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  • CMS Proposes Major Change in SNF Payment System

    The payment world could change dramatically for skilled nursing facilities (SNFs) as early as October of next year if the US Centers for Medicare and Medicaid Services (CMS) follows through on a proposed rule.

    On April 27, CMS unveiled its proposed SNF rule for 2019, which includes plans to replace the existing SNF case-mix methodology, known as Resource Utilization Groups Version IV (RUG-IV) with an entirely new system dubbed the Patient-Driven Payment Model (PDPM). CMS believes the new model will save money and improve care by reducing administrative burden and tying payment to patient conditions rather than services provided. The new system would go into effect on October 1, 2019.

    Under the PDPM, payments would be based on a resident's classification among 5 components—physical therapy, occupational therapy, speech-language pathology, nursing, and "non-therapy ancillary services," a category mostly related to drugs and medical supplies. Payment would be calculated by multiplying the case-mix index for the resident's group with each component, first by a base payment rate and then by days of service received. The payment calculations for each component would then be added together to create a resident's total per diem rate.

    The big picture: CMS believes the new system would shift payment away from the focus on volume-based services associated with RUG-IV and toward "incentives to treat the whole patient." That shift also would come with "significantly" reduced administrative burdens, according to a CMS fact sheet on the proposed rule.

    The new model is itself an overhaul of sorts of a case-mix methodology system CMS floated last year. That model, known as the Resident Classification System (RCS-I), met with heavy criticism from a wide range of stakeholders, including APTA. The association argued that the plan was based on an inadequate set of patient characteristics and a poor understanding of the impact of comorbidities, and likely would reduce therapy for patients most in need. Initial analysis of the PDPM reveals that CMS may have listened to that criticism, creating a system that it says "puts the unique care needs of the patient first."

    To ensure that SNFs are delivering the kind of care envisioned, CMS would add 2 new therapy reporting requirements to the discharge assessment—the first aimed at documenting therapy minutes and each therapy mode used, and a second focused on days for each discipline and mode of therapy. CMS hopes that monitoring both minutes and days will allow it to get a better handle on the daily intensity of services provided—something that's difficult to do under the current RUG system. In addition, the new system would limit concurrent and group therapy to 25% for each discipline.

    Other elements of the proposed SNF rule:

    • Overall payments to SNFs would increase by 2.4%, or $850 million.
    • The reporting window for the public display of SNF outcome measures would be expanded from 1 to 2 years, a change that CMS believes will require more SNFs to participate and is in line with current requirements for inpatient rehab facilities and long-term care hospitals.
    • Beginning as early as 2020, CMS would begin publicly displaying data related to changes in self-care and mobility during SNF care and at discharge.
    • CMS would add a cost-benefit analysis as an additional factor when considering potential outcome measures to remove from its list of requirements.

    And while no actual changes are being proposed, CMS is using the release of the proposed rule to remind SNFs that beginning in October 2018, SNFs could receive increased or reduced payments depending on their performance on the SNF value-based purchasing program's readmission measure. The measure, based on all-cause 30-day hospital readmissions, doesn't require SNFs to report additional information, since CMS will use existing claims information to make the assessment.

    APTA regulatory affairs staff are reviewing the rule and will draft comments for submission before the deadline of June 26, 2018.

    Proposed CMS Hospital Payment Rule Includes Payment Increases, Reductions in Reporting and EHR Requirements

    In its proposed rule for hospital payment in 2019, the US Centers for Medicare and Medicaid Services (CMS) is continuing its shift toward fewer reporting requirements and reduced burdens associated with electronic health records (EHRs), while recommending payment increases that could mean a 3.4% boost for some acute care hospitals (ACHs).

    The inpatient prospective payment system (IPPS) proposed rule released last week (CMS fact sheet here) covers a range of areas related to how ACHs and long-term care hospitals (LTCHs) would operate in relation to Medicare and Medicaid beneficiaries. Here are a few highlights of the proposed rule:

    • ACHs could see a $4 billion payment increase. That's the CMS estimate of what the proposed 3.4% increase could mean (last year's final rule included a $2.4 billion increase). The increase will apply only to hospitals that successfully participate in the CMS Hospital Inpatient Quality Reporting Program.
    • Technically, LTCHs also would see a payment increase…but, practically speaking, probably not. The rule proposes a 1.5% increase for LTCHs, but other provisions in the proposed rule offset the increase, leaving LTCHs to face a 0.1% decrease in 2019. In 2018 LTCH payment was reduced by 2.4%.The proposed rule also would end a policy that pays LTCHs at a rate comparable to an ACH if an LTCH admits more than 25% of its patients from a single ACH. That program was suspended in 2018—the proposed rule would make the change permanent.
    • CMS continues to back off on quality-measure reporting requirements. For hospitals involved in Medicare and Medicaid EHR incentive programs, the proposed rule would eliminate 40 quality-reporting measures CMS has identified as duplicative, excessively burdensome, or "topped out"—measures on which the "overwhelming majority of providers" are performing highly. Measures proposed to be eliminated include stroke education and assessment for rehabilitation, both of which CMS describes as measures whose costs outweigh the benefits of continued use.
    • EHR incentive programs are getting retooled. Incentive programs related to EHR use would receive what CMS is calling an "overhaul" in 2019. The aim of the rule, according to CMS, is to increase interoperability and decrease burdens on hospitals and providers. Changes include shortened reporting periods for 1 self-selected quarter and fewer required measures to be reported. CMS also hopes to change the name of the program from "Meaningful Use " to "Promoting Interoperability" and add 2 new measures: Query of the [Prescription Drug Monitoring Program] and Verify Opioid Treatment Agreement.
    • CMS is asking for public input on price transparency. Specifically, CMS wants to hear from the public about "barriers preventing providers from informing patients of their out-of-pocket costs." To underscore its intention to increase price transparency, CMS also proposes upping the ante when it comes to hospitals sharing lists of standard charges: in addition to requiring hospitals to "make public a list of their standard charges," (something they already do), CMS wants to mandate that those charges be made available on the Internet.

    The proposed rule also includes information on how the Rural Community Hospital Demonstration has been carried out. That project, designed to evaluate the possibility of applying cost-based reimbursement for rural hospitals that are too large to be crucial-access hospitals, must remain budget neutral.

    APTA regulatory affairs staff are reviewing the rule and will draft comments for submission to CMS before the deadline of June 25, 2018.

    PTJ Special Issue Podcasts: Physical Therapy for Pain May Reduce Overall Costs, Opioid Use

    For some patients, physical therapy can both decrease overall health care utilization and save money down the road—especially if delivered sooner rather than later. These were the takeaways from 2 articles in a May 2018 special issue on nonpharmacological management of pain published by PTJ (Physical Therapy), APTA's scientific journal. PTJ Editor-in-Chief Alan Jette, PT, PhD, FAPTA, interviewed authors of each of the studies via podcast.

    One study, coauthored by Xinliang “Albert” Liu, PhD, examined the effect of timing of physical therapy on downstream health care use and costs for patients with acute low back pain (LBP) in New York state. The patients were categorized by whether and how soon they received physical therapy after seeing a physician for LBP: at 3 days, 4–14 days, 15–28 days, 29–90 days, and no physical therapy. Patients who received physical therapy within 3 days (30%) incurred the lowest costs and utilization rates, while those who didn’t see a PT at all saw the greatest of both.

    In the PTJ podcast, Liu observed that among those who did not receive physical therapy there was “greater variety in health care utilization and costs," pointing out that factors influencing costs include age, living in nonmetropolitan areas, type of insurance coverage, comorbidities, and whether they were prescribed opioids or other medications. He cautioned that “we don’t have the evidence” yet to say that all patients with LBP should be referred immediately to physical therapists, but he hopes that future research can “identify subgroups that would potentially benefit from physical therapy and lower their health care utilization and costs.”

    A separate study explored downstream health care utilization and costs for Veterans Affairs patients who received physical therapy, opioids, or both after hip surgery. After 2 years, patients who received only physical therapy had lower overall health care costs than those who only received opioids and had fewer return visits for surgical fixes or replacements. Among the 56% of patients who received both, those who received physical therapy first had lower costs, had fewer opioid prescriptions, and were less likely to use opioids long-term.

    Coauthor Daniel Rhon, PT, DPT, DSc, told Jette, “Perhaps when you see a physical therapist first, there is more appropriate pain education and pain management…and that sends the patient down this pathway that results in better outcomes. I think there’s a prevailing thought…that you need to be pain-free before you get to physical therapy, and that it’s going to be really painful, and some physicians and some patients might wait” to refer a patient to physical therapy.

    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.

    Successful WCPT Efforts in Africa Subject of Capitol Hill Meeting

    The World Confederation for Physical Therapy (WCPT) is making a difference in the lives of people in need of rehabilitation in conflict-affected countries in Africa, thanks to an innovative program supported by the Leahy War Victims Fund, a special USAID program created by US Sen Patrick Leahy (VT) and funded by Congress. Recently, WCPT leaders and APTA staff shared that success story with Leahy's office.

    The visit to Capitol Hill allowed WCPT President Emma Stokes and CEO Jonathon Kruger to personally thank representatives for the Leahy War Fund grant that helped the confederation strengthen the physical therapy profession in West Africa, particularly in the strife-ridden countries of Mali, Niger, and Senegal. The program, known as the SUDA Project, has bolstered the physical therapy associations in those countries, improved the quality and standards of physical therapist education programs, and established a model for capacity-building that can be transferred to other low-resource countries.

    The Leahy War Victims Fund, an initiative focused on providing assistance to people with disabilities in countries experiencing conflict, provided a $1.2 million grant to the SUDA Project. In addition to thanking representatives of the program for its support, Stokes and Kruger also outlined ideas for expanding or replicating the project in other countries.

    “Our meeting provided a wonderful opportunity to give feedback on the SUDA project and to explore future opportunities for the current administration to fund projects that support the development of the global physical therapy profession,” said Kruger. “WCPT is very grateful for the support provided by APTA President Sharon Dunn, PT, PhD, as well as APTA CEO Justin Moore, PT, DPT, and his team to make this meeting happen,” added Stokes.

    "APTA was pleased to be able to facilitate a meeting between WCPT and Senator Leahy's office," said Justin Elliott, APTA vice president of government affairs. "The SUDA Project is a success by any measure, and the Leahy War Victims Fund made that project possible. APTA and WCPT will continue to work together to support this important arm of USAID."


    2018 - 04 - 24 - Group shot
    From left: Emilio J. Rouco, MA, APTA director of public and media relations;
    Justin Elliott, APTA vice president of government affairs; WCPT President Emma Stokes;
    WCPT CEO Jonathon Kruger.

    2017 APTA Annual Report Posted

    Now available: the 2017 APTA Annual Report, an e-published document that provides an overview of a year fueled by collaboration and marked by accomplishments in areas ranging from national public relations campaigns to membership milestones and the end of the hard cap on payment for rehabilitation services under Medicare.

    The report builds on a 2017 "year in review" released in December 2017. In addition to the contents of that publication, the report includes financial information, a treasurer's report, and membership statistics.

    "APTA's past year was impressive," writes APTA President Sharon Dunn, PT, PhD. "But even more impressive is the way we accomplished what we did—through a commitment to working together, sharing ideas, and learning from each other."

    2018 House of Delegates Motions Now Posted

    APTA members can now access the first official packet of motions that will be considered by the 2018 APTA House of Delegates (House) when it convenes June 25-27, 2018, in Orlando, Florida.

    Called "Packet 1 Preview," the compilation contains 57 motions to the 2018 House of Delegates and is provided as the official notice of all motions, including 4 bylaws amendments that are coming before the 2018 House of Delegates. On May 18, “Packet I Preview” will be replaced with a document titled “Packet I with Background Papers,” a further edited and formatted version of the preview packet that will also include background papers on various motions. The differences between the 2 packets will be editorial only, and will not affect the scope of the motions.

    Proposed amendments to APTA bylaws are:

    • RC 53-18 Amend: Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates, Section 3: Voting Delegates, A. Qualifications of Voting Delegates, (1) Chapter Delegates
    • RC 54-18 Amend: Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates, Section 4: Nonvoting Delegates, A. Qualifications of Nonvoting Delegates, (1) Section Delegates
    • RC 55-18 Amend: Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates, Section 4: Nonvoting Delegates, A. Qualifications of Nonvoting Delegates, (2) PTA Caucus Delegates
    • RC 56-18 Amend: Bylaws of the American Physical Therapy Association to Allow Sections to Vote in the House of Delegates

    Delegates should continue using the Motions Discussion forum in the House of Delegates online Hub community to participate in discussion. Chief, section, and assembly delegates wishing to cosponsor a motion or request that a motion be placed on consent should visit the Motions, House Reports, and Background Papers file library.

    Contact APTA’s Cheryl Robinson with any questions.

    Joint Commission Wants Your Comments on Proposed Pain Assessment and Management Requirements

    The Joint Commission is developing new requirements related to pain assessment and management in 3 important settings, and your comments can help shape final standards and more clearly define the roles of physical therapists (PTs) and physical therapist assistants (PTAs). Comments are due May 22, 2018.

    The proposed requirements are focused on office-based surgery, ambulatory care, and acute care hospital settings. The Joint Commission describes the new requirements as ones that "emphasize active participation of administrative and physician leadership in pain management and safe opioid prescribing protocols and strengthen organizations’ practices for pain assessment, treatment, education, and monitoring."

    To comment, follow the instructions on the standard field reviews page—download and review the proposal, then submit comments by May 22 via an online survey, an online form, or email to The Joint Commission. Direct any questions you have to Kate Kornfeind, Division of Standards and Survey Methods, 630/792-5756 or kkornfeind@jointcommission.org.

    Sign up for The Joint Commission Hub Community to stay on top of field reviews and other news.

    2018 APTA Honors and Awards Program Recipients Announced

    APTA's national awards program has announced the full 2018 list of recipients of recognition for their outstanding contributions to the physical therapy profession.

    The honorees include newly named Catherine Worthingham Fellows as well as recipients of the Lucy Blair Service Award. APTA also has announced recipients for 2 new award categories for societal impact and humanitarian efforts.

    Recipients will be recognized at the Honors and Awards Ceremony on Thursday, June 28, during the 2018 NEXT Conference and Exposition in Orlando, Florida, with a reception to follow. The winner of the Mary McMillan Lecture Award (lecture to be delivered in 2019) also will be announced. Family, friends, colleagues, and conference attendees are encouraged to attend this important event to support and honor these members’ achievements and contributions to the profession.

    Nominations for the 2019 Honors and Awards Program will open September 2018.

    APTA's Member Renewal Efforts Earn National Award

    APTA's successful efforts to keep membership strong have been recognized as a model for associations across the country.

    Earlier this month, the American Society of Association Executives (ASAE) announced that APTA’s multipronged initiative to retain members was selected as this year's Gold Circle award winner for outstanding member retention campaign. The campaign was part of #APTA100K, a larger APTA push to reach 100,000 members. The association reached that goal in summer of 2017.

    The award-winning program, "On-Time Renewal to #APTA100K," was supported by a range of offerings including webinars, free meeting registrations, personal visits and written contact, and a series of renewal "touchpoint" emails and online prompts that were user- and handheld-friendly. The result? Renewals increased, and overall membership grew at a rate APTA hadn't seen in 2 decades.

    "The #APTA100K membership campaign was truly an all-hands-on-deck effort that involved staff, volunteers, and components," said APTA CEO Justin Moore, PT, DPT. "More than just promoting the value of membership, we made membership easier through our new automated renewal reminders. This award is a wonderful recognition of those efforts, but it’s also a tribute to our association’s tremendous positive momentum and the value created by our more than 100,000 members."

    This isn't APTA's first Gold Circle award. Last year, ASAE recognized APTA's public service announcement video for its #ChoosePT campaign as the winner for best video of the year. According to ASAE, the awards recognize association initiatives that "set an example for associations developing their own campaigns."

    The Good Stuff: Members and the Profession in the Media, April 2018

    "The Good Stuff," is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Oh baby! Josh Thorington PT, DPT, and his twin brother, Justin, have that whole twin vibe going on—right down to their wives giving birth on the same day in the same hospital. (Traverse City, Michigan, Record-Eagle)

    That's a stretch: Zachary Long, PT, DPT, explains why certain stretching exercises can help people with ankylosing spondylitis. (everydayhealth.com)

    Ready patient 1: Maureen Simmonds PT, PhD, is working with virtual reality in the treatment of back pain. (KSAT12 News, San Antonio, Texas)

    The benefits of a mourning run: Rachel Tavel PT, DPT, shares how running has helped her face her grief over the loss of her father. (Self magazine)

    Quotable: "Through aquatic physical therapy, I was able to get strong enough to regain my balance and coordination, and start walking without a walker." – Glastonbury, Connecticut, resident Christine Depierro-Gacek, in her remarks to the Glastonbury town council as the council debated the feasibility of a year-round aquatic center. (Hartford, Connecticut, Courant)

    A PT gets a "Chasing Genius" grant: Asha Gummadi, PT, was awarded a grant from National Geographic to pursue development of an app to help patients understand their exercises—offered in multiple languages. (Forbes.com)

    Illinois State University PT students do their part: The students, including Melissa Gifford, SPT, took part in a free health screenings program at the ISU health center. (Terre Haute, Indiana, Statesman)

    Don't run away from good form: Michael Roberts PT, DPT, outlines how musculoskeletal imbalances in one area of a runner's body can create pain in another area. (Milwaukee Journal Sentinel)

    The road to better pain management: Jill Boorman, PT, explains the importance of physical therapy in pain management. (Charleston, South Carolina, Post and Courier)

    Cloudy with a chance of injury: Karena Wu, PT, DPT, describes the physical challenges of running in heavy rain. (accuweather.com)

    Dry needling basics: Gerad Donahue, PT, DPT, breaks down the fundamentals of how dry needling works. (WXPR-FM, Rhinelander, Wisconsin)

    The play's the thing: Regina Harbourne PT, PhD, FAPTA, discusses the importance of play-based pediatric physical therapy. (WESA-FM, Pittsburgh)

    Wherefore art thou, orthotics? Robert Gillanders, PT, DPT, provides guidance for runners considering orthotics. (aaptiv.com)

    Opioid-free TKA: John Baker, PT, DScPT, is taking part in a protocol that has eliminated opioids in TKA recovery. (Frederick, Marlyand, News-Post)

    Take a (bicycle) seat: Shane Page, PT, DPT, was named the winner of a development award that will help him make his "physiosaddle" bicycle seat a reality. (WHOTV 7 News, Dayton, Ohio)

    Good pain or bad pain? Christopher Ricardo PT, DPT, offers tips on how to tell which post-workout pain is ok, and which isn't. (The Washington Post)

    Care for the pelvic floor: Ingrid Harm-Ernandes, PT, helps her patient understand how best to treat her pelvic floor dysfunction. (Women'sHealth.com)

    A pain in the neck: Andrew Lui, PT, provides tips on identifying and correcting poor posture that could lead to neck pain. (USA Today)

    The problem with alternatives to opioids: Mark Bishop, PT, PhD, FAPTA, explains how prior authorization requirements can slow progress for patients seeking physical therapy as an alternative to opioids for pain management. (Tampa Bay Times)

    The heart of firefighting: Donald Shaw PT, PhD, is part of a research team that recently completed a study analyzing firefighters' heart rates when responding to different types of calls. (Prescott, Arizona, Daily Courier)

    Quotable: "Physical therapy is one of the best choices you can make in the treatment of chronic pain." - "Chronic Pain: Treat it With Mindfulness Meditation, Not Opioids," US News and World Report

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

    Foundation Announces 2018 Scholarship, Grant Opportunities

    The Foundation for Physical Therapy (Foundation) now is accepting applications for the 2018 Florence P. Kendall Doctoral Scholarships and the 2018 Research Grants.

    The Kendall Post-Professional Doctoral Scholarships assist physical therapists and physical therapist assistants with outstanding potential who are in their first year of postprofessional doctoral degree studies. The $5,000 awards are given to meet tuition expenses or academic fees associated with a doctoral program. Application deadline is August 2, 2018, at 12:00 pm ET.

    Grant opportunities include:

    • Magistro Family Foundation Research Grant: $100,000 for a research project investigating physical therapist interventions. Investigators at any level are welcome to apply regardless of funding history. A letter of intent is required; applicants will be invited to submit full applications based on content. Letter of intent is due May 31, 2018, at noon ET; full application is due August 2, 2018, at noon ET.
    • Foundation Research Grant: $40,000 for an investigator-initiated research project by an emerging investigator. Full application is due August 2, 2018, at noon ET.
    • Health Services Research Pipeline Grant: $50,000 awarded to support research that examines how patients obtain physical therapy-related health care, how much that care costs, and outcomes, with an emphasis on the most-effective ways to organize, manage, finance, and deliver high-quality physical therapy-related care while potentially reducing medical errors and improving safety for patients. Full application is due August 2, 2018, at noon ET.
    • Acute Care Research Grant: $40,000 to an emerging investigator seeking to advance the practice of acute care physical therapy. This grant is made possible by the Academy of Acute Care Physical Therapy. Full application is due August 2, 2018, at noon ET.
    • Paris Patla Musculoskeletal Grant: $240,000 to support research on the musculoskeletal system and manual therapy. This new funding mechanism will award $120,000 per year for 2 years with a possible third year of funding through a competitive renewal, providing funding up to $360,000 over a 3-year period. Investigators at any level are welcome to apply regardless of funding history. A letter of intent is required and is due May 31, 2018, at noon ET. Full application is due August 2, 2018, at noon ET.
    • Pediatrics Research Grant: $40,000 to an emerging investigator seeking to conduct research consistent with the current Academy of Pediatric Physical Therapy research agenda. This grant is made possible by the Academy of Pediatric Physical Therapy. Full application is due August 2, 2018, at noon ET.
    • Geriatric Research Grant: $40,000 to an emerging investigator for research focused on the development of interventions to address mobility in adults 75 years or older (or those 65-70 age range is justified) with multiple chronic health conditions. Full application is due August 2, 2018, at noon ET.
    • Orthopaedic Research Grant: $40,000 to an emerging investigator exploring clinical outcomes of physical therapist practice for patients with musculoskeletal conditions. This grant is made possible by the Orthopaedic Section Endowment Fund. Full application is due August 2, 2018, at noon ET.

    Questions? Email the Foundation, or call 800/875-1378.

    Note: Before starting your funding application, be sure to carefully read all eligibility guidelines, instructions, and information on funding mechanism deadlines. Also, it's a good idea to start the submission process early to allow for potential questions to be answered.

    APTA Adds Its Voice to Coalition Calling for Medicare Advantage to Rein in Prior Authorization

    With nearly a third of the total Medicare population enrolled in a Medicare Advantage (MA) plan and growth expected to continue, it's time for the public-private hybrid system to evolve and move away from excessive use of prior authorization—that's the message being delivered to the Centers for Medicare and Medicaid Services (CMS) from a coalition of health care and consumer organizations including APTA.

    In an April 10 letter to CMS Administrator Seema Verma, the Coalition to Preserve Rehabilitation (CPR) writes that MA's uses of prior authorization "may be sources of increasing barriers to accessing needed care, particularly inpatient and outpatient rehabilitation services and devices, for beneficiaries nationwide." The coalition argues that in many cases, prior authorization "often serves as an unnecessary delay for beneficiaries seeking medically necessary care, and often results in no cost savings to the plan."

    Addressing the issue sooner rather than later is important, according to CPR, if for no other reason than MA's rapid growth, which is expected to continue from 19 million beneficiaries in 2017 to a projected 32 million by 2028. "The fast pace of growth of this program suggests the need for greater scrutiny of mechanisms imposed by these plans to manage services utilization, such as prior authorization," the coalition writes.

    While the letter acknowledges that prior authorization can be appropriate in some instances, the system increasingly is being overused, often in circumstances that are "difficult to justify" such as rehabilitation services and devices that are "unlikely to be overutilized and often need to be provided in a timely manner in order to maximize their medical efficacy."

    Adding to the problem, according to CPR, are recent moves by managed care plans to farm out benefits management to companies that are incentivized to save money by denying services.

    The letter suggests that CMS take its cue from the private insurance industry, which has been moving away from prior authorization—or at least taking a closer look at which prior authorization policies get in the way of medically necessary care. The coalition also recommends that CMS impose greater oversight of MA plans, with "stronger directives to MA plans to limit the use of prior authorization to services that are demonstrably overutilized."

    In addition to APTA, the 28 CPR members that signed the letter include the American Association of People with Disabilities, the American Occupational Therapy Association, the Brain Injury Association of America, the Epilepsy Foundation, the Michael J. Fox Foundation for Parkinson's Research, and the Paralyzed Veterans of America. APTA will monitor this issue and share developments as they arise.

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    Study: Primary Care Physician PT Referral Rates Dropped 50% Between 2003 and 2014

    Over the past 20 years, there have been vast gains in direct access to physical therapists (PTs), and most providers and clinical practice guidelines recommend physical therapy as a "first-line treatment" for many musculoskeletal conditions. However, researchers found that physician referral to physical therapy for these conditions declined between 2003 and 2014, while referral to specialist physicians increased.

    In an article published in the Journal of General Internal Medicine (citation only available for free), authors analyzed 12 years of primary care physician (PCP) data from the National Ambulatory Medical Care Survey. The survey includes patient and visit characteristics, physician diagnosis, services, and tests ordered, including physical therapy. Authors included APTA members Janet K. Freburger, PT, PhD, and Samannaaz Khoja, PT, PhD.

    For all musculoskeletal-related visits, the rate of referral to a PT dropped by 50%, from 94.4 per 1,000 visits, to just 42.9. The decrease in referral rates "followed similar trends" for each of the 3 diagnostic subgroups that researchers examined: arthropathy, spine, and soft tissue disorders. At the same time, referrals to specialist physicians increased at approximately the same rate.

    Authors are unsure whether the results are due to "more appropriate" physical therapy referral or "missed opportunities" for referral, but they note, "Had the decrease in [physical therapy] referral rates reflected more judicious use of specialists by PCPs, we would have expected a similar trend for referrals to physicians."

    Whatever the underlying cause, researchers think the trend isn't exactly in sync with the way health care is evolving.

    "As primary care moves to value-based payment, the need for multidisciplinary, team-based care and care delivery by non-physician providers will be necessary to deliver high-value care," authors write.

    Final Rule on ACA Insurance Exchanges Opens the Door for Market Instability, Disruptions in Care

    The US Department of Health and Human Services (HHS) is making good on the Trump administration's promise to relax requirements in the Affordable Care Act (ACA), releasing a set of rule changes—most opposed by APTA—that will alter the way states deal with "essential health benefits" (EHBs) and potentially reduce consumer access to help in choosing an insurance plan in the state marketplaces, among other provisions.

    HHS describes the final rule, issued on April 9, as "intended to advance the Administration's goals for increasing flexibility, improving affordability, strengthening program integrity, empowering consumers, promoting stability, and reducing unnecessary regulatory burdens associated with the [ACA]." APTA and many other health care and consumer organizations see things differently, and in comments mostly ignored by HHS when the proposed rule was released last year, warned that many of the changes will reduce care and disrupt markets.

    At the top of the list of changes opposed by APTA is the HHS decision to move ahead with a loosening of requirements around how states configure their "benchmark" plans—the minimum health insurance requirements for policies offered through a state's insurance exchange. Although HHS backed down from its original 2019 implementation date and made slight alterations from its proposed rule, the overall impact remains: beginning in 2020, states will be allowed to mix and match provisions in their benchmark plans, borrowing parts or entire plans from other states or otherwise selecting “a set of benefits to become its EHB-benchmark plan," primarily through adopting a private insurer's plan provisions that meet certain criteria.

    While the benchmark plans must contain the 10 EHBs required in the ACA (1 of which is rehabilitation and habilitation), the new rule allows states to significantly alter just how those EHBs are handled by adopting other, possibly less-generous, plan elements.

    "The final rule related to benchmark plans is only slightly better than the rule proposed in the fall of 2017, but HHS left some of the most potentially harmful provisions intact," said Kara Gainer, JD, APTA director of regulatory affairs. "Consumers will be left with a confusing, unsteady coverage system that could disrupt their care—practically the opposite scenario from the original intent of the ACA."

    Making matters worse, those disruptions in care could reoccur every year. The new rule also allows states to rearrange coverage provisions in benchmark plans annually. While APTA and other organizations contended that the change would create instability, the Centers for Medicare and Medicaid Services (CMS) argued that "because of the level of effort needed" to make a change, states probably won't attempt to mix things up every year. Plus, CMS added, if a state does decide to make an annual change, "there may be a specific reason…such as for a medical innovation."

    And maintaining consistent coverage through the insurance exchanges isn't the only thing that will become more difficult: it will also be harder for consumers to get help finding out what's available and signing up for a plan. Under the new rule, HHS will do away with certain requirements for "navigator" entities, the organizations that help consumers understand and choose an insurance plan through an exchange. Beginning this year, HHS will reduce the minimum number of navigator entities per exchange from 2 to 1, and will also lift a requirement that 1 navigator per exchange must be a community-focused nonprofit. Also eliminated: a mandate that the navigator entity be physically present in the exchange area it serves.

    APTA argued that "it is misguided for [CMS] to drastically reduce the level of assistance" provided to consumers, and pushed for even more navigator services. In its reply to comments, CMS cast the change as one that provides "increased flexibility."

    Other changes in the rule include giving more power to states to determine network adequacy—albeit with no direction on what constitutes an adequate network review process—and a loosening of requirements for Small Business Health Options Programs (SHOPs) to notify an employer of eligibility to purchase a qualified health plan (QHP) for their employees. Under the new rule, employers such as physical therapists in private practice would be left guessing about eligibility, and if they guessed wrong, purchased a QHP plan, and were later found ineligible, they would face a daunting and potentially costly appeals process. The rule also adds more options for exemptions from the individual mandate for health insurance—a mandate that lost its teeth in December 2017, when Congress approved a tax bill that eliminated the tax penalty for not having coverage.

    A full rundown of all the changes can be found on a fact sheet released by CMS.

    "These changes, all made under the guise of increased flexibility for states, amount to a weakening of the ACA through undermining the individual market and reducing health benefit protections," Gainer said. "APTA has long stated that there are many areas for improvement in the ACA and that we should be having discussions about needed changes. But these changes, no matter how they're characterized by CMS, are a move away from the real improvements consumers need."

    As APTA's Financial Solutions Center Marks 1 Year, Student Debt Looms Large in the News

    The challenges associated with college costs, student debt, and postgraduation financial management continue to make headlines, with very little progress being made in identifying ways to curb what seems to be a growing—and worsening—issue.

    APTA's Financial Solutions Center, launched 1 year ago this month, was designed to help physical therapists, physical therapist assistants, and students respond to those challenges by helping them deepen their financial knowledge and potentially refinance student debt at a discounted rate. But as the news will attest, the underlying issues affect a broad swath of those who are pursuing or have completed a college degree. Here's a roundup of recent coverage of college costs and student debt in the news:

    The Urban Institute released an interactive map that charts the intensity and distribution of student debt across the country.
    A new online tool allows users to zero in on county-by-county data on median student loan debt, monthly payments, nonwhite population share, and average household income, among other statistics. The (unsurprising) bottom line: student debt problems are generally more severe in areas with higher-cost colleges, but this article from Inside Higher Ed points out other nuances of the data.

    Where do people have the most college debt? Here are the top 10 states.
    CNBC distilled the data from the Urban Institute project and came up with a list of the "10 states where student debt is a big problem."

    Also from CNBC: an exploration of the disproportionate share of student debt held by women.
    According to the American Association of University Women, women hold about two-thirds of all student debt in the United States. This CNBC analysis identifies 4 major reasons for the disparity.

    Student loan forgiveness programs may be too costly to become widespread.
    Statistics website FiveThirtyEight.com looks at how the federal government may not have anticipated the cost of various loan forgiveness programs. Expansion of those programs is unlikely, and reductions in offerings may lie ahead.

    Many currently enrolled college students face financial trouble including hunger and homelessness.
    National Public Radio was 1 of several media outlets to report on the results of a recent survey of college students that found more than 1 in 3 reporting that they were food insecure, with the same ratio reporting that they were housing insecure. And nearly 1 in 10 said they were homeless.

    The APTA Financial Solutions Center features 3 major offerings: the APTA Financial Education Program, a customizable, multiformat learning platform powered by Enrich; the APTA Student Loan Refinancing Program, provided by Laurel Road, which offers discounts on loan repayment rates for eligible APTA members; and a lookup service that helps users find a Certified Financial Planner. In addition, the webpage offers resources on scholarships, employment, and other member discount opportunities.

    PTs Honored for International Volunteer Efforts

    Two physical therapists (PTs) are among the volunteers who have been honored for their efforts to strengthen the health care workforce in some of the world's most in-need places.

    Health Volunteers Overseas (HVO), the organization that educates local health care workforces in resource-scarce countries, announced that APTA member Janna Beling, PT, PhD, and Pamela Cole, PT, are among this year's recipients of its "Golden Apple Award" for exceptional contributions to improving global health care. Only a small number of volunteers among all types of health disciplines receive the prestigious award.

    Beling, who has been volunteering with HVO for 18 years, has logged more than 100 service days in Suriname, Malawi, and Vietnam, where she currently serves as project director for HVO's physical therapy program at the DeNang Orthopedic and Rehabilitation Hospital. Over her time as a volunteer, she also has mentored more than 60 PT students in global health delivery.

    Cole began her service with HVO in Haiti in 2013 at the Hopital Albert Schweitzer in Deschapelles, where she joined HVO's wound management project. A certified wound specialist, Cole was named project director the following year. According to the award announcement from HVO, "[Cole's] work with the site has demonstrated her commitment to relevant and practical education and her profound dedication to improving the lives of the Haitian people."

    HVO describes the Golden Apple award as an honor "that recognizes work in curriculum development, mentoring of faculty, students, clinicians, or fellow volunteers, didactic or clinical training, development of education resources, leadership, and/or extraordinary contribution to the sustainability and effectiveness of HVO." Since the awards program's launch in 2006, 19 PTs have received the recognition.

    PTJ: To Avoid Adverse Events, Rehab Facilities Need to Get to the Root of the Problem

    While rehabilitation services are “generally safe,” say Veterans Health Administration (VHA) researchers, “low risk does not mean no risk”—and adverse events still occur. A new study published in PTJ, APTA's scientific journal, outlines several concrete suggestions for improving patient safety that may apply to many civilian rehabilitation facilities.

    When serious adverse events are reported in the VHA, the facility often performs a root cause analysis to identify flawed systems, processes, or environmental conditions that need to be addressed. Authors examined 25 adverse event reports associated with physical therapy, occupational therapy, and speech-language pathology that occurred between 2009 and 2016.

    Researchers found that the most frequent adverse events were delays in care (32%) and falls (28%). Adverse events were most often caused by staff errors in policy and procedures (38.3%) and communications (25.5%).

    Authors also categorized the prescribed action plans as “strong,” “intermediate,” or “weak.” They concluded that 88% of action plans were strong, such as standardizing emergency terminology, or intermediate, such as improving documentation and verbal communication. The majority of recommendations, authors write, included changes in policy and procedures (48.8%) and staff training and education (21.3%).

    Authors' recommendations for mitigating risk of adverse events include:

    • Establishing clear emergency procedures and practicing them “at regular intervals with all staff”
    • Implementing strong actions to avoid adverse events, such as posting signs and standardizing terms for an emergency scenario
    • Ensuring that clinical staff have the skills to recognize “red flag” situations before they become emergencies
    • Using checklists to quickly identify patients at high risk of “deteriorating health” and those with acute illness who need immediate referral to another provider

    “Guidelines are beneficial, but unique clinics will need customized strong actions to optimize patient safety,” authors note. “Rehab departments can strengthen their safety record by developing practices and strong actions to ensure that all staff are prepared for an emergency response.”

    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.

    Bill to Weaken ADA Met With Strong Opposition From Senators, APTA, Other Organizations

    A bill that would weaken the Americans with Disabilities Act (ADA) may not be taken up for consideration by the US Senate, thanks to a coalition of senators and strong opposition from disability rights supporters including APTA.

    But the fight isn't over yet.

    Known as the ADA Education and Reform Act (HR 620), the bill would add a "notice and cure" clause to the ADA, effectively shifting the burden of compliance for public accommodations away from public establishments and on to the individual with the disability. Under HR 620 an individual with a disability who experiences discrimination in access to a public accommodation would have to notify the establishment owner, who would have up to 60 days to respond to the complaint. If no response or progress to address the issue is made, the individual with a disability would have to wait another 120 days before being allowed to file a lawsuit.

    Supporters of the bill, which passed in the US House of Representatives, characterized HR 620 as a measure aimed at discouraging frivolous lawsuits. Opponents including APTA see the bill as nothing less than an effort to undermine the ADA.

    "The ADA was landmark civil rights legislation barring discrimination on the basis of disability that was long overdue when it was signed into law more than 25 years ago," said Katy Neas, executive vice president of public affairs for APTA. "This attempt to erode the rights guaranteed in the ADA runs counter to the values of the physical therapy profession and its commitment to assisting all people with disabilities to set and achieve high goals."

    APTA has joined hundreds of organizations including AARP, NAACP, Paralyzed Veterans of America, and the National Disability Rights Network to oppose the bill. Recently, that opposition was taken up by 43 US senators, led by Sen Tammy Duckworth (IL), who signed on to a letter promising to prevent the measure from receiving a vote.

    "When supporters of the discriminatory HR 620 argue for its necessity by citing examples of alleged 'minor' accessibility infractions, they miss the point that this bill undermines the rights of people with disabilities, rather than protects them," the senators write. "There is nothing minor about a combat veteran with a disability having to suffer the indignity of being unable to independently access a restaurant in the country they were willing to defend abroad. There is nothing minor about a child with cerebral palsy being forced to suffer the humiliation of being unable to access a movie theater alongside her friends."

    Although the number of senators who have pledged to oppose the bill is sufficient to prevent passage, Neas says it's important that groups fighting HR 620 keep up the pressure.

    "The leadership of the senators who signed on to the opposition letter provides an important boost to our efforts to stop HR 620, but now is not the time to sit back and relax," Neas said. "We need to keep up the pressure to ensure that this bill never reaches the finish line."

    Individuals who want to join the opposition to HR 620 can find out more by visiting the Disability Rights Education and Defense Fund; APTA members and supporters are encouraged to visit the association's Legislative Action Center, and contact their senators to urge them to not consider HR 620 in the Senate.

    Researchers Say Frequent TV-Watching Comes With VTE Risk That Can't Be Eliminated Through Physical Activity

    Dedicated binge-watchers take note: a new study has found that in addition to its link to other well-established negative health effects, regular long periods of television viewing can also increase risk for venous thromboembolism (VTE)—and it's a risk that isn't dramatically offset by increased levels of physical activity (PA).

    The study tracked the self-reported television viewing and PA habits of 15,792 participants aged 45-64 over a series of surveys that began in 1987-1989, with follow-ups every 3 years after that, through 2011. Participants were part of the Atherosclerosis Risk in Communities (ARIC) research initiative administered in Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and suburbs of Minneapolis. Researchers excluded participants who reported baseline VTE or anticoagulant use.

    Participants were asked to rate their television viewing habits during leisure time as "never," "seldom," "sometimes," "often," or "very often" at baseline, visit 3 (1993-1995), and visit 5 (2009-2011). Researchers also tracked estimates of physical activity using the Baecke physical activity questionnaire, which asks respondents to estimate the duration and intensity of PA during the previous year. Demographic variables and body mass index (BMI) also were recorded. Results were published in The Journal of Thrombosis and Thrombolysis (abstract only available for free).

    For purposes of the study, researchers divided PA responses into 3 levels based on American Heart Association recommendations: "recommended" (75 or more minutes per week of vigorous intensity PA or 150 or more minutes of a combination of moderate and vigorous intensity PA), "intermediate" (up to 74 minutes per week of vigorous intensity PA or up to 149 minutes per week of a combination of moderate and vigorous intensity PA), and "poor" (no reported vigorous or moderate PA). They also reduced television-viewing categories from 5 to 4 after finding that no participant reported "never" watching television. Here's what they found:

    • Among all participants, 18.6% reported watching television "seldom," 46.8% reported watching "sometimes," 26.5% reported watching "often," and 8.1% reported watching "very often."
    • Age, sex, and race-adjusted models showed a positive dose-response correlation between frequency of television viewing and VTE incidence (a total of 691 events during the study period), with participants who watched television very often having a 1.71 times higher risk of VTE than those reporting "seldom" watching television.
    • The relationship of VTE risk to television viewing remained in place despite levels of PA. Participants who reported "recommended" levels of PA and watching television "very often" were found to have a 1.8 times greater risk of VTE than the seldom-watch group—a risk rating not much different from the 2.07 times increased risk associated with the group that reported watching television very often and having no PA.
    • BMI did play a role. Obese individuals who reported watching television "very often" were found to have a 3.7 times higher risk of VTE than normal-weight individuals who reported watching television “seldom.” However, authors note that higher BMI did not explain the associations observed between television viewing and PA.

    The relationship between sedentary behavior and poorer health may be well-known, but authors of this study believe they've added a new dynamic—the inability of PA to counteract the risk for VTE caused by prolonged sitting.

    "These results suggest that sedentary behavior is not just the opposite issue from [PA]," authors write. While they acknowledge that individuals who engaged in more PA did lower their risk of VTE independent of television viewing frequency, the researchers also point out that "even individuals who met the…recommended level of [PA], when they viewed TV very often, had an increased risk of VTE compared with those who met the recommended level and seldom watched TV."

    The results echo findings in a study from 2017 that concluded that risk of a mobility disability increased relative to television-viewing time, regardless of hours spent in PA.

    [Editor's note: for more information on the role of the physical therapist in the treatment of individuals diagnosed with VTE, check out this clinical practice guideline available at PTNow.]

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

    2018 APTA State Legislative Leadership Award Nominations Open

    APTA is calling on components to submit their nominations for the 2018 State Legislative Leadership Award, the annual association recognition of an individual member who has provided outstanding service and leadership on behalf of a component's legislative efforts.

    The award will be presented at the State Policy and Payment Forum, September 15-16, 2018, in Kansas City, Missouri. APTA will pay travel expenses for the selected recipient to attend the forum. In addition, the recipient will receive recognition on APTA's website as well as in its publications.

    Nominations will be accepted until Tuesday, May 1. More information on the award, including the nomination form (pdf) is available on the award webpage. Contact Angela Shuman with questions.

    From PT in Motion: PTs Pack a Punch When It Comes to Treating Combat Athletes

    "Combat athletes"—individuals who compete in sports such as boxing, wrestling, mixed martial arts, and Brazilian jiu jitsu—subject their bodies to intensely demanding situations that can lead to serious injury. But physical therapists (PTs) and physical therapist assistants (PTAs) can be instrumental in helping them recover from (and even prevent) those injuries and come out swinging—or kicking. Or both.

    The April edition of PT in Motion magazine features an exploration of the world of combat sports and the PTs who treat this special class of athletes. The PTs interviewed in the piece bring a wealth of experience to the topic—not only through their professional knowledge, but by way of their own involvement in combat sports, from karate to Muay Thai (Thai boxing) and Krav Maga, the Israeli self-defense and fighting system.

    Although the types of injuries PTs see vary somewhat by the type of combat sport in question, most PTs in the story say that hip and shoulder impingements aren't uncommon, with shoulder conditions often caused by postural problems that are a carryover from training.

    "Many of these patients stay in 'fight stance,' continuing to cover their chin as they go to their [daytime or salaried] jobs," Jessica Probst, PT, DPT, tells PT in Motion. "For these patients, my first goal is to fully normalize thoracic mobility, costal mobility, and cervical mobility through manual intervention."

    In addition to applying a PT's knowledge and skills to the challenges of treating the combat athlete, it's also helpful if the clinician has a thorough understanding of the sport itself, according to Charles Rainey, PT, DPT, DSc, MS, a lieutenant commander with the Naval Health Clinic in Hawaii. Rainey was himself a competitive combat athlete.

    "I have a common line of communication with the athletes because we speak the same language," Rainey says in the article. "So, when an athlete says he was put into a Kimura [an armlock] and adds, 'I didn't tap out quick enough,' I know which shoulder anatomical structures might have experienced trauma. I also know what physical demands these athletes face day in and day out, and I understand the dynamics of training, rest, and recovery."

    The feature article also includes perspectives from the athletes themselves, who share a sincere appreciation for the power of physical therapy to not only help them quickly recover from injury, but to prevent future injury.

    "As an athlete, extending the life of my body is key to my success as a professional fighter, so it is important to make sure everything is working properly and efficiently," Muay Thai athlete Kru Vivek Nakarmi tells PT in Motion. "A good PT is a key partner in injury treatment and prevention for athletes. Also it's important to avoid unnecessary surgery, and physical therapy often provides an effective alternative to surgery."

    "Working With Combat Athletes" is featured in the April issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.