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  • Study: PTs in Emergency Departments Reduce Likelihood of ED Revisits for Falls

    Talk about hammering home a point: just after publication of one study that says putting physical therapists (PTs) in hospital emergency departments (EDs) leads to better overall results comes another, unrelated research effort that pinpoints an example: namely, the effect PTs in the ED has on lowering the odds for an ED revisit for patients whose initial visit was fall-related. According to authors of the new study, consultation by a PT in the ED reduced the odds of a fall-related revisit within 30 days by 35% and within 60 days by 32%, compared with patients treated in EDs with no PT consultation.

    The study, published in Journal of the American Geriatrics Society, is based on Medicare claims data for individuals 65 and older who visited an ED for treatment related to a ground-level fall between 2012 and 2013. Researchers divided the claims data into 2 groups: individuals who received PT services during the ED visit (N=17,975) and a control group that didn't (N=542,302). Then, they tracked the rates of ED revisits for fall-related injury within 30 and 60 days of the initial visit. The data they examined also included injury severity (initial visit) as expressed in the New Injury Severity Score (NISS) as well as the presence of various comorbidities as identified in Medicare's Comorbidity Conditions Warehouse (CCW).

    While all-cause revisits were only slightly higher for the non-PT group at 30 days (21.7% for the non-PT group compared with 20.4% for the PT group) and just about the same at 60 days (about 30% for both), researchers found more striking differences when it came to revisits related to a fall. At 30 days, 1.7% of the PT group had revisited the ED for a fall, compared with 2.6% of the non-PT group; at 60 days, the rate was 2.6% for the PT group, compared with 3.6% of the non-PT group.

    There were some differences between the PT and non-PT groups. Individuals in the PT group tended to be slightly older than the non-PT group (average age of 82.4 compared with 80.6), and NISS ratings tended to be lower (less severe injury) among the PT group. Researchers explored the possibility that the lower NISS figures may have played a role in the revisit data, but when they compared individuals with an NISS of 0 (no injury noted) from both groups, they found revisit rates similar to the groups as a whole.

    Other factors, however, were related to greater chances of an ED revisit. Being male, Medicaid-eligible, and having a comorbidity raised the odds of a revisit; age, however, did not. Of the comorbidities most strongly linked to increased odds of revisit, Alzheimer's disease was associated with the strongest impact.

    Authors acknowledge that a PT consult in the ED may not always be appropriate, either due to the severity of injuries sustained or the intensity and prevalence of comorbidities such as dementia. Still, they argue, the consultation rates fall far short of where they should be, given the data they uncovered.

    "Our results suggest that EDs could play an important role in reducing fall-related ED revisits by linking individuals who have fallen with appropriate follow-up care, yet data suggest the likelihood of receiving a PT referral from the ED after a visit for a fall is rare," authors write. "Only 3.2% of older adults presenting for a fall-related ED visit received PT services during that visit, according to claims data."

    Further, authors point out, their study only tracked whether the individual received PT services during the initial ED visit—it didn't include data on whether the patients participated in any rehabilitation or falls prevention interventions after the visit, possibly "the most likely pathway through which reduction in future falls would be achieved."

    APTA is a strong supporter of the importance of PTs in the ED. A House of Delegates position promotes physical therapy as a professional service in the emergency care environment, and the association offers a webpage on the topic that includes an online toolkit, a video, and links to resources from the US Department of Health and Human Services.

    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.

    Study: Listen to the CPGs—Cardiac Rehab Works

    The clinical practice guidelines are right: Ambulatory cardiac rehabilitation (CR) should be routine for patients with cardiovascular events such as myocardial infarction, say authors of a study in the European Heart Journal (abstract only available for free). However, despite evidence of its effectiveness—including a nearly 50% drop all-cause mortality for patient who receive CR—CR “remains significantly underused,” they write.

    Authors compared the long-term outcomes of an early discharge CR program for patients with ST-elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, planned percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) versus no CR at all. At one hospital, all 839 patients received early CR; at a second, none of the 441 patients received CR, as it was not available. The hospitals were in the same geographic area.

    The CR program included evaluations, cycle-ergometer tests, and echocardiograms for all patients. Patients with STEMI or CABG received 5 weeks of exercise bicycle training followed by 6 weeks of gym training, supervised by a nurse and a physical therapist. The program was tailored to each patient’s needs.

    After a 5-year follow-up period, researchers analyzed the data to account for confounding demographic variables and found:

    • All-cause mortality in the CR group was lower (10%) compared to the non-CR group (19%).
    • Cardiovascular mortality was 2% for the CR group and 7% for the non-CR group.
    • Hospitalization for cardiovascular causes was lower for the CR group (11% for the CR group, 25% for the non-CR group).
    • Combined hospitalization for cardiovascular causes and cardiovascular mortality was 13% for the CR group, compared with 29% for the non-CR group.

    Authors think that the CR method used for their study "can be adopted without the use of expensive resources and can be applied in any ambulatory CR center," thus making it easier for CR to become more widespread.

    And it's that the lack of widespread use of CR that's the problem, they note.

    "Despite these evidences supporting the benefits of CR programs, this service is greatly underutilized, especially by women, elderly, and diabetic patients," authors write. "Referral and participation range is between 30% and 50% in Europe and it is around 25% in [the United States]."

    Past APTA President Ward Named Presiding Officer for Upcoming WCPT Meeting

    Former APTA president R. Scott Ward, PT, PhD, FAPTA, has been appointed by the World Confederation for Physical Therapy (WCPT) to serve as the presiding officer of its 19th General Meeting in Geneva, Switzerland, May 7-9, 2019.

    The General Meeting of the WCPT draws together delegates from over 100 member organizations, representing the primary physical therapy associations in their respective countries around the globe. As the presiding officer, Ward will conduct and coordinate the business of the delegate assembly of the General Meeting.

    Ward brings to this prestigious appointment a wealth of experience and expertise in governance, leadership, scholarship, and international service. He served as APTA’s delegate to the 17th WCPT General Meeting in Amsterdam in 2011 and as alternate delegate to the 18th General Meeting in Singapore in 2015. While president of APTA, Ward represented APTA at all meetings of the North American Caribbean region of WCPT. For more than 8 years he has provided education to physical therapists under the World Health Organization’s curriculum for the provision of manual wheelchairs in less-advantaged countries.

    Ward led APTA as its president from 2006 to 2012, was a member of APTA’s Board of Directors, was president of APTA’s Utah Chapter, and has received numerous awards and recognition for his longstanding service and contributions to physical therapy. He currently is chair of the Department of Physical Therapy and Athletic Training at the University of Utah and is a board member of the American Council of Academic Physical Therapy.

    "Scott stands out as a leader, and his experience in the US and internationally are well suited to WCPT,” said APTA President Sharon Dunn, PT, PhD in an APTA news release. “He has been an asset to APTA, both as a member, former president, and friend. And I am sure his leadership and guidance will be invaluable during WCPT’s General Meeting.”

    APTA is a founding member of WCPT and has participated in all 19 General Meetings. Dunn also will attend as a voting delegate along with 2 nonvoting delegates from APTA.

    QPP, MIPS, AAPMs: Learn What’s What With New Payment System Webinar Recordings

    The federal rule that would move physical therapists (PTs) into a completely new payment system for Medicare has not yet been finalized, but there's no better time than the present to start learning about the payment environment PTs will likely practice in come January 1, 2019. APTA has you covered.

    Now available: 2 recordings of recent APTA webinars focused on the Centers for Medicare and Medicaid Services' (CMS) Quality Payment Program (QPP), the system that CMS proposes to apply to PTs starting next year. If adopted as described in the 2019 physician fee schedule, QPP would initiate a major shift toward value-based payment for physical therapy under Medicare. QPP incorporates the Merit-based Incentive Payment System (MIPS) and the Alternative Advanced Payment Model (AAPM) programs.

    Both recordings are led by APTA staff members Heather Smith, director of quality, and Kara Gainer, director of regulatory affairs. Smith and Gainer are joined by Barbara Connors, DO, MPH, a chief medical officer for CMS, and Patrick Hamilton, MPH, a CMS health insurance specialist (Hamilton joins the August 23 webinar only). The recordings are free to APTA members.

    What's available:

    August 7, 2018, recording and supporting slide deck on MIPS and its relationship to QPP
    Format: Webinar with accompanying slide deck, followed by question-and-answer session
    Duration: 1 hour (approx)
    Recording: here
    Accompanying slide deck: here

    August 23, 2018, recording and supporting slide deck on QPP, MIPS, and advanced alternative payment models (AAPMs)
    Format: Question-and-answer session on all QPP provisions
    Duration: 1 hour (approx)
    Recording: here
    Related slide deck: here

    [TIP: The August 7 recording is accompanied by a slide presentation. The August 23 session is audio-only but supported by another slide deck not used during the actual webinar. Users of the August 23 materials may find it most helpful to listen to the audio recording first, and then view the slide deck.]

    The recordings are among the first in a series of resources APTA will provide on QPP. After the final rule is out, look for more webinars with CMS staff, APTA Learning Center offerings, and other online resources. Questions? Contact advocacy@apta.org.

    Study: Widespread Fall-Risk Screening Efforts, Followed by Appropriate Interventions, Could Produce 'Striking' Results

    If health care providers delivered consistent, widespread screening for fall risk, would it make a difference in health outcomes? Authors of a new study think so, asserting that assessments, followed by connecting patients to interventions that address their specific risk areas, could result in a "striking" reduction in falls and associated medical costs—as many 45,000 fewer falls in a single risk area, with a resultant $442 million drop in expenses.

    The study, published in the American Journal of Preventive Medicine, paired a review of meta-analyses on various fall interventions with data on the percentage of older adults with various risk factors for falls. Researchers established an "effectiveness" score for each intervention's ability to reduce falls over 1 year, determined the percentage of adults potentially eligible for each intervention, and then assigned a 10% compliance rate to estimate both the overall number of falls that could be prevented with each intervention and the number medically treated falls prevented. Last, they estimated the direct medical costs that could be averted through each intervention.

    The risk factors and related interventions studied were: poor balance associated with neurologic gait disorders or mobility problems addressed through tai chi or the Otago Exercise Program managed by a physical therapist (PT); taking a medication possibly linked to falls addressed through a medication review; vitamin D insufficiency addressed through vitamin supplementation; cataracts addressed through expedited first-eye cataract surgery; poor depth perception due to multifocal eyewear addressed through single-vision distance lenses for outdoor activities; and home hazards addressed through home modifications delivered by an occupational therapist. Here's what they found:

    • The fall risk affecting the largest number of adults aged 65 and over was home hazards, with an estimated 38 million individuals demonstrating a risk factor for falls. The intervention—home modifications delivered by an occupational therapist—was estimated to result in the prevention of nearly 400,000 falls, resulting in $442,000 in medical cost reductions.
    • Visual impairments, either from cataract or poor depth perception related to eyewear, was a risk factor estimated to affect 27.3 million older adults, with the related interventions (cataract surgery and single-vision distance lenses) preventing an estimated 500,641 falls combined.
    • The Otago program managed by a PT potentially could be used on a subset of 11.5 million older adults with neurologic gait disorders and 13.1 million older adults with mobility problems, resulting in a reduction of a little more than 62,000 falls and $229 million in averted medical costs.
    • Even a basic medication review and modification program could produce results if applied consistently, according to the study, with an estimated reduction of 114,000 falls leading to a medical cost reduction of $418 million.

    When all the numbers were crunched, researchers foundhe results convincing. "The potential for reducing falls and averting the associated direct medical costs was striking," authors write, adding that the falls reduction and savings estimates are likely on the conservative side, since they looked at risks factors separately rather than approaching the issue from the more realistic perspective of individuals having 2 or more risk factors for falls.

    Authors acknowledged that in addition to the its focus on individual risk factors, the study also was limited through its application of a 10% participation rate that may or may not be accurate across all interventions, and did not consider the costs associated with implementing the various interventions. However, authors pointed out, an earlier study of the Otago program and a tai chi program known as "Moving Better for Balance" showed that both programs were cost-effective.

    "Healthcare providers are well positioned to implement evidence-based clinical interventions, such as those described in this analysis," authors write, through a combination of easy-to-conduct in-office screenings for medications and vitamin D intake, referral to specialists, and community- and home-based interventions. "When put into practice, clinical fall prevention efforts…could prevent falls and help America's older adult population live safe, healthy, and independent lives."

    APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has also published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.

    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.

    An APTA National Student Conclave Sneak Peek, Courtesy of the Pulse Blog

    APTA has a vibrant, diverse, and engaged student member population. But you don't have to take our word for it: see for yourself at the 2018 APTA National Student Conclave (NSC), the association's premier event designed specifically for students in physical therapist (PT) and physical therapist assistant (PTA) education programs.

    This year's conference, set for October 11–13 in Providence, Rhode Island, features a wide range of speakers and programming that touches on not only the issues facing current students, but the professional world after the diploma. Advance registration rates end on September 14.

    Want to get a taste of what NSC will be delivering? Check out these APTA Student Pulse blog posts authored by presenters at the upcoming meeting.

    Our Profession: Thriving With the Help of Young Leaders
    APTA Chapter Presidents Michael Gans, PT, DPT (CT); Jason Harvey, PT, MSPT (RI); Heather Jennings, PT, DPT (MA); Mark Mailloux, PT, MBA (NH); and Matt Hyland, PT, PhD, MPA, vice president of APTA, write about the challenges of being a #FreshPT and the rewards of stepping up to involvement with APTA and its chapters.

    Session info: "Millennial and Gen X Leaders Share Their Stories," October 13, 12:30 pm–1:30 pm; or 1:45 pm–2:00 pm

    The Wanderlust PTs
    Ever considered life as a traveling PT or PTA? Gabe Renzi, PT, DPT, and Jessica Renzi, PT, DPT, are living it and helping others interested in experiencing the same.

    Session info: "Traveling PT 101: Make Travel Your Therapy," October 12, 1:15 pm–2:15 pm; or 4:45 pm–5:45 pm

    Nutrition and Physical Therapy: A Powerful Combination
    Nutrition specialist Joe Tatta, PT, DPT, outlines 5 ways to integrate nutrition into your PT practice.

    Session info: "PT + Nutrition: The Perfect Combo to Help You Stand Out," October 13, 12:30 pm–1:30 pm; or 1:45 pm–2:00 pm

    Cancer Rehabilitation: Challenging and Incredibly Rewarding
    Steve Wechsler, PT, DPT, provides a glimpse into the important role PTs and PTAs can play in cancer rehabilitation.

    Session info: "Cancer Rehabilitation: What Every PT and PTA Needs to Know," October 13, 12:30 pm–1:30 pm; or 1:45 pm–2:00 pm

    Tools to Treat the Whole Patient
    Lindsay Walston, PT, DPT, board-certified neurologic and orthopaedic specialist, sees an important connection between orthopaedic and neurologic rehabilitation.

    Session info: "Bridging the Gap Between Orthopaedic and Neurologic Rehabilitation," October 12, 1:15 pm–2:15 pm; or 4:45 pm–5:45 pm

    Riding the Wave in a Changing Community
    Carol Ferkovic Mack, PT, DPT, could feel her community changing—so she changed her career path and started up a sports specialty practice.

    Session info: "Building a Sports Specialty Practice from the Ground Up," October 12, 1:15 pm–2:15 pm; or 4:45 pm–5:45 pm

    PT, PTA, Student Involvement in Special Olympics is Improving Health…and Changing Attitudes

    2018 - 08 - 22 - Special Olympics
    APTA President Sharon Dunn, PT, PhD (standing, left) and Vicki Tilley, PT, look on during a FUNfitness screening at the recent Special Olympics USA National Games. Tilley is co-global clinical advisor for the program.

    Vicki Tilley, PT, and Donna Bainbridge, PT, ATC, EdD, wanted to make a difference in the lives of others by working with Special Olympics. Along the way, Special Olympics returned the favor.

    "I have a different lens now," Tilley said. "Being able to engage, explore, and interact with the ID [intellectual disabilities] population in a way that's positive has changed the way I think about people in general, and about inclusion and access."

    "My experiences with Special Olympics have shaped my entire career path in practice, research, and programming," Bainbridge added. "I have a better understanding of the health needs of individuals with ID, and what we as physical therapists can do to improve the lives and function of people with ID at all ages."

    As Special Olympics celebrates its 50th year, Tilley and Bainbridge are marking their 19th year with the program, and their 18th with "Healthy Athletes," an initiative that brings health professionals and students from multiple disciplines to provide education, screenings, and other services to athletes. Both were instrumental in the creation of FUNfitness, the branch of Healthy Athletes responsible for screenings and education around balance, strength, flexibility, and aerobics fitness. FUNfitness is primarily performed by physical therapists (PTs), physical therapist assistants (PTAs), and students.

    Officially, Tilley and Bainbridge serve as co-global clinical advisors for FUNfitness. Together, they help to guide not only the programs offered at every Special Olympics world and national event, but a worldwide outreach and education initiative that helps health care providers better understand the often-overlooked health needs of individuals with an intellectual disability. But both Tilley and Bainbridge are more than program managers—they're hands-on PTs who love being able to provide services at the games alongside other volunteers.

    Over the summer, Tilley, Bainbridge, and a contingent of PTs, PTAs, and students brought their skills to the Special Olympics USA Games in Seattle, where they provided nearly 1,500 services to 761 athletes who visited the FUNfitness area of the Healthy Athletes program. Overall, Healthy Athletes provided 7,125 screenings to 1,762 athletes during the games. Physical therapy education programs that participated included those from the University of Washington, the University of Puget Sound, Pacific University, Touro University – Nevada, Eastern Washington University, and PIMA Medical Institute.

    According to Bainbridge, the origins of the physical therapy profession's involvement with Special Olympics can be traced back to 1999. Back then, Bainbridge worked for APTA, serving as director of practice. The association saw an opportunity and seized it.

    "The association's involvement with Special Olympics was and is a great fit that came at just the right time," Bainbridge said. "At the time, APTA was focused on changing the paradigm of the profession from just rehab and the medical model to health and wellness—our involvement with Special Olympics was one of our first steps in that direction."

    Tilley's involvement came about the same year, when the world games came to her home state of North Carolina. Like APTA national, the North Carolina chapter of APTA saw an opportunity—to pilot the idea of providing a flexibility screen—and asked Tilley to help out. At first, Special Olympics organizers didn't quite understand the role that PTs and PTAs could play, Tilley said. "They understood the idea of an athletic trainer on the field to help with injury, but we had to show them that we could offer even more off the field to help with injuries and keep athletes injury-free," she explained.

    After seeing the PTs and PTAs in action, Special Olympics didn't need much more convincing.

    "After the games they liked it so much, when we met with Special Olympics about expanding to balance, strength, and cardiovascular fitness, they were on board," Tilley said.

    Both FUNfitness and the larger Healthy Athletes program are helping to spread an important concept—that ongoing health matters.

    "Healthy Athletes was in this nice little add-on space, in a sense," Tilley said. "It was originally thought of as add-on features—it wasn't something that coaches thought was really important. But then over time, the coaches began to connect the dots, and started to see that this isn't just a once-a-year thing, and that overall health is really important." Thanks to additional funding from the US Centers for Disease Control and Prevention, and subsequent donations from the Golisano Foundation, Special Olympics and the Healthy Athletes program is expanding efforts to promote community-based year-round health for individuals with ID around the globe.

    "Special Olympics has also realized that the ultimate key to change lies in systems and policy change, so this has become a new focus," added Bainbridge. "We're now working with [the World Health Organization], [the Pan American Health Organization], and [the United Nations Educational, Scientific, and Cultural Organization] on efforts to expand services equitably to all."

    Those efforts, both locally and globally, are at the heart of why, after years of more informal collaboration, APTA established a formal partnership with Special Olympics in 2017, according to APTA CEO Justin Moore, PT, DPT. This year, APTA established an even stronger presence at the games, with Moore, APTA President Sharon Dunn, PT, PhD, and the president of the APTA Sports Physical Therapy Section in attendance, along with the president and executive director of the Washington chapter of APTA.

    Moore described the partnership as one that allows APTA to help live out its mission of building a community that advances the profession of physical therapy to improve the health of society. "What [Special Olympics is] doing in health care by trying to create a more equitable and inclusive health care system is truly incredible, and we are privileged to be in this partnership," Moore said in an interview. "What a great lasting legacy that Special Olympics is providing these athletes."

    Particularly inspiring, Moore believes, is the way Special Olympics does its work through a strong commitment to collaboration. "It helps our profession understand—how do we work with dentists, podiatrists, dieticians, and others in collaborative ways and always put the athlete, the patient, first?" he said.

    When it comes to collaboration, Tilley thinks that the physical therapy profession has much to offer other health care disciplines, if for no other reason than the variety of patients often seen by PTs and PTAs. "Dentists, optometrists, nutritionists, nurses…they don't necessarily get much exposure to people with ID," Tilley said. "For PTs, we learn how to work with different populations—it's just not as much of a reach for us."

    "The importance of the contributions of PTs, PTAs, and students can't be overstated," Bainbridge said. "We could not stage FUNfitness in our US states without the help and support of these professionals—they are both our clinical directors and our volunteers, and nothing would happen without them."

    But as Bainbridge points, out, it's not all about what PTs can do for Special Olympics—it's also about what Special Olympics does for the profession and for the person who volunteers.

    "Involvement with Special Olympics is a critical value for physical therapy professionals," Bainbridge said. "It allows them to work with and find best ways of communicating with persons with cognitive impairment, a skill that will help them with many other types of patients as well. And it exposes them to a population that they might not usually see in their practices. Although we work with persons with developmental disabilities who might also have an intellectual disability, we much less frequently see those who only had ID unless they have another physical problem. So, this is a population that we do not see routinely, who obviously, from our data, have problems with fitness in all its components."

    "Healthy Athletes and FUNfitness allow providers to see these athletes as part of the wider community," Tilley said. "They come to realize that individuals with ID are just people, with many of the same interests, challenges, and emotions they have—and that can have a big impact."

    According to Tilley, that interaction and understanding can change entire outlooks. Thanks to her involvement with Special Olympics, Tilley explained, she now tends to look at any new physical therapy program, approach, or modality with an eye toward how it may or may not be able to be applied to the population of individuals with Id. Another impact is that she has made Special Olympics a part of her family: both her 18-year old daughter and 21-year-old son have been volunteering with Special Olympics for as long as they can remember. Tilley believes their participation has enriched her kids' lives immeasurably.

    Bainbridge echoes Tilley's comments. "I have made so many wonderful relationships with athletes and their families and caregivers," she said. "Those relationships and experiences have contributed to who I am today, and have given me great understanding, patience, and a concern for equity that I bring to everything I do."

    MedPAC Recommendations for PT Payment Decreases Met With Strong Responses From APTA, Private Practice Section, Alliance

    The Medicare Payment Advisory Commission (MedPAC) may be right in its claim that Medicare Part B payment should be increased for ambulatory evaluation and management (E&M) services, but it's dead wrong when it says that those increases should be paid for by cuts to physical therapy-related payment: that's the message APTA, its Private Practice Section (PPS), and the Alliance for Physical Therapy Quality and Innovation (Alliance) delivered to MedPAC recently.

    The comments were provided in response to MedPAC's 2018 report to Congress on Medicare. In the chapter titled "Rebalancing Medicare's physician fee schedule toward ambulatory evaluation and management services,” MedPAC argues that ambulatory E&M services—defined by MedPAC as office visits, hospital outpatient department visits, visits to patients in other settings such as nursing facilities, and home visits—are "underpriced." That's a problem in need of fixing, MedPAC says, because E&M services "are critical for both primary and specialty care."

    MedPAC's suggestion for how to pay for repriced E&M services, however, isn't exactly a study in nuance. The commission recommends that the increase can be accomplished in a way that won't hurt Medicare's bottom line simply by reducing payment for a wide range of "procedures, images, and tests" that it believes are over-valued—including physical therapy-related services. Depending on the procedure, imaging, or test in question, the recommended cuts are as high as 3.8%.

    In separate letters—1 from APTA alone, and 1 from the 3 organizations jointly—APTA, PPS, and the Alliance write that the goal of adjusting pricing for E&M services is laudable, but when it comes to physical therapy, the logic behind MedPAC's pay-for approach is built on fundamental misunderstandings of the payment code valuation process, the impact of the Multiple Procedure Payment Reduction (MPPR) payment policy, and the true role of the physical therapist (PT) in health care, among other concepts.

    "Our organizations have concerns about the Commission's recommendation to reduce the value of physical therapist services," the combined group letter states. "Such reduction to reimbursement would exacerbate the overall inadequacies in physical therapy reimbursement…and harm the sustainability of the value of the physical therapy profession, and in turn diminish clinical care and outcomes and increase the cost of care to thousands of Americans each and every day."

    At the heart of the MedPAC argument is an assertion that certain non-E&M services have experienced "efficiency gains" over time, making them less complex and time-consuming for providers, and thus ripe for reimbursement reductions. The letters from APTA and the combined group suggest that MedPAC is ignoring important Medicare policies that already address that exact issue—particularly the process for reassessing possibly "misvalued" coding and the MPPR, which requires a reduction in payment when multiple procedures are provided to a patient on the same day of service.

    Essentially, the letters argue that the misvalued code initiative—a process that resulted in revalued codes for many physical therapy-related services in 2017—is already serving as a check against so-called efficiency gains, and that adopting a separate reduction scheme that ignores that process courts disaster.

    "Our organizations have serious concerns that payment policy recommendations which supersede the misvalued codes initiative would not only harm beneficiary accessibility to services offered by physical therapists, but would also compound the payment challenges facing small, medium, and large-sized physical therapy practices," the joint letter states. "To that end, we fail to see where…the Commission assessed how beneficiary access to physical therapy would be impacted should their recommendation be adopted by CMS."

    APTA, PPS, and the Alliance argue that in a similar way, the MPPR already addresses the idea of payment reductions related to efficiencies—a factor also seemingly ignored by MedPAC when it developed its proposal.

    "Should CMS move forward with the Commission's suggestions to further reduce reimbursement for services furnished by physical therapists, the 50% MPPR on the [practice expense] for physical therapy services would duplicate the payment adjustments that MedPAC is recommending to account for the 'efficiencies' in therapy services," the joint letter states. "Moreover, because commercial payers frequently follow CMS's lead regarding code valuations, physical therapists would be subjected to even lower reimbursement from such payers, further challenging their ability to continue to deliver care to patients."

    The APTA letter extends a similar criticism to MedPAC's lack of attention to the potential impact of a proposal to introduce payment differentials for services provided by physical therapist assistants (PTAs), asserting that that change alone could result in reductions in care, only to be made worse through adopting the MedPAC recommendations.

    Beyond those failures in analysis, the MedPAC proposal also includes a more general lack of awareness of the value of physical therapy—both as a key player in value-based care, and an important tool in pain management in ways that help reduce the severity of the opioid crisis in the United States.

    "Moving forward, it is imperative that [the US Centers for Medicare and Medicaid Services] acknowledge the important role physical therapists play in prevention and treatment of acute and chronic pain," the joint letter states. "MedPAC's proposal to reduce reimbursement for physical therapy services at a time when benefit design and reimbursement models should support early access to nonpharmacological interventions—including physical therapy—for the primary care of pain conditions is short-sighted and unfounded."

    The APTA letter also characterizes the MedPAC proposal as "contradictory to the commission's current efforts to incentivize value over volume."

    "Reducing reimbursement for highly sought-after (and consequently, highly utilized) services will force providers to find ways to increase the volume of services; thus, in future years, the commission will be prompted to recommend greater reimbursement recommendations, and so forth, resulting in a vicious, circuitous cycle that may encourage fraud, waste, and abuse," APTA writes. "We recommend the commission examine payment policies that will incentivize providers, including PTs, to transition to a value-based payment system, as opposed to putting forth proposals that promote the delivery of unnecessary interventions."

    The APTA letter also argues that there's a solid case to be made for including physical therapy among the E&M services in need of repricing, asserting that PTs meet MedPAC's definition of E&M services as those provided by clinicians to diagnose and manage patients' chronic conditions, treat acute illnesses, develop care plans, coordinate care across providers and settings, discuss patient preferences, and engage in shared decision-making with patients. According to APTA, that's what PTs do, too.

    "PTs, like most health professionals, are educated to provide services in the health services delivery environment," APTA writes. "PTs are also uniquely educated and trained to adapt health care recommendations to the community environment where individuals live, work, and play. This knowledge and ability enables PTs to adapt medical recommendations to specific environments, to meaningfully interpret health recommendations, to help individuals modify their health behaviors, and to ensure that clinical and community services are integrated, available, and mutually reinforcing."

    What's the Latest at CMS? Your 2018 Guide to Recent Proposed and Final CMS Rules

    The Centers for Medicare and Medicaid Services (CMS) spent its spring and summer issuing proposed and final rules, some of which contain major shifts in the payment and reporting systems for physical therapists (PTs) in private practice, as well as those working in skilled nursing facilities (SNFs) and home health settings.

    Here's a quick guide to the status of some of these rules and resources available from APTA—including an August 23 webinar, cohosted by APTA and CMS, focused on the proposed transition of physical therapists to the Quality Payment Program (QPP) beginning in 2019 (12:00 pm–1:00 pm, ET).

    Medicare Physician Fee Schedule (MPFS)
    Status: Proposed; comments due September 10
    Resources:CMS fact sheet, PT in Motion News series (part 1, part 2, part 3), APTA fact sheets (part 1, part 2, part 3); recorded webinar (from August 7); August 23 webinar

    It's hard to overstate the magnitude of the changes that will be faced by PTs in private practice who furnish services under Medicare if the proposed fee schedule is adopted as written. Basically, these PTs would be subject to an entirely new payment system, known as the Quality Payment Program—a significant shift toward value-based care models. At the same time, the unpopular Functional Limitation Reporting system would go away—thanks in part to APTA’s continued advocacy against it.

    Under QPP, qualifying PTs would have a choice of participating in the Merit-based Incentive Payment System (MIPS) or—if available to them—an advanced alternative payment model (AAPM). MIPS requires reporting in 4 performance categories (PTs in 2019 will be required to report under only 2 categories: quality and improvement activities), with providers earning points in each category. An annual MIPS score would determine whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Several of the data points must be reported electronically through certified electronic health record (her) vendors or registries such as APTA’s Physical Therapy Outcomes Registry. The inclusion of PTs comes as MIPS enters its third year of the program.

    The AAPM-based QPP option allows participants to be exempted from MIPS and opens up the possibility of a 5% annual payment bonus (beginning in 2021 for the 2019 performance year) in addition to payment adjustments up or down; however, certain patient or payment thresholds must be met. The proposed rule also includes an option for QPP participation through Medicare Advantage.

    But that's only 1 element of the fee schedule. The proposal also contains provisions around coding for services furnished by physical therapist assistants (PTAs), and a slight boost in payment. And yes, CMS intends to continue use of the KX modifier for claims that exceed an annual dollar threshold (currently $2,010 for physical therapy and speech-language pathology services combined).

    [Editor's note: don't miss the August 23 live webinar on QPP, MIPS, and Advanced APMs hosted by CMS and APTA.]

    Home Health Prospective Payment System (HH PPS)
    Status: Proposed; comments due August 31
    Resources: CMS fact sheet; PT in Motion News coverage

    Another big change in the works: CMS wants to adopt an entirely new payment methodology for home health, known as the Patient Driven Groupings Model (PDGM). The new system, mandated by the Bipartisan Budget Act of 2018, lays out a new payment landscape through changes that include shifting care from 60-day to 30-day episodes, removing therapy service-use thresholds from case-mix parameters, and establishing a 5-parameter system that plays into payment determinations.

    Under the proposed rule, payment for 30-day episodes would be tied to 1 of 216 payment groupings that reflect the patient's status related to 5 major factors: timing, admission source, clinical group, function level, and comorbidities. The proposed rule also includes changes to certifying and recertifying patient eligibility for continued home health care; an allowance for home health agencies to report the cost of remote patient monitoring; and a transition toward payment for home infusion therapy. The changes proposed by CMS would result in an estimated 2.1% increase in payments in 2019, or about $400 million.

    Skilled Nursing Facility Prospective Payment System (SNF PPS)
    Status: Final, effective October 1, 2018
    Resources: CMS fact sheet; PT in Motion News coverage; APTA fact sheet

    SNFs were not exempt from a major payment revamp, either: effective FY 2020—which begins October 1, 2019—CMS will do away with the Resource Utilization Groups Version IV (RUG-IV) process and implement an entirely new system called the Patient-Driven Payment Model (PDPM). The model bases payments on a resident's classification among 5 components including physical therapy and uses case-mix groupings as multipliers to establish a per-diem rate. The rule also includes a 2.4% payment increase for FY 2019.

    Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)
    Status: Final, effective October 1, 2018
    Resources:CMS fact sheet; PT in Motion News coverage; APTA fact sheet

    For PTs, the biggest news here is that CMS is dropping the Functional Independence Measure instrument from the IRF-PAI, effective FY 2020—which begins October 1, 2019—and eliminating reporting requirements around methicillin resistant staph aureus (MRSA) infection and the percent of patients assessed and given the seasonal flu vaccine. CMS also will allow physicians to lead team meetings remotely and will evaluate that change with an eye toward expanding the flexibility to other team members.

    Inpatient Prospective Payment System (IPPS)
    Status: Final, effective October 1, 2018
    Resources: CMS fact sheet; PT in Motion News coverage

    CMS is upping payment to acute care hospitals (ACHs) to the tune of some $4 billion and reducing reporting requirements. The final rule drops 40 quality-reporting measures for hospitals involved in Medicare and Medicaid EHR incentive programs, but it backs away from a proposal to eliminate 4 measures of patient safety and retools (and renames) the EHR Program, now called the "Promoting Interoperability Program." Long-term care hospitals (LTCHs) will see an estimated 0.1% drop in payment and an end to a CMS 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 rule makes the change permanent.

    Outpatient Prospective Payment System (OPPS)
    Status: Proposed, comments due by September 24
    Resources:CMS fact sheet; PT in Motion News coverage 

    Should Medicare reimburse outpatient facilities owned by hospitals at higher rates than it does independent providers' facilities? CMS doesn't think so. The proposed rule would eliminate the payment differential that favors "off campus" hospital-owned facilities, resulting in an estimated $760 million in savings. Those savings would help to offset an overall payment increase of $4.9 billion—a 1.25% increase. The proposed rule also ups payment for ambulatory surgical center (ASC) payment by 2% and establishes separate payment for nonopioid pain management drugs that function as a supply when used in an ASC surgical procedure.

    Short-Term, Limited-Duration Health Plans
    Status: Final, effective October 2, 2018
    Resources: CMS Fact Sheet; PT in Motion News coverage

    Not really a CMS rule, but something worthy of attention. The US Department of Health and Human Services has expanded the use of short-term, limited duration health plans that were originally intended to provide consumers with temporary gap coverage after changing jobs. Now, consumers can enroll in short term plans for just under a year, with an option to renew for up to 3 years. Short-term plans differ from typical Affordable Care Act (ACA) marketplace health plans in that they do not have to cover essential health benefits or ensure certain consumer protections required by the ACA, including those related to preexisting conditions and continued coverage.

    Study: Emergency Department PTs Are Just What the Doctor Ordered

    More hospitals should incorporate physical therapists (PTs) into their emergency department (ED) workflow, say authors of a review in the American Journal of Emergency Medicine (abstract only available for free). Hospitals that have done so already, they write, have seen “positive impacts in clinical care and patient and physician satisfaction” due to PT expertise, “extended bedside care,” and patient education.

    Researchers examined the typical ED PT practice patterns and clinical outcomes, intangible impacts of ED PT services, and considerations for building an ED PT program. Study coauthors include APTA members Kyle J. Strickland, PT, and Michael T. Lebec, PT, PhD.

    According to the authors, ED PTs are most often consulted for patients with acute musculoskeletal issues, not only to provide patient education and develop a plan of care for these conditions, but to help physicians make a more specific diagnosis to begin with. “Nearly half of all medical schools do not require curriculum in musculoskeletal medicine,” authors write, adding that emergency medicine training is geared toward identifying and managing life-threatening conditions.

    According to preliminary reports, hospitals with ED PT programs have noticed increased patient and provider satisfaction, decreased wait times, and decreased admission rates for patients with orthopedic symptoms.

    Physical therapists also may be consulted for patients with suspected peripheral vertigo after a physician has excluded more serious causes. Due to the protracted assessment time for such patients, PT involvement and expertise takes some of the burden off physicians who cannot devote uninterrupted time.

    Emergency department PTs are increasingly being called to assist with gait training and patient disposition planning. The ED physicians who have access to PTs cite PT evaluation of patient mobility and safety as “a significant added value,” authors write.

    Authors hypothesize that the inclusion of ED physical therapist services also may increase workplace satisfaction, improve patient flow, decrease opioid usage, reduce unnecessary diagnostic imaging, decrease downstream health care utilization, and prevent unnecessary hospitalization.

    Hospitals wishing to create such a program can learn from the experiences of existing programs, authors suggest. Important steps in implementation “include engaging with key stakeholders in physical therapy and emergency medicine, estimating initial clinical volume and staffing needs, and targeting appropriate personnel for the unique practice environment of the ED,” they write.

    "This review is consistent with a position that APTA has supported for several years—that PTs have an important role to play in the ED," said Anita Bemis-Dougherty PT, DPT, MAS, APTA's vice president of practice. "In 2008, the association's House of Delegates adopted a position promoting physical therapy as a professional service in the emergency care environment, but that official statement reflected beliefs that were widely shared in the profession for some time." The official House motion can be found here. In addition, APTA offers a webpage on the topic that includes an online toolkit, a video, and links to resources from the US Department of Health and Human Services.

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

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

    Innovation + wellness = Grouphab: Patrice Hazan PT, DPT, MA, and Charlotte Walter PT, DPT, discuss the "grouphab" wellness program they designed to help keep people of all ages mobile and injury-free. (WSPA News 7, Spartanburg, NC)

    Lights, camera, caring: Winston-Salem State University PT students Sam Lucier, SPT; Corey Shelton SPT; and Apu Seyenkulo, SPT, discuss the benefits of a WSSU program that incorporates filmmaking into the physical therapy curriculum. (Fox 8 News, Winston-Salem, NC)

    Balance in all things: Libby Krause PT, DPT, and Lori Ginoza PT, DPT, help a USC doctoral student regain her balance after removal of an acoustic neuroma. (University of Southern California News)

    Return of the PT Ninja Warrior: Todd Bourgeois PT, DPT, who participated in the American Ninja Warrior competition in 2014, is back. And this time he's headed for the finals. (Ninjaguide.com)

    Concussion consciousness: Amanda Stewart, PT, explains the signs of possible concussion, and what to do after a concussion diagnosis. (KUTV 2 News, Salt Lake City, UT)

    Doing business like nobody's business: Bryan Wright PT, DPT, owner of Wright Physical Therapy in Twin Falls, Idaho, was named national Small Business of the Month for July. (legistorm.com)

    Alabama's a sweet home for Go Baby Go: University of Alabama-Birmingham PT students joined with UAB engineering students and occupational therapy students to adapt toy vehicles for children with mobility challenges. (CBS42 News, Birmingham, AL)

    When neck pain is a pain in the neck: Karen Litzy, PT, DPT, offers pointers to avoid neck pain. (Health.com)

    Making connections to the pelvic floor: Adrianne McAuley PT, DPT, and Erin Hartigan, PT, share perspectives—and plans for research—on the ways weak pelvic floor muscles can impact recovery from injury to other areas of the body. (Bangor, ME, Daily News)

    Collaboration is crucial: Eric Lederhaus, PT, and Rebecca Fung PT, DPT, write on the importance of applying integrated care to the opioid crisis. (Managed Care magazine)

    Quotable: “I think it’s something that I really want to do because you get to help so many people. You’re working with patients from different backgrounds with the same goal: to get better." - High schooler Heather Artz, on why she wants to pursue a career in physical therapy. (Herkimer, NY, Times-Telegram)

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

    2018 ELI Fellows Class Brings APTA's Educational Leadership Program Past 100 Graduates

    Sixteen seasoned physical therapy educators have deepened their knowledge and skills over the past year, thanks to the APTA Education Leadership Institute (ELI) Fellowship. The latest cohort pushes the program past the 100-graduate mark.

    These physical therapists (PTs) made up ELI's seventh cohort of ELI fellows when they graduated in July after completing a yearlong higher education program that consisted of:

    • 9 online modules provided by content expert faculty;
    • 3 2-day face-to-face mentorship sessions and ongoing mentorship provided by experienced physical therapy program directors;
    • higher-education mentorship provided by physical therapy education leaders; and
    • implementation of a personal leadership plan and an institution-based leadership project.

    The ELI Fellowship strives to provide developing and aspiring program directors in physical therapist and physical therapist assistant education programs with the skills and resources they need to be innovative, influential, and visionary leaders who can function within a rapidly evolving, politico-sociocultural environment.

    Partners who help promote and support the ELI Fellowship include the American Physical Therapy Association, American Council of Academic Physical Therapy, Academy of Physical Therapy Education, and PTA Educators Special Interest Group. Find out more information about the ELI Fellowship on APTA's website, and view video testimonials of previous ELI graduates. Questions about the program? Contact eli@apta.org.

    The program was first accredited in 2012 by the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE), the accrediting body for postprofessional residency and fellowship programs in physical therapy, and it was reaccredited in 2017 for a 10-year period.

    Short-Term Insurance Rule Adds More Uncertainty to Care

    As APTA continues to advocate for the maintenance of essential health benefits (EHBs) in insurance offered through Affordable Care Act (ACA) marketplaces, the association and other stakeholders are facing another potential challenge to patient access to care: private insurer short-term, temporary health plans that can skirt many ACA requirements around EHBs, preexisting conditions, and continued coverage.

    Earlier this month, the Department of Health and Human Services (HHS) adopted a final rule on the short-term plans, allowing the policies to provide 1 year of coverage, renewable for up to 3 years. Previously, the plans could only be used for a maximum of 3 months.

    The plans are intended to offer a cheaper insurance alternative than plans available through the ACA (although most individuals who purchase insurance through the ACA marketplaces receive subsidies that lower the out-of-pocket costs). But they are not required to comply with many of the consumer protections included in ACA plans. Instead, the plans are able to deny coverage of a preexisting condition, drop coverage should a customer's health status change, and refuse coverage for services such as mental health, prescription drugs—and, possibly, physical therapy.

    "These plans create more options, but they also create more uncertainty for patients and physical therapists," said Kate Gilliard, APTA regulatory affairs senior specialist. "We're concerned that, perhaps unknowingly, patients who purchase these plans may be moving onto plans that don't cover physical therapy or that offer very limited physical therapy benefits."

    Gilliard said the short-term plans were a hot topic at a recent National Association of Insurance Commissioners (NAIC) conference she attended as a representative of APTA.

    "The plans received mixed reviews from the commissioners," Gilliard said. "Some states openly thanked HHS for allowing more consumer options and for giving states more control over their own markets, but other states criticized the plans for the weaker consumer protections and predicted that the plans will cause prices in the ACA marketplace to rise." According to Gilliard, NAIC attendees described a variety of approaches being taken by states in reaction to the HHS rule, from accepting the provisions as written, to placing shorter time limits on coverage, to banning the plans completely.

    "Many of these states are trying to frame these plans as options that should only be used when consumers are in between major medical plans—like when they are between jobs or waiting for ACA marketplace open enrollment—and not to be relied upon as real, full health insurance," Gilliard said.

    APTA regulatory affairs staff are reviewing the rule to better understand potential impacts to patients and the physical therapy profession. However, the association has already gone on record in support of consistent EHBs and has voiced its opposition to an HHS rule change that allows states to lower the bar on required EHB coverage provisions in so-called "benchmark" plans that set the floor for coverage offered in a state marketplace. Many of the short-term plans are even skimpier than what's being offered through the ACA exchanges, even with the recent benchmark changes.

    "While APTA has always supported the importance of patient choice in health care, we are also committed to advocating for access to needed care and consumer certainty that the care patients receive today will be there tomorrow," said Kara Gainer, APTA's director of regulatory affairs. "Short-term plans offer choice but run the risk of decreasing access and creating uncertainty, and the recent final rule from HHS would appear to make matters worse."

    CoHSTAR Seeks Postdoctoral Fellow

    The Center on Health Services Training and Research (CoHSTAR) has opened its latest call for a full-time postdoctoral fellow—this time for a project related to postacute stroke services.

    The 2-year position, to be located at the University of Pittsburgh, will begin in January 2019. Qualifications for consideration include being a physical therapist with an advanced degree (PhD, ScD, DrPH) completed in the last 5 years and status as a US citizen or noncitizen national. Individuals with strong analytic and writing skills and experience with the analysis of claims data, electronic health record data, and other large data are preferred.

    The successful candidate will work with the Comprehensive Post-Acute Stroke Services (COMPASS) trial, a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The study is entering its fourth year and has produced a wealth of data that provides opportunities for secondary analyses. This fellowship will focus on data related to uptake of rehabilitation care and associated outcomes.

    APTA was a major financial contributor to CoHSTAR, having donated $1 million toward the center's startup in 2015. In addition to APTA’s contribution, funding for CoHSTAR came from gifts from 50 APTA components, as well as foundations, corporations, and individual physical therapists. The Foundation for Physical Therapy also awarded the center a $2.5 grant.

    Study: Estimated 1 in 3 Medicare Beneficiaries Receiving Inpatient/SNF Rehab Report No Improvement in Function

    Authors of a new study on inpatient and skilled nursing facility (SNF) rehabilitation say that when it comes to patients' own opinions of their progress, an estimated 1 in 3 Medicare beneficiaries are likely to report experiencing no improvement in functioning while they were receiving rehabilitation in those settings. And those rates can trend higher depending on certain demographic and health-related variables.

    The study, published in the Journal of the American Medical Directors Association (abstract only available for free), analyzes survey responses from 479 Medicare beneficiaries who received inpatient or SNF rehabilitation between 2015 and 2016. Data were drawn from the National Health and Aging Trends Study (NHATS), with respondents comprising a nationally representative sample of the Medicare population.

    Participants were asked, "While you were receiving rehab services in the last year, did your functioning and ability to do activities improve, get worse, or stay about the same?" Responses were compared with various demographic, socioeconomic, health, and rehabilitation variables to investigate possible correlations. Here's what researchers found:

    • Overall, 33.4% of respondents said that they did not improve in functioning during treatment.
    • Respondents who reported no improvement were more likely to have less formal education, more anxiety, and 1 or more impairments in their ability to perform instrumental activities of daily living (IADL)—preparing meals, doing the laundry, doing light housework, shopping for groceries, managing money, taking medicine, or making phone calls. These respondents also were more likely to require a proxy respondent to answer survey questions due to physiological or cognitive disability.
    • Respondents who reported no improvement were less likely to have received rehabilitation services for surgical reasons.
    • Impairment related to activities of daily living (ADL)—eating, transferring out of bed, transferring out of chairs, walking inside, going outside, dressing, bathing, or toileting—was not associated with lower patient-reported outcomes. The same was true for specific medical conditions and clinically significant depression.
    • Respondents with IADL impairments whose primary condition was "other musculoskeletal condition" or a cardiovascular condition, and who received less than 1 month of rehabilitation services with no outpatient services also were more likely to report no improvement in functioning.

    Authors write that the correlation between lack of improvement and a patient's education level is a "somewhat concerning" finding in the study.

    "Health literacy can be a substantial barrier to effective medical care," authors write, "and perhaps those with less education had a lower level of health literacy, which may have affected their expectations for rehabilitation outcomes and/or negatively impacted their ability to participate in and receive the full benefits of rehabilitation services."

    As for the reasons why impairment in IADLs would be more strongly associated with reports of no improvement than would impairment in ADLs, authors speculate that "perhaps ADL limitations are more amenable to rehabilitation than are IADL impairments, especially because IADL involve more complex tasks that may be particularly sensitive to cognitive status."

    The relationship between rehabilitation of less than 1 month and the absence of outpatient rehabilitation services also was singled out for additional comment by the study's authors, who believe that "effective rehabilitation for some…may be a longer-term process that extends months and spans nursing home, inpatient, outpatient, and/or in-home settings."

    Authors point to a move toward more integrated, multisetting care as a positive step, writing that "As about 1 in 5 community-dwelling Medicare beneficiaries report receiving any rehabilitation services in the prior year, more closely integrating rehabilitation services across service settings (and with other health and social services) offers promise in improving outcomes in Medicare beneficiaries who desire to maintain their independence."

    The study, according to authors, contains its share of limitations, including a relatively small sample size, no differentiation between inpatient facility settings, the use of self-reported data, and lack of information on whether the patients actually met their rehabilitation goals.

    Despite those issues, authors of the study think their analysis opens up areas for future research. They write: "Our findings lead to more questions: does health literacy play a role in patient-reported outcomes? Are those with IADL impairments less able to engage in and thereby benefit from rehabilitation services? How do contextual factors and the dose of rehabilitation services affect patient-reported outcomes? Would patient-reported outcomes among this population be improved if: (1) more of these patients received rehabilitation services longer and/or in outpatient or home settings or (2) if patient-centered rehabilitation targets were more incorporated into treatment planning?"

    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 Stark Reality: APTA Continues Efforts to Shore Up Self-Referral Law

    As the US Centers for Medicare and Medicaid Services (CMS), lawmakers, and others continue to press for more value-based approaches to care, attention has turned to a law that bars physicians from referring Medicare patients to services in which the physician has a financial interest, aka "self-referral." CMS has hinted that the prohibition, known as the Stark law, may interfere with the adoption of new, more integrated models of care, and a US House of Representatives subcommittee held a hearing on "modernizing" the law, perhaps through loosening up restrictions. APTA argues that at least part of the reform efforts should be aimed at eliminating exceptions as a way to increase value-based care opportunities.

    Recently, APTA staff were on Capitol Hill to encourage legislators and their staff to take a careful approach to decisions about the Stark law, which was the subject of a July 17 House Ways and Means Health Subcommittee hearing. During that hearing, legislators were weighing the law's effect on the ability to create alternative payment models (APMs)—systems that often seek to streamline and coordinate entire episodes of care. The hearing echoed a recent CMS request for information from the public on the Stark law, and discussed whether there is a need for "revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law."

    In comments provided to the House subcommittee, the association argues that a reformed Stark law with fewer loopholes could actually promote the growth of value-based care by leveling the playing field for physical therapists (PTs).

    As APTA explains in its comments, the current version of the Stark law includes an exception that allows physicians to self-refer for so-called "in-office ancillary services" (IOAS) that include physical therapy. That exception winds up hurting the development of APMs because it "fail[s] to promote collaboration with small- and medium-sized physical therapy and nonphysician practices," APTA writes.

    "Until [the US Department of Health and Human Services] creates a more level playing field between these different types of providers, physical therapists will be unable to meaningfully participate in Medicare and Medicaid APMs, despite their desire to do so, potentially impeding patient freedom of choice and access to the highest-quality care," the comment letter states.

    The association isn't alone in its commitment to eliminating Stark law loopholes. In 2017, APTA joined with the Alliance for Integrity in Medicare to support a bill in the House of Representatives that seeks to eliminate the IOAS exemptions. That bill, also supported by AARP, has not been scheduled for House committee review

    "We see the recent subcommittee meeting as a chance to highlight the need for more opportunities for physical therapist to participate in alternative payment models, all while protecting patient choice, increasing transparency, and strengthening access," said Justin Elliott, APTA's vice president of government affairs. "Effective value-based care is important. Eliminating conflicts of interest in health care is important. There's no reason why the two can't coexist."

    APTA will share that sentiment with CMS when it delivers the association's response to the CMS request for information (RFI) on the Stark law. The CMS call for feedback is largely focused on how the Stark law could be weakened through the creation of more exceptions or other tweaks, all in the name of promoting more coordinated care models. APTA is coordinating with the APTA Private Practice Section to draft comments by the August 24 deadline.

    The association also has developed a template letter that allows individuals to create a customized-but-consistent response to the CMS request (scroll down the webpage to the second bullet point under "APTA's Current Regulatory Advocacy Efforts).

    APTA is a strong supporter of easing unnecessary regulatory burdens on providers, but CMS and Congress must proceed with caution," said Kara Gainer, APTA's director of regulatory affairs. "We are urging CMS to think very carefully about the unintended consequences of making any changes that increase self-referral. A weaker Stark law could actually impede the transition to value-based care and worsen the patient experience in the process."

    From PTJ: Common Activity Trackers May Be Inaccurate for Patients With PD

    It's important for physical therapists (PTs) to encourage patients with Parkinson Disease (PD) to stay physically active, and it would seem as though commercially available fitness trackers would be a good way to do that, by allowing the PT and patient to set home goals and track progress through step counts. But new research suggests that PTs may want to think twice about the data they get from the devices.

    In an article published in the August issue of PTJ(Physical Therapy), researchers in Boston analyzed data from 4 fitness trackers—2 worn on the wrist and 2 that attach at the waist—to see how the tracker step reports stacked up against videos that allowed PTs to visually observe and count steps taken. The trackers in question were the wrist-worn Fitbit Surge and the Jawbone Up 2 and the waist-worn Fitbit Zip and Jawbone Up Move.

    A total of 33 patients with mild to moderate PD were recruited for the study, which involved tests of both continuous and discontinuous walking while wearing all 4 activity trackers, with the wrist trackers worn on the less-affected arm. The continuous walking tests involved 2 bouts of 2-minute walks around a 92-meter rectangular track, the first lap at a comfortable speed, and second at a fast speed; the discontinuous walking tests consisted of an "obstacle navigation course" and a "household" course, where patients were required walk to different areas to perform typical household tasks such as taking off and hanging up a coat, washing and drying hands, throwing away trash, and picking up and setting down a glass. In addition to recording tracker data, the tests also were video-recorded so that a pair of PTs could count steps taken. Researchers then compared tracker data with the results of the video monitoring. Here's what they found:

    • Overall, the trackers were reasonably accurate at recording steps taken during continuous walking, with the waist-worn Fitbit Zip showing the highest accuracy, followed by the wrist-worn Jawbone Surge, and wrist-worn Fitbit Surge, and the waist-worn Jawbone Up 2.
    • Tracking discontinuous walking proved to be more problematic, with authors of the study describing all 4 trackers as "generally inaccurate" in both courses. The Jawbone Up Move proved to be the least reliable device, with a mean absolute percent error rate approaching 60% in the household course. The Fitbit Zip was the most reliable, but that's not saying much: its error rate in the household course was close to 30%. The devices fared somewhat better in the obstacle negotiation course but still produced error rates ranging from about 10% to 20%. All devices underreported steps taken.

    Authors speculate that the inaccuracies may have something to do with a lack of tracker sensitivity to steps taken "in environments with greater discontinuity, where starting, stopping, and turning occur frequently." The longer, more symmetrical step lengths associated with continuous walking are better suited to the device's abilities, whereas the "smaller, slower, shuffling steps" taken by participants during the discontinuous walking tests tend to be missed by the devices, they write.

    As for waist-worn versus wrist-worn devices, authors think that the higher accuracy of the waist-worn devices may be due to the fact that the device is closer to an individual's center of mass, which allows for more accurate measurement. Wrist devices worn by patients with PD may be less accurate due to the effects of tremor, dyskinesia, extraneous upper extremity movement, and reduced arm swing often associated with individuals with PD, they believe.

    Another common feature of PD—freezing of gait—may also come into play as a factor affecting device accuracy, according to authors. Although only 1 participant in the study experienced freezing during the tests, that individual's devices produced an aggregate 60% error rate in the household course and 20% error rate in the obstacle negotiation course. "In general, the magnitude of this error exceeded that observed among nonfreezers," they write.

    The overarching problem, according to authors, is that none of the devices studied performed reliably in the setting that arguably would be the most important one for PTs treating patients with PD—the patient's home. "Other mechanisms of monitoring discontinuous walking, such as time spent walking, may be better options when the goal of intervention is focused on increasing physical activity in the home environment," they write.

    APTA members Nicholas Wendel, PT, DPT; Chelsea Macpherson, PT, DPT; Tamara DeAngelis, PT, DPT; and Cristina Colon-Semenza, PT, MPT, were among the coauthors of the study.

    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.

    From PT in Motion Magazine: How to Defend Yourself Against Scams and Cyberattacks

    As technology and information sharing evolves at a rapid pace, it becomes harder to keep up with criminals and scammers—even if you are an experienced professional. Last year, a staggering 83% of physicians said they had experienced some form of cyberattack, according to an American Medical Association report. What kind of scams are out there? What should you be wary of? What new threats are emerging?

    A feature in this month's PT in Motion magazine describes common cybercrimes and scams, including data breaches, phishing, and ransomware. Author Katherine Malmo reports that cyberattacks happen to more organizations than we might think, since people don't want to share their experiences. Robert Latz, PT, DPT, told PT in Motion, "The question is less if there will be a breach and more what to do when the breach happens."

    The article examines other scams that take advantage not of security holes but human error, such as fraudulent job ads that require financial transactions or predatory scholarly journals that publish anything as long as you pay, which can damage your credibility. "What is most astounding," Chad Cook, PT, DPT, comments, "is that really talented people submit to these publications."

    "How to Defend Yourself Against Scams and Cyberattacks" is featured in the August issue of  PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one 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.

    SNF, IRF Final Rules Follow Through on Proposed Shifts in SNF Payment Systems, IRF Reporting Requirements

    The final 2019 rules for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are substantially similar to what the Centers for Medicare and Medicaid (CMS) proposed in the spring, but that's not to say physical therapists (PTs) should assume it's a "same rule, different year" situation.

    In fact, the situation is far from a "same as usual" scenario—at least for PTs in SNF settings, who will be facing a dramatic change in how payment is determined.

    The new rules, set to go into effect in October of this year, include increases in payment of 2.4% for SNFS and 0.9% for IRFs, but the heart of the changes have less to do with payment increases and more to do with how payment will be determined and what needs to be reported. For PTs in IRFs, the reporting process could become a bit less burdensome, while PTs in SNFS will need to get up to speed with an entirely new payment system that does away with the Resource Utilization Groups Version IV (RUG-IV) process.

    SNFs: Hello Patient-Driven Payment Model (PDPM)
    The biggest takeaway from the proposed SNF payment rule was the adoption of the PDPM, and the same is true of the final rule. In doing away with the RUG-IV process, CMS adopted a model that bases payments on a resident's classification among 5 components, including physical therapy. Final payment is then calculated by multiplying the patient's case-mix group with each component (both base payment rate and days of service received) and then adding those up to establish a per diem rate. (Editor's note: more detail on the proposed rule appears in a PT in Motion News story published in April.)

    Between its release of the proposed rule and publication of the final version, CMS tweaked a few details—one around clinical categorization in the PDPM having to do with identifying surgical procedures that occurred during the patient's preceding hospital stay, and another related to a new assessment known as the Interim Payment Assessment (IPA), intended to accommodate reclassification of some residents from the initial 5-day classification. In the case of the IPA, CMS decided to make the assessment optional.

    IRFs: Goodbye Functional Independence Measure (FIM)
    As in the proposed rule, the final rule for IRFs drops the FIM and 2 quality-reporting measures related to methicillin resistant staph aureus (MRSA) infection and flu vaccine rates. According to CMS, data associated with FIM are being captured through other parts of assessment, while the costs of gathering data on MRSA and flu vaccines outweigh the benefits. (Editor's note: more detail on the proposed rule appears in a PT in Motion News story published in May.)

    The rule also allows for postadmission physician evaluation to count as one of the required face-to face physician visits and removes requirements for admission order documentation (but not the orders themselves). Additionally, under the new rule physicians will be allowed to lead team meetings remotely—a change that, when proposed, prompted APTA and others to ask CMS to extend that allowance to all team members. CMS stated in the final rule that it will evaluate how the new policy is working out and consider expanding flexibility.

    APTA comments on the proposed rules are available online (for SNF comments, visit APTA's Medicare Payment and Policies for Skilled Nursing Facilities webpage and look under APTA Comments; for IRF comments, look for the same header on the association Medicare Payment and Policies for Hospital Settings webpage). APTA summaries of the rules will be posted in the coming weeks.

    2018 State Policy and Payment Form Offers a Packed Agenda

    Issues that directly affect physical therapists (PTs), physical therapist assistants (PTAs), and society as a whole—population health, the opioid crisis, innovative delivery models, and much more—will be front and center at the 2018 APTA State Policy and Payment Forum. Registrations are now open for this important members-only gathering, to be held September 15–16 at the Westin Crown Center in Kansas City, Missouri.

    The forum is designed to increase PT and PTA involvement in and knowledge of state legislative and payment issues that have an impact on the practice of physical therapy, and to improve legislative, regulatory, and payment advocacy efforts at the state level.

    In addition to presentations on current advocacy efforts in the states, the forum will include information on federal regulatory issues; a presentation on state telehealth policy; and breakout sessions on state issues in pediatrics, value driving payment and contracting, and the physical therapy licensure compact. The event also includes a workshop for legislative chairs and lobbyists, and another aimed at payment chairs.

    Registration is online-only and is open through August 17—no onsite registrations will be offered. Visit the forum registration page to sign up and learn more about the event.

    Tiered Coding for PT Evaluations: New APTA Podcast Series Answers Common Questions

    As the payment landscape for 2019 comes into focus, it's becoming clear that physical therapists (PTs) will continue coding evaluations according to a 3-tiered system based on patient complexity. It's also clear that for now, at least, Medicare will not be using a tiered payment system, even as some commercial payers and state Medicaid plans adopt systems that reflect the complexity levels. Through it all, APTA continues to offer resources that help to reinforce accurate and consistent coding.

    CMS has indicated that its flat reimbursement policy, opposed by APTA from the start, will allow the agency to evaluate the distribution of utilization of the tiered codes in order to better determine the payment model. That distribution is beginning to come into focus: APTA research into nearly 4 million evaluations billed by providers across settings has revealed that 47% of evaluations were billed in the low-complexity category, 45% in the moderate-complexity category, and 8% in the high-complexity category.

    "At this point in time we have a sampling of baseline data that reflects practice in the first year of the tiered codes," said Alice Bell, APTA senior payment specialist. "CMS is also looking at this data and has indicated that they feel it will take 2 years of data to have an accurate representation. That means it's important that coding remain accurate and consistent."

    In its latest efforts to help underscore the importance of continued accurate coding, APTA produced a series of free podcasts on the CPT evaluation codes. The 5-part series covers a general overview of the coding change and addresses common questions related to determining levels of stability, documenting elements, the relationship of examination time to code selection, and coding in reevaluation. With episodes ranging from 5 to 8 minutes in length, the individual podcasts are convenient for quick listens on the go or during breaks at the clinic.

    "APTA is committed to supporting physical therapists through this transition to tiered coding in order to ensure that code selection truly reflects the level of complexity of the evaluation," Bell said. "Before we see further changes in reimbursement based on the tiered codes we want to make sure therapists have the tools and resources necessary to make the appropriate code selection. Accuracy in coding is critical if we are to make a compelling case for achieving our long-term goal of establishing reimbursement rates that truly reflect patient complexity."