.5 million stays among 15,055 facilities. The file breaks down the numbers in multiple ways, allowing users to look at payments arranged by resource utilization groups (RUGs), average payment amount per beneficiary, geographic regions, and therapy minutes. The data were based on SNF Part A institutional claims.

    According to CMS, the data on the use of RV and RU therapy contain a telling detail: namely a significant number of patients whose therapy time was within 10 minutes of the lowest possible threshold that would still allow the SNF to get the RV or RU payments. The report shows that in 2013, more than 1 in 5 SNFs reported 75% or more of their RV or RU minutes in amounts just over the required minimums (between 500 and 510 minutes per week for RV 720-730 minutes for RU).

    Overall, RU received $16.6 billion in 2013, while RV was associated with $5.5 billion in payments.

    "CMS strives to ensure that patient need, rather than payment system incentives, are driving the provision of therapy services," said Shantanu Agrawal, deputy administrator for program integrity and director of the CMS Center for Program Integrity in a news release. Agrawal added that concerns over the ways in which RV and RU were being used have prompted CMS to refer the issue to the RACs for investigation. "Our hope is that data transparency will facilitate real changes," Agrawal said.

    The RAC referral adds to what have been difficult times for SNFs over the past few months, as the press, the US Department of Justice, and the US Department of Health and Human Services have focused attention on SNF billing practices.

    Among other SNF-related data in the file:

    • The average standardized payment per stay for all SNFs was $10,919, with an average stay of 28 days.
    • The states with the highest average standardized payment per stay were Indiana ($12,406), Texas ($12,064), and California ($11,862).
    • States in the southwest had "notably high" percentages of RU assessments that fell just inside the thresholds, according to CMS, but so did California, Nevada, and "a few Southeastern states."

    From PTJ: Analysis Paints Dire Picture of Unmet Mobility and Therapy Needs Among Children

    When it comes to the mobility aid and therapy needs of children, as of 2010, the outlook was not good: nearly 1 in 10 children requiring mobility aids were not receiving them, and nearly 1 in 5 did not receive the therapy they needed. The rates were even more dismal for children with developmental disabilities or from low-income households.

    The statistics are part of an analysis that appeared in the February issue ofPhysical Therapy (PTJ), the research journal of APTA. Authors Beth M. McManus, PT, ScD, MPH, Laura A. Prosser, PT, PhD, and Mary E. Gannotti, PT, PhD, used the 2009–2010 National Survey of Children With Special Health Care Needs to address what they believe is a scarcity of information on how well children's needs for mobility aids and therapy are being met.

    Authors screened caregiver-reported survey results related to 372,698 children from 196,195 households. Of that total, 40,242 children were categorized as having a special health care need. In addition, "More than 70% of the children with a need for therapy or mobility aids had a diagnosis of developmental disability," the authors note.

    Overall, therapy needs were revealed to be more prevalent than the need for mobility aids. When authors took a closer look at the data, they uncovered some troubling details about the unmet needs for physical therapy, occupational therapy, and speech therapy services among children. Among them:

    • Nearly 1 in 5 children (17.7%) reported unmet therapy needs.
    • Children diagnosed with a developmental disability were almost 3 times more likely to have unmet therapy needs than children with medical conditions.
    • Children with conditions "always" affecting their ability to function were nearly 3 times more likely to have an unmet therapy need than children whose condition affected them "very little" of the time.
    • Children whose condition "usually" affected them were 2 times more likely to experience an unmet therapy need than those with conditions affecting them "very little of the time."
    • Compared with the oldest group surveyed (ages 12–17), children ages 3 to 5 had much higher odds of encountering an unmet need for therapy.
    • Black, non-Hispanic children experienced a 30% greater likelihood of having an unmet therapy need compared to white, non-Hispanic children.
    • Being uninsured at any point during the previous 12 months made children twice as likely to have unmet needs as children benefiting from continuous health coverage.
    • Children residing in households with incomes ranging between 200% and 399% of the federal poverty level (FPL) were nearly 50% more likely to have an unmet therapy need than households with incomes greater than 400% FPL.

    The authors identify the most common reasons for unmet therapy needs as "cost (23.1%), followed by lack of resources at school (17.3%), unavailability of services or transportation (15.0%), problems with health plan (14.3%), and appointments unavailable or not convenient (12.2%)."

    When it came to mobility aids, the needs were somewhat less dire, but still dramatic:

    • Nearly 1 in 10 children (7.7%) requiring mobility aids reported having an unmet need.
    • Children ages 3 to 5 had the highest percentage of unmet needs (12.1%).
    • Children "always" affected by a condition were 6 times more likely to have an unmet need than those who were affected "very little of the time."

    Overall, authors write that the likelihood of unmet therapy increased with the "diagnosis of a developmental disability, having a condition that always affected function, and insurance discontinuity."

    Authors note that the expansion of the State Children's Health Insurance Program under the Affordable Care Act is likely to increase coverage, and they believe that baseline statistics such as the ones they uncovered will help build a foundational understanding of the issue—and help to serve as reminder of the needs of an underserved population.

    For more insights, listen to the podcast of PTJ Editor in Chief Alan Jette's interview with coauthor Beth McManus. The children's needs article appears in the final installment of PTJ's special series on health services research. Check out the entire series at the PTJ website.

    WebMD Adds Physical Therapy to Fibromyalgia Resources

    The hugely popular WebMD health site just got a little better, because now it includes a new section on physical therapy's role in the treatment of fibromyalgia.

    "The benefit of physical therapy is that it allows a person with fibromyalgia to work closely with a trained professional who can design a fibromyalgia-specific treatment program," WebMD says in its new "Fibromyalgia and Physical Therapy" page. "Physical therapists work with all types of patients—from infants to adults. They provide health services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities. Working one-on-one with people, physical therapists help restore overall fitness and health."

    The page explains what physical therapy is, how physical therapists (PTs) can help individuals with fibromyalgia, and the various tools and approaches used by PTs including hydrotherapy, deep tissue massage, aerobic conditioning, pain relief exercise, transcutaneous electrical nerve stimulation, and stretching and strengthening exercises.

    "[PTs] can show people with fibromyalgia how to relieve symptoms of pain and stiffness in everyday life," states the WebMD site, adding that PTs can help patients build strength and range of motion, show individuals with fibromyalgia how to get relief from deep muscle pain, and help patients "make sensible decisions about daily activities that will prevent painful flare-ups."

    HHS: 30-Day Readmissions Are Down – For Real

    Hospital 30-day readmission rates are dropping and, with it, concerns that hospitals are accomplishing the decreases through ramped-up use of "observation status" stays that would allow them to do an end-run around potential readmission penalties. Instead, say Department of Health and Human Services (HHS) researchers, the decreases may be related to actual "behavioral change" in hospitals.

    Focusing on Medicare beneficiaries who are elderly, authors of the study reviewed files for more than 52 million stays in 3,387 hospitals across the country between 2007 and 2015, tracking readmission rates and related conditions. Researchers separated files into 2 groups: stays related to "targeted conditions" to which HHS may apply penalties for higher-than-usual readmission rates, and conditions that were not linked to penalties. The study was published in the New England Journal of Medicine.

    Though total knee arthroplasty (TKA) and total hip arthroplasty (THA) are now included in the HHS list of targeted readmission conditions, during most of the time period studied, targeted conditions only included acute myocardial infarction, heart failure, and pneumonia. TKA and THA readmissions were added in late 2014, and were not included in the study.

    What researchers found was that risk-adjusted rates of 30-day readmissions for targeted conditions have fallen from 21.5% to 17.8% from 2007 to 2015, and from 15.3% to 13.1% for nontargeted conditions. The decline in readmission rates accelerated after the passage of the Affordable Care Act (ACA) in 2009 but slowed somewhat between 2012 and 2015. The 30-day readmission penalty program was not introduced until October 2012.

    Authors of the study also looked at the number of stays that were defined as "observation status," a designation that potentially allows hospitals to avoid defining a stay as a readmission. Some critics of the HHS readmission reduction efforts—known as the Hospital Readmissions Reduction (HRR) program—speculated that hospitals would simply move to a greater use of observation status, and not make any actual progress in reducing readmissions.

    According to researchers, that's not the case. They found that while use of observation status has increased, from 2.6% to 4.7% for targeted conditions and from 2.5% to 4.2% for nontargeted conditions, this increase was happening before ACA was enacted and doesn't account for the drop in 30-day readmissions.

    Researchers also found that observation status rates rose more slowly during the implementation phase of ACA than they did during the later "long-term follow-up period." Authors of the study believe the rates imply that hospitals weren't reacting to the startup of the ACA by rushing to substitute observation status for what would've been called a readmission prior to the law.

    "We saw a steady increase in observation-unit stays during the entire analysis period, with no significant changes at the passage of the ACA," authors write. "It seems likely that the upward trend in observation-service use may be attributable to factors that are largely unrelated to the [HRR], such as whether an inpatient stay would be deemed inappropriate by Medicare recovery audit contractors."

    As for the readmission rates themselves, authors of the study believe the pressure was already on hospitals to reduce readmissions before the enactment of ACA, and the new law "catalyzed behavioral change by many hospitals."

    Malpractice Claims Report Shows Increases for PTs, PTAs

    The growth of the physical therapy profession over the past 5 years seems to be bringing another increase with it—the cost of malpractice claims filed against physical therapists (PTs) and physical therapist assistants (PTAs).

    According to a new report from Healthcare Providers' Service Organization (HPSO), between 2011 and 2015, payments for malpractice claims rose to $42 million. The previous HPSO study, published in 2011, reported a total of $44 million in malpractice payments, but the older study period spanned 10 years, not 5.

    In terms of the kinds of allegations made against PTs and PTAs, claims of improper management over the course of physical therapy treatment nearly doubled during the study period. Now at 22.5%, the management category represents the largest percentage of closed claims, compared with allegations related to manual therapy, failure to supervise or monitor, improper use of therapeutic exercise, and improper use of a biophysical agent.

    HPSO's examples of improper management include failure to follow practitioner orders, failure to obtain informed consent, failure to complete a proper patient assessment, failure to cease treatment following excessive/unexpected pain, and failure to report the patient's condition to the referring practitioner.

    HPSO provides malpractice and liability insurance to PTs, and is a strategic business partner of APTA. The claim report update is published by HPSO in partnership with CNA, and is designed to help PTs better understand and assess their professional risk and ways to reduce exposure.

    "APTA is committed to a collaborative effort to achieving positive outcomes for patients and the physical therapy profession," said APTA CEO J. Michael Bowers in an HPSO news release. "The report will greatly assist our members in enhancing their risk management practices."

    APTA offers several resources to help PTs and PTAs understand and manage risk, including a Risk Management webpage, and the online APTA Center for Integrity in Practice.

    Newest Report on Burden of Musculoskeletal Conditions Now Available

    The latest edition of a wide-ranging report brings high-powered data to something physical therapists and physical therapist assistants know at a very personal level—the overwhelming prevalence of musculoskeletal conditions among the US population.

    The US Bone and Joint Initiative's (USBJI) newest revision of "The Burden of Musculoskeletal Diseases in the US" compiles extensive data on a wide range of conditions, including low back pain, neck pain, arthritis, osteoporosis, and injuries. The report also looks at musculoskeletal conditions in children, adolescents, and special populations, and offers insight on economic impact.

    According to USBJI, half of all adults in the US were diagnosed with a musculoskeletal condition in 2012, with nearly 6% of the population reporting a condition that made them unable to perform at least 1 common activity, such as walking, getting out of a chair, or bathing. Back or neck pain accounted for 290.8 million lost workdays in 2012 alone.

    The website allows free access to all data and features a "report builder" resource that allows visitors to select particular datapoints among the resources and create a customized report.

    USBJI hopes that the resources will help to highlight the need for more attention on prevention and treatment of an area of health that is placing an enormous burden on the health care system.

    "When musculoskeletal disorders that could be prevented or ameliorated are not addressed in a timely manner, we miss opportunities to intervene earlier and more effectively in the disease process—a program exacerbated by lack of access to both screening and treatment," USBJI writes in an executive summary of the report. "These missed opportunities rob people of their ability to work and live full lives, and add unnecessary expenditures to the health care system."

    APTA is a founding member of USBJI.

    The Fastest-Growing of the Fastest-Growing: PTs, PTAs Near the Top of Employment Growth Projections

    The health care employment outlook is projected to grow rapidly in the next 3 years, and physical therapy-related professions aren't just a part of that growth—they're among the leaders.

    The US Bureau of Labor Statistics (BLS) projects that, overall, health care will become the largest job sector in the US within the next 3 years. Across all professions, 3 different physical therapy-related careers are cited as areas of particularly strong growth over the next 8 years, with all 3—physical therapist (PT), physical therapist assistant (PTA), and physical therapy aide—registering in the top 10 overall.

    The BLS rates, published in December 2015, estimates PTAs as the third fastest-growing occupation in the country, projecting a 41% increase in employment through 2024. Physical therapy aides were fourth, with a projected increase of 39%, and PTs were in eighth position, with a projected increase of 34%.

    Wind turbine service technician was the top-ranked occupation, with a projected growth of 108% between 2014 and 2024.Other occupations listed in the top 10 include occupational therapy assistants (second at 43%), home health aides (fifth at 38%), commercial divers (sixth at 37%), nurse practitioners (seventh at 35%), statisticians (ninth at 34%), and ambulance drivers and attendants (10th at 33%).

    The BLS list also includes median pay for each occupation. In 2014, BLS estimated the median annual pay of PTs at $82,390. PTA annual pay was estimated at $54,410 annually, with physical therapy aide pay at $24,650.

    As an employment sector, health care fared especially well last year, adding 480,000 jobs, according to an article inTIME Money. If growth continues as projected, health care will surpass retail employment as the country's largest employment sector by 2020.

    Take advantage of the favorable outlook for PTs and PTAs—join the upcoming APTA Virtual Career Fair, April 14 at 1:00 pm, ET. The fair is an online event that puts you in contact with multiple employers, all from the convenience of your computer, tablet, or smartphone. You can chat online with employers from large and small providers about their current and future needs, and your experience and interests.

    Oregon First State to Sign On to PT, PTA Licensure Compact

    Oregon has made physical therapy history by becoming the first state to join the Physical Therapy Licensure Compact (PTLC), a system that aims to make it possible for physical therapists (PTs) and physical therapist assistants (PTAs) to practice in multiple states through a single license and privilege.

    The legislation, signed into law by Gov Kate Brown, adopts standard language allowing Oregon to participate in a system in which a PT or PTA with a valid, unencumbered license in one participating state may practice in any other participating state. Qualified PTs and PTAs would be able to choose any or all participating compact states to gain practice privileges, but would only need to maintain licensure in their "home" state.

    The push for adoption of the PTLC among states is being led by the Federation of State Boards of Physical Therapy (FSBPT) and APTA, working with state APTA chapters, state regulatory boards, and supporters of increased licensure portability. That effort officially launched earlier this year.

    Though decidedly good news, Oregon's adoption of the PTLC is only a first step: to become operational the system must have at least 10 participating states. In a recent article on the PTLC in PT in Motion magazine, APTA Vice President of Government Affairs Justin Elliott said that states should consider moving on the issue soon. "The creation of a compact for PTs and PTAs is truly going to transform the state licensure process," Elliott said, "all while maintaining and even improving the level of public protection in the compact states."

    "The federation is thrilled Oregon was the first state to enact the Physical Therapy Licensure Compact," said FSBPT President Maggie Donohue, PT. "This is a demonstration of how APTA, the FSBPT, the Oregon Chapter, and the Oregon Physical Therapy Licensing Board can work together to benefit the health care consumer. We trust Oregon is the model for continued collaboration and advancement of patient access to physical therapy services."

    Like Donohoe, APTA President Sharon L. Dunn, PT, PhD, OCS, hopes that Oregon's decision will pave the way for other states.

    "The PTLC is a common-sense solution to provide greater licensure portability and increased patient access, and to facilitate the use of telehealth." Dunn said. "We applaud the state of Oregon for being the first to enact the compact legislation and look forward to more states joining in the near future."

    Moffat Honored Through Creation of Endowed Chair at NYU

    Moffat, Marilyn

    Physical therapy leader Marilyn Moffat, PT, PhD, DPT, FAPTA, was recently recognized by New York University's Department of Physical Therapy for her excellence as an educator, researcher, and physical therapist—excellence that has led to the creation of the department's first-ever endowed chair position.

    The Marilyn Moffat Endowed Chair in Physical Therapy was announced in June 2015; on March 7, a ceremony was held to officially recognize the chair's namesake. The chair was established through $2 million in gifts.

    "An endowed professorship is one of the highest honors in academia. Offering a master teacher and researcher a named chair—especially one honoring such an esteemed professor—enables us to recruit an immensely talented individual to the Department of Physical Therapy and the Steinhardt community," said Dominic Brewer, Gale and Ira Drukier Dean of the NYU Steinhardt School of Culture, Education, and Human Development.

    Moffat is a past president of APTA and of the World Confederation for Physical Therapy, as well as a Catherine Worthingham Fellow of APTA. She delivered the 35th Mary McMillan Lecture and also was given APTA’s Lucy Blair Service Award. She directs both the professional doctoral program in physical therapy and the postprofessional graduate master's degree program in pathokinesiology at NYU, and is a well-known author of several influential physical therapy texts.

    The university continues to accept applications for the position. The new hire will join the Department of Physical Therapy and the Steinhardt School as an associate professor.

    Jimmo Advocates Back in Court, Alleging CMS Hasn't Lived Up to its Agreement to Educate Stakeholders

    Three years after a settlement was reached, the Jimmo v Sibelius battle has returned to court—this time, to address allegations that the US Centers for Medicare and Medicaid Services (CMS) has not kept its promise to adequately educate Medicare providers, contractors, and adjudicators on why they can't use the "improvement standard" as a basis to deny claims for skilled maintenance therapy.

    According to the Center for Medicare Advocacy (CMA), which has joined with Vermont Legal Aid to represent 7 individual plaintiffs and 7 organizations, CMS has "clearly failed to educate key components of the provider community and Medicare decision-making system" about the fallacy of the assumption that a patient must demonstrate improvement in order to receive coverage. In February, CMA issued a statement essentially warning CMS of CMA's dissatisfaction with the education efforts; on March 1, it filed a Motion for Resolution of Non-Compliance.

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

    In a recent article in the Barre Montpelier, Vermont Times-Argus—a newspaper from the home state of Glenda Jimmo—APTA President Sharon L. Dunn, PT, PhD, OCS, acknowledges that the association continues to receive questions about the settlement. "We have found many providers have not received any information about the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit," Dunn says.

    CMA argues that the CMS education efforts amounted to a single briefing for providers and adjudicators in early December 2013, with nearly nothing done since. "Unfortunately, providers and contractors continue to illegally deny Medicare coverage and care based on the 'improvement standard,' resulting in beneficiaries nationwide failing to obtain needed skilled nursing and therapy coverage," CMA states in a news release.

    In the CMA release, Executive Director Judith Stein says that CMS could be helping to eliminate incorrect denials, "but has refused to provide any more education or written information—although attorneys for the plaintiffs have repeatedly provided evidence of problems, dozens of examples, and even prepared much of the material needed to provide further education and information."

    CMS will reportedly file a response to the motion by April 26.

    APTA maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.

    Therapy Cap Repeal Amendment Gives Senators an Opportunity to Keep Up the Drumbeat to End a Flawed Policy

    Two US senators are working to keep repeal of the Medicare therapy cap front-of-mind on Capitol Hill. Though the chance of passage is slim this year, sponsors Ben Cardin (D-MD) and Dean Heller (R-NV) hope that an amendment they sponsored will refocus attention on ending the therapy cap, and help to keep the issue well-positioned when the current exceptions process runs out in December 2017.

    The amendment calls for a full repeal of the payment caps for physical therapy treatment under Medicare Part B, which sets limits at $1,960—an amount that also includes speech-language pathology services. In past years (including 2015 and 2016) the cap has been accompanied by an exceptions process that allows payment for physical therapy over the limit. APTA describes the therapy cap as a policy that "discriminates against the most vulnerable Medicare beneficiaries," and the exceptions process as an "arbitrary" system.

    The senators hope to attach the amendment to a popular bill that addresses the opioid epidemic, but the realistic chances of that happening are not good. Cardin and Heller argue that given the role of physical therapy in the management of chronic pain, it's appropriate to include the cap repeal in the opioid bill. However, both senators feel that even if they aren't successful in getting the amendment added, their efforts will help to remind the Senate that it will take up the issue next year, when the current exceptions process runs out on December 31.

    In past years, a debate over the elimination of the therapy cap has been a more-or-less annual event that was part of the fight to end the flawed sustainable growth rate (SGR), a system that routinely required the so-called "doc fix" to the physician fee schedule to avoid severe payment cuts. With the elimination of the SGR in 2015, the 2 issues were separated. Congress came close to a full repeal of the cap, but in the end decided to keep it—and its exceptions process—in place until the end of 2017. Cardin and Heller aim to remind their colleagues that the issue has not disappeared by any means.

    "These arbitrary caps create an unnecessary and burdensome financial barrier to Medicare beneficiaries who rely on essential rehab services such as physical and occupational therapy to live healthy and productive lives," Cardin said in his floor speech (video of Cardin's entire speech available here). As for the appropriateness of the amendment in the opioid bill, Cardin cited a recent Centers for Disease Control and Prevention (CDC) clinical guideline that asserts physical therapy and other nondrug approaches to chronic pain "have been underutilized and, therefore, can serve as a primary strategy to reduce prescription drug medication abuse and improve the lives of individuals with chronic pain."

    Heller described the effect of a therapy cap repeal in plain terms. "If patients had better access to physical therapy, they would not be as dependent on highly addictive pain medication," he said, adding that "seniors would also have a higher quality of life by treating the sources of the pain and rebuilding their strength."

    Repeal of the therapy cap remains 1 of APTA's highest public policy priorities, and APTA President Sharon L. Dunn, PT, DPT, OCS, voiced the association's strong support of the senators' efforts during this session.

    “APTA believes the latest extension of the exceptions process must be the last, and the therapy cap must be repealed and replaced with meaningful reforms that are in the best interest of the patient,” Dunn said. “APTA will continue to shine a spotlight at every opportunity before Congress on how the misguided therapy cap policy negatively impacts the patients we serve.”

    Repeal of the therapy cap will require a strong, unified voice from the physical therapy profession. Find out how you can take action—and if you really want to get involved, don't miss the upcoming APTA Federal Advocacy Forum in Washington DC, April 3-5. Registration deadline is March 18.

    Medicare Reaches Value-Based Payment Goal a Year Ahead of Schedule

    Medicare's march toward payment systems that are tied to value and not volume has been moving along at a faster-than-expected clip, according to the Department of Health and Human Services (HHS), which says that Medicare has reached its goal to tie 30% of all payments to value-based systems nearly 1 year ahead of schedule.

    According to an HHS announcement, growth of alternative payment models including accountable care organizations (ACOs) and bundled payment systems have allowed Medicare to shift $117 billion out of a projected $380 billion away from fee-for-service payments. HHS says that this shift has resulted in better care and greater savings, including $411 million savings in 2014 attributed to ACOs participating in the Medicare Shared Savings and Pioneer ACO programs.

    The move away from quantity was a major feature of the Affordable Care Act (ACA), which created programs such as Medicare Shared Savings and the Center for Medicare and Medicaid Innovation.

    In a fact sheet from the Centers for Medicare and Medicaid Services (CMS), the agency says that the transition to more alternative payment systems has coincided with other improvements in health care, including a 17% drop in hospital-acquired conditions, lower hospital readmission rates, and slower growth in per-enrollee spending.

    "Alternative payment models, such as bundled payments or [ACOs], make doctors and hospitals attentive to the total costs of treating a patient at a high level of quality over time," CMS states. "This focus makes care more accessible to patients, including after-hours availability, quicker follow-up, more seamless transitions from one doctor or clinician to another, fewer repeated or duplicative tests, and keeping patients healthier overall."

    Many physical therapists and physical therapist assistants are already involved in alternative payment systems (and some are even helping to pioneer approaches through APTA's Innovation 2.0 program), but that involvement is bound to increase soon, when CMS launches its Comprehensive Care for Joint Replacement (CJR) program. That system, which will require hospitals in 67 metropolitan areas to participate in a bundled payment program for total knee and total hip replacements, is set to start April 1.

    APTA has been helping its members keep up with the transition to value-based and collaborative care models, most recently developing resources to help PTs and PTAs understand the CJR. The association will host a webinar on the program on March 24.

    At an even broader level, the association has developed a new alternative payment system for the profession. Called the Physical Therapy Classification and Payment System (PTCPS), it's a system that uses a severity-intensity framework as a basis for payment, rather than a procedural-based, fee-for-service system. The evaluation codes associated with the new system will be implemented January 1, 2017.

    "The new coding system that will begin in January marks an important step for the physical therapy profession toward exactly the kinds of models CMS says will be the future of health care," said Carmen Elliott, APTA vice president of payment and practice management. "The fact that CMS is achieving its transition goals sooner than expected makes it even more important that we continue to work together to develop a model that will help the profession thrive in a quickly-changing environment."

    Why does the move toward value-based systems matter, and what's the big picture? Check out this article from APTA's series, "Physical Therapy: A Profession in Transformation."

    US Obesity Rates Nearing 1 in 3 Adults; Physical Activity Rates Looking Better

    At a rate of 30% in 2015, Americans are more obese than ever, according to data from the US Centers for Disease Control and Prevention (CDC). But there are some bright spots when it comes to rates of physical activity (PA).

    In recent reports, the CDC lists the 2015 obesity rate at 30.6% among US adults, a slight bump up from the 29.9% rate recorded in 2014, and a dramatic increase from the 19.4% rate of 1997.

    Obesity rates were highest among adults 40-59 (34.9%), followed by the 60-and-over age group (30.1%) and adults 20-39 (26.7%). In all but the 60-and-older group, prevalence was higher among males than females. In terms of race/ethnicity and sex, non-Hispanic black females were most likely to be obese (45.2%), followed by non-Hispanic black men (34.5%) and Hispanic women (33%).

    While the obesity news was not encouraging, more positive data were reported when it came to rates of PA in 2015, where 49.5% of adults 18 and over reported meeting the 2008 federal physical activity guidelines for aerobic activity through leisure-time PA. That rate was only slightly lower than 2014's 50% estimate. The PA rate was about 43% in 2008.

    The percentage of adults who met the 2008 PA guidelines for both aerobic and muscle-strengthening activities was also higher than 2008 levels, at 21.1%—about the same level as 2014 (21.2%). In 2008 the rate was about 17%.

    Non-Hispanic white adults were more likely to meet both the aerobic and aerobic-and-muscle goals than non-Hispanic black adults and Hispanic adults. In both PA categories, percentages were highest in the 18-24 age group and declined with age.

    Findings were taken from the National Health Interview Survey.

    APTA has been a strong advocate in the battle against obesity, and offers multiple resources on the role physical therapists and physical therapist assistants play in addressing prevention and wellness, including a 2-part podcast on the inactivity epidemic (part 1, part 2). Additionally, the consumer-focused MoveForwardPT.com offers a guide to obesity, and PTNow includes several practice guidelines related to obesity. And look for more activity in the future: the 2015 APTA House of Delegates approved a measure to create and strengthen partnerships between the association and other organizations committed to addressing obesity.

    CSM 2016: Highlights, Videos, Photos Now Available

    Maybe you couldn't attend the 2016 APTA Combined Sections Meeting (CSM). Or maybe you made it to Anaheim, but you're in that post-CSM letdown mode— missing all those great conversations, inspiring sessions, and the general feeling of energy that seemed to be in the air.

    Either way, it's now possible to feel just a bit closer to the record-setting event.

    Take heart: APTA has released a Storify collection (embedded below and linked here that offers video highlights from the national event, and features pictures and more from attendees. You can also browse and order photos from CSM. Visit the official CSM photography website to check out what's available—just click on the appropriate CSM 2016 link under "Recent Photos" and enter password: thoracic. Click "Go" and then click on the event of your choice. Select your photos and order through the shopping cart.

    Also, check out videos and news articles from CSM, available at the CSM website.

    Want to attend CSM next year? Save the date: February 15-18 in San Antonio, Texas. But don't wait until 2017 to attend an APTA national conference. This June 8-11 you can become part of the NEXT evolution in physical therapy by attending the NEXT Conference and Exposition in Nashville.

    From PT in Motion Magazine: Get the Basics on CMS Bundling Program for TKA, THA

    Remember, back last year, when the Centers for Medicare and Medicaid Services (CMS) said it would be moving from fee-for-service models and toward more outcomes-based payment systems? It wasn't kidding.

    This month in PT in Motion magazine's "Compliance Matters" column: the publication's first detailed look at the coming Comprehensive Care for Joint Replacement (CJR) model. The CJR, which will be mandatory in 67 metropolitan statistical areas, will require that hospitals engage in bundled care systems for total knee arthroplasty (TKA) and total hip arthroplasty (THA).

    The basic idea is that in many parts of the country, CMS will assign a single rate for the entire episode of care for its Medicare beneficiaries who receive TKA or THA, from admission through rehab. Although providers will continue to be paid under their respective payment systems, at the end of the year, CMS will reconcile the payments against the total episode rate. Depending on whether the total payments are above or below that rate, the hospital could be eligible for additional payment—or (in the years to come) be required to pay back CMS. But there's much more to it than that.

    APTA staffers Roshunda Drummond-Dye, JD, and Health Smith, PT, MPH, take readers through the details of how the CJR will work, the ways it will affect PTs and PTAs, and what APTA is doing to prepare its members for the change (including an upcoming webinar devoted to the topic). The article even includes a listing of the metropolitan statistical areas that will be mandated to comply with CJR.

    "The Comprehensive Care Joint Replacement Model" is featured in the March issue of PT in Motion. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    What HE Said: 6 Great Quotes From the Huffington Post Interview With APTA Executive Vice President Justin Moore, PT, DPT

    Your call: you could spend your Huffington Post browsing time reviewing stories on the latest antics of political candidates or staring at yet another cute animal video, or you could devote a few minutes to an APTA staffer's views on physical therapy—its current state, its future, and what might be done to increase innovation in the profession.

    APTA Executive Vice President of Public Affairs Justin Moore, PT, DPT, participated in a recent Q-and-A style interview with blogger Marquis Cabrera and physical therapist DPT student Lauren Jarmusz. The interview posted on March 1, and it's a worthwhile read. Here are a few highlights among Moore's quotes.

    • "The current medical hierarchy is a culture of control over collaboration and care," 1 of 3 barriers to innovation in physical therapy cited by Moore. The other 2: the fee-for-service model and payment restrictions such as the therapy cap.
    • "We need to show the quality of our services through a reformed coding model," on the need for a retooled system that accounts for patient management or condition.
    • "As the US health care system evolves, PTs will be taking on more primary roles. They'll be more engaged, for example, in community health care models."
    • "There's a huge potential in patients working with PTs to better manage their health. When PTs actively participate with patients and other providers to manage conditions, the result will be reduced health care costs and better patient outcomes."
    • "Treatment by PTs traditionally has been positioned at the back end of the health care continuum. To reduce the amount spent on musculoskeletal disorders, physical therapy should be positioned on the front end."
    • "Patients put their quality of life in our hands, and that role is so important to who we are as a profession."

    The interview also covered the association's consumer education efforts, the Innovation 2.0 initiative, and Moore's advice to students in DPT programs, something he called "a unique and entrepreneurial calling."

    SNF Use of Ultrahigh Therapy in the News Again

    The issue of some skilled nursing facilities (SNFs) gaming the Medicare system by excessive use of "ultrahigh" care continues to make headlines—this time in California, where an Orange County Register article claims that SNFs in the state use ultrahigh therapy at rates exceeding the already-high national average.

    In "Big money in nursing home therapy, but is all the treatment necessary?" reporters Deborah Schoch and Ron Campbell take a close look at billing practices among SNFs in the Orange County area of California, near Los Angeles. Orange County is the sixth largest county in the country.

    According to the Register, 72% of Medicare rehabilitation patients in the county's SNFs received treatment at the ultrahigh rate—an average well above the state's overall 66% rate, which itself is higher than the 58% rate across the US. The article goes on to describe therapists' claims of being pressured to increase hours inappropriately, and outlines some of the steps being taken to address concerns about misuse of the therapy rates.

    Along the way, the report quotes Roshunda Drummond-Dye, APTA's director of regulatory affairs, who confirms that APTA regularly receives calls from physical therapists (PTs) "who are being pressured to do practices that are unnecessary or illegal." The Register story also cites a Physical Therapy-published study that, while acknowledging certain benefits of receiving an extra hour of therapy a week for patients recovering from hip fractures, also found that therapy above the ultrahigh threshold of 720 minutes a week "was less effective than lower intensity therapy in returning patients home," according to the Register.

    The article adds to the growing media focus on SNF billing practices. Late last summer, the Wall Street Journal published a report outlining the findings of its study of the use of ultrahigh therapy hours, and the issue resurfaced in October when the Office of the Inspector General of the US Department of Health and Human Services (HHS) issued a report highly critical of SNFs. That report was in turn the subject of a New York Times article on the issue, an article that prompted a letter to the editor from APTA President Sharon L. Dunn, PT, PhD, OCS.

    More recently, the US Department of Justice (DOJ) announced that the nation's largest nursing home therapy provider had agreed to pay $125 million to settle a DOJ lawsuit that alleged the company engaged in a "systematic and broad-ranging scheme" to increase Medicare reimbursements by submitting false claims for rehabilitation therapy. The RehabCare settlement was the result of a whistleblower lawsuit brought to the DOJ by APTA member Janet Mahoney, PT, DPT, and Shawn Fahey, an occupational therapist. Both worked for RehabCare.

    The Register article includes some therapists' accounts of the pressure they faced to increase therapy hours among patients—pressures that forced providers such as Melissa Lathon to quit.

    Lathon, a former social series director at 6 nursing homes, is quoted in the Register article as saying that management "would pretty much twist the therapists' arms and say, we need another week at the ultrahigh level."

    According to the Register, Lathon left her position "after a supervisor ordered her to fill out a document saying a patient needed assistance in walking when he had clearly shown he was walking independently."

    Helping physical therapists and physical therapist assistants understand their obligation to eliminate fraud, abuse, and waste is the central idea behind APTA's online Center for Integrity in Practice—a suite of resources to support care based on patient need and clinical judgment.