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  • 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.

    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."

    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."

    CMS to Host Fee Schedule Webinar for APTA Members

    If the 2019 physician fee schedule is adopted as proposed by the Centers for Medicare and Medicaid Services (CMS), physical therapists (PTs) will need to get up to speed quickly. Now CMS is offering APTA members a head start.

    On August 7 from 12:00 noon to 1:00 pm ET, CMS will host a live webinar on the Quality Payment Program (QPP), the value-based payment model that will require PT participation beginning in 2019 under the proposed fee schedule. Presenters will focus on the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs), and offer a brief question-and-answer session.

    The webinar is free, but space is limited. Interested APTA members are encouraged to complete the online registration (APTA login required) as early as possible. For members unable to join the live presentation, a recording will be posted on the APTA MIPS webpage at a later date.

    What's the proposed 2019 fee schedule all about? This 3-part series from PT in Motion News takes a look at MIPS, AAPMs, and more (part 1, part 2, part 3).

    At the State Level, a Very Good Year for PTs and PTAs

    With the dust just about settled around most state legislatures, APTA, its state chapters, and supporters are beginning to assess how the practice and payment landscape has changed at the state level for physical therapists, (PTs), physical therapist assistants (PTAs), and the patients they serve. The news is decidedly good.

    "This has been an extremely busy year for physical therapy-related legislation in many states, and the hard work and collaborative efforts of chapters and APTA have paid off," said Angela Shuman, director of state legislative affairs for APTA. "We have a lot to be proud of."

    Among the highest-profile wins is the steady expansion of states joining the Physical Therapy Licensure Compact (PTLC), the game-changing system that allows PTs and PTAs licensed in 1 state to obtain practice privileges in other participating states. Mississippi, Missouri, North Dakota, and Tennessee have officially enacted the compact system. Other states have passed the necessary legislation and are preparing to flip the switch on the compact, with this year's addition of Iowa, Louisiana, Nebraska, New Jersey, Oklahoma, South Carolina, and West Virginia bringing the total number of compact states to 21. A bill to adopt the compact is pending in Pennsylvania.

    But that's not all that's been happening in state capitols. Here's a rundown of some of the big issues addressed across the country.

    The issue: direct access
    Bottom line: direct access provisions are expanding

    Illinois could be strengthening its direct access provisions by permitting PTs to provide physical therapy without a referral as long as the PT notifies the patient's treating health care profession within 5 business days after the first visit. The bill is pending the governor's approval. California's legislature is considering a bill that would permit direct access to a PT for wellness services and services provided as part of an individualized education or family service plan.

    The issue: the opioid epidemic and access to nonopioid pain management approaches, including physical therapy
    Bottom line: states are pressing payers, providers, and policymakers to take action

    Connecticut will convene a work group to investigate the efficacy of physical therapy, acupuncture, massage, and chiropractic care in reducing the need for opioids for individuals with chronic pain. Florida, Oklahoma, West Virginia, and Tennessee will put more pressure on physicians to educate themselves and their patients on nonopioid options for pain management, with Tennessee requiring providers to obtain informed consent from patients acknowledging that they have been offered information on reasonable alternatives to opioids. Vermont will require reductions in copay amounts for PT services under certain health plans and has established a work group to study insurance coverage for nonopioid approaches to pain management, including cost-sharing for physical therapy. West Virginia will require that health plans, including Medicaid and state health plans, provide coverage for 20 PT visits when related to treatment of chronic pain, with deductibles prohibited from being higher than deductibles for a primary care visit; Delaware is taking similar action, pending the governor's approval. The Massachusetts legislature is considering establishing a commission to make recommendations on nonpharmacological strategies for pain management, and the commission would include a representative from the state's APTA chapter.

    The issue: dry needling
    Bottom line: more states have added or may add dry needing to their physical therapy practice acts

    In Idaho and South Dakota, where dry needling by PTs had been prohibited, language is now in place permitting PTs to perform the treatment. The New Jersey legislature is considering a bill to allow dry needing. Colorado has added dry needling to its physical therapy practice act, effectively ending a debate and legal challenge over dry needling rules that the Colorado licensure board had enacted several years ago.

    The issue: concussions
    Bottom line: states are recognizing the PT's role in making return-to-play determinations

    Arizona and Oregon have cleared the way for PTs to provide clearance for student athletes to return to play after a concussion or suspected concussion, with Arizona's law limiting the ability to only PTs with a sports specialist certification, and Oregon's law permitting all PTs to make the determinations. A similar bill is pending in New Jersey.

    The issue: telehealth
    Bottom line: states are acknowledging the validity of telehealth and including PTs in the mix

    Illinois has added PTs to the state's telehealth act, authorizing delivery of services through telehealth if the PT is licensed to practice in Illinois and acting within the PT scope of practice in the licensing law. Iowa and Kentucky adopted laws requiring health plans to cover telehealth services.

    The issue: certification of disability by a PT
    Bottom line: states are recognizing the PT's role in disability certification

    Kentucky and Michigan became the latest states to add PTs to the list of providers who may provide certification of disability for purposes of parking placards and license plates. In Kentucky, PTs can make determinations for temporary parking placards, while in Michigan, PTs can make determinations for temporary parking placards, license plates, and free parking stickers.

    More wins

    • Connecticut: The use of the title "DPT" and "Doctor of Physical Therapy" is now protected by law.
    • New Mexico: A group has been commissioned to investigate whether state workforce incentives, including student loan repayment assistance, are adequately incentivizing PTs and PTAs to relocate to and remain in the state—the group includes representatives from the APTA New Mexico Chapter and the state's physical therapy licensing board.
    • New York: The annual visit limit for physical therapy under Medicaid has been expanded from 20 to 40.
    • Ohio: The legislature is considering a bill to modernize the definition of physical therapy, including a clarification that diagnosis is a part of PT practice.
    • Utah: Licensed radiologic technologists are now permitted to accept an order from PTs for plain radiographs and magnetic resonance imaging if the PT designates a physician to receive the results and the physician agrees to accept them.
    • Washington: Health care payers are no longer permitted to impose prior authorization requirements for initial evaluation and up to 6 treatment visits for chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies provided the services meet the standards of medical necessity and are subject to quantitative treatment limits.

    (Editor's note: Stay tuned—APTA will publish State Briefs with more details on legislative changes at the individual state level on its State Advocacy webpage in the coming weeks.)

    The 2019 Fee Schedule, Part 3: The End of FLR, the Move to PTA-Specific Codes, and a Nod to Technology

    Part 3 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment: there's more to the proposed rule than PTs being required to participate in the Quality Payment Program—including some very good news.

    The fact that physical therapists (PTs) could be widely engaged in a value-based payment model in 2019 is definitely the big takeaway from the proposed 2019 physician fee schedule released by the US Centers for Medicare and Medicaid Services. But the sweeping proposal also includes some other significant changes that could affect both PTs and physical therapist assistants (PTAs). Here's a rundown of 3 of the biggest non-Quality Payment Program-related changes included in the proposed rule.

    Something to celebrate: the end of functional limitation reporting (FLR).
    Criticized by APTA as an undue administrative burden that yields little of value, FLR would finally be put out to pasture if the proposed rule is adopted. In its reasons for eliminating the requirement, CMS described the "general consensus" of commenters responding to a CMS request for ways to reduce administrative burden that FLR was "overly complex and burdensome." The agency estimates that PTs in private practice would have saved between 130,000 and 190,000 hours of administrative work in 2017 had FLR not been in place.

    The change is a win for APTA and its members, and the association is mentioned in the proposed rule as a "specialty society" that supplied CMS with data on the inconsistent timing of FLR reporting—another issue that fueled the decision to eliminate the requirement.

    Something to be concerned about: is CMS setting the stage for the PTA payment differential?
    If enacted as proposed, the rule would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The modifiers, mandated by the Bipartisan Budget Act of 2018, would be used in place of the GP and GO modifiers—the ones currently used to identify PT and OT services furnished under an outpatient plan of care—and will pave the way for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022.

    Although the modifiers won't officially be in place until 2020, CMS plans on accepting voluntary use of the modifiers next year. CMS also proposes to define “in part” to mean any minute of the outpatient therapy service that is therapeutic in nature and that is provided by the PTA or OTA when acting as an extension of the therapist. The new modifiers would not be applied when a PTA or OTA furnishes non-therapeutic services—such as scheduling appointments, greeting the patient, or preparing the treatment area.

    APTA is opposed to the adoption of a payment differential system and will be advocating for changes before the 2022 implementation date.

    Something to keep an eye on: CMS may be warming up to broader use of technology.
    While it appears that, for now at least, the changes will be limited to physicians and other qualified health professionals who can report evaluation and monitoring services, CMS is proposing that activities such as virtual check-ins, interprofessional internet consultation, and remote evaluation of prerecorded patient information could qualify for some form of payment. APTA is seeking clarification from CMS as to whether any of these services could be furnished and billed by PTs.

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the Registry to submit their data to CMS.

    APTA Offers Help With Payment Denials

    Putting together an appeal of a denied claim isn't anyone's idea of a good time, but at least APTA is making the process a little easier.

    Now available to APTA members: customizable template letters that help make the case for payment. The letters target 3 types of denials:

    Denials related to change in practice location. This letter is crafted to address a Medicare Administrative Contractor's (MAC) denial of payment based on an erroneous conclusion that the provider didn't give sufficient notice of a change in practice location.

    Denials related to the use of the 59 modifier. The template, applicable to both MAC and private insurer denials, helps make the case for valid use of the 59 modifier, used to represent a service that is separate and distinct from another service it's paired with.

    Denials related to medical necessity. Also usable in both Medicare and private insurance-related appeals, this letter helps a member articulate why services were in fact medically necessary.

    The templates, offered in Word, include directions for inserting crucial patient and treatment details to strengthen the appeal argument. All 3 letters are available on APTA's Medicare Denials, Audits, and Appeals webpage; the 2 letters applicable to private insurers also can be found on the association's Commercial Insurance webpage, along with a general appeal letter outline.

    APTA will post more templated appeal letters in the coming months, so be sure to check back.

    APTA Helps Create New Grant Opportunities for PTs

    A new "mini grant" project aimed supporting implementation of a self-directed and group intervention program for adults living with arthritis is now accepting applications. The grants of at least $2,000 each are available to individual physical therapists (PTs) as well as APTA state chapters. APTA is a cosponsor of the program.

    The grants will be awarded to successful applicants who propose ways to implement the "Walk With Ease" (WWE) program either directly or in partnership with an external agency. Developed by the Arthritis Foundation, WWE is a community-based walking program based on group walking sessions and pre-walk discussions held multiple times per week. The initiative is a US Centers of Disease Control and Prevention (CDC)-recommended physical activity program.

    Grantees are expected to recruit at least 200 participants and work to ensure all participants complete 100% of the intervention by September 29, 2018, the end of the 3-month project period. Selected applicants can anticipate an average award of $2,000, although the number of awards is contingent on the availability of federal funds.

    Applications will be accepted and considered for funding on a rolling basis. Final applications must be received by Friday, July 27, 2018 at 11:59 pm ET and can be downloaded from the grant announcement webpage. Interested applicants must email the completed application to nmccoy@chronicdisease.org.

    APTA collaborated with the National Association of Chronic Disease Directors and the CDC's Division of Population Health Arthritis Program in the creation of the grants program.

    Innovative Collaborative Effort Between APTA, United Healthcare, and OptumLabs Could Introduce Important Changes to Pain Management Policies

    What would happen if payers encouraged patients with low back pain (LBP) to explore low-risk treatments such as physical therapy by waiving copays for initial sessions? Thanks to a collaboration between APTA and the nation’s largest private health insurer, we may find out.

    Through its work with APTA, United Healthcare is identifying 10 markets for a pilot program that would employ a variety of policy changes to its pain management program, including the elimination of cost-sharing for an initial physical therapist (PT) visit, easier appointment scheduling for patients, and stepped-up public and physician education efforts emphasizing the benefits of early referral to a PT for pain. If successful, the pilot could help to transform the payment landscape in ways recommended in a recent APTA white paper on addressing the opioid epidemic through better pain management policies.

    The pilot accelerates the practical application of findings from a joint study by APTA, United Healthcare, and OptumLabs on the potential impact of early physical therapy and other nonopioid strategies to address LBP. That study paid particular attention to cost and downstream utilization associated with early physical therapy for LBP.

    The study was one of the topics covered during the 2018 Rothstein Roundtable at the APTA NEXT Conference and Exposition (see video dispatch below). During the Rothstein discussion, David Elton, senior vice president of clinical programs for OptumHealth, characterized the study's findings as ones that "confirm what we've seen"—that "good things happen" when physical therapy is used early in an episode of LBP.

    While not yet finalized for publication—something that could happen as early as fall of this year—the study's results were convincing enough to cause the insurer to move quickly toward the creation of the pilot program.

    "The collaborative work between APTA, United Healthcare, and Optum is an innovative approach that brings providers and payers together to work on truly transforming the health care system in ways that make a difference to patients," said Carmen Elliott, MS, APTA vice president of payment and practice management. "We are excited about the publication of the joint study and pleased for the opportunity to make real-world changes to improve patient access."

    According to United Healthcare, APTA chapter leadership in the 10 markets under consideration will be contacted to schedule webinars that provide an overview of the pilot.

    OptumLabs and OptumHealth are businesses of Optum. Optum and UnitedHealthCare are benefits and services companies of UnitedHealth Group.