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  • VA Rolls Out New Community Care Program

    The US Department of Veterans Affairs (VA) released final rules related to a completely retooled program that allows veterans more choice in health care providers, but some of the provisions will apply only to certain regions (for now), and other interpretations of the new rule—including whether physical therapists (PTs) will be considered primary care providers—will be made as needs arise.

    The final rules released this week are related to implementation of the VA Mission Act of 2018, which consolidates VA’s community care programs into a new community care program known as the Veterans Community Care Program. Among programs being consolidated is VA Choice, the program created in 2014 to increase access and reduce wait times for VA patients by allowing greater use of non-VA providers. The VA Choice Program will continue to provide care to veterans until the new program is fully operational.

    Community Care Eligibility Criteria
    The Veterans Community Care Program final rule provides the nuts-and-bolts guidance on the operation of the new Community Care Network, the centerpiece of the Mission Act, and specifically on 2 of the central features of the Mission Act: how and when veterans might qualify for receiving covered non-VA care, and who can provide it. The new community care provisions will apply only to certain regions of the country upon rollout and will expand incrementally.

    When it comes to which veterans would qualify for non-VA care, the rule includes a long list of criteria, including the inability of a VA facility to provide the type of care the veteran requires, as well as factors including treatment frequency, geographical proximity of an appropriate VA facility, the veteran's ability to travel, and a "compelling reason" for the veteran to receive non-VA services, among others.

    Entities who want to be included as eligible non-VA providers will need to enter into a contract with VA, and either not be a part of (or employee of) VA or not provide the same services provided within the VA. The provider must also be accessible to the veteran, which includes a reasonable wait time to receive services. The rule also states that VA will announce quality standards through a separate document but predicts that "quality comparisons will generally be based on care that is locally available and not on national averages." In its comments on the proposed rule, APTA asked VA to clarify how it would define types of care, including primary and specialty care, and whether physical therapy would be considered primary care. The VA responded by taking a wait-and-see approach, writing that "we believe in a majority of cases that it will be clear what standard should be applied to what care."

    For now, the new system is being rolled out in states in Regions 1, 2, and 3 of VA’s new Community Care Network, which includes mid-Atlantic, southern, and Midwestern states: Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Iowa, Kansas Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, US Virgin Islands, Vermont, Virginia, Washington DC, West Virginia, and Wisconsin. The program isn’t expected to be operational everywhere until the end of 2019 at the earliest.

    Urgent care
    In another rule, VA clarified policies and procedures around covering veteran access to urgent care from non-VA providers without prior approval from VA. Qualifying facilities would include urgent care and walk-in retail health clinics.

    As in the community care rule, qualifying non-VA providers would need to enter into a contract or agreement with VA. Veterans could in turn go to those facilities to seek a range of urgent care, including flu shots, vaccines, certain screenings, and other services, so long as the care isn't emergent or based on care over an extended period of time. In the rule, VA states it will provide veterans with information on participating urgent care providers.

    In its comments on the proposed rule, APTA asked VA about whether follow-up care related to a covered urgent care visit would need separate VA authorization. VA responded by stating that follow-up care must be coordinated by VA.

    APTA regulatory affairs staff continues to monitor the implementation of the Mission Act and will post resources and information on its Veterans Affairs and TRICARE webpage.

    Final HHS Report on Pain Management Adds to Drumbeat for Better Access to Nondrug Approaches

    The final report from a US Department Health and Human Services (HHS) inter-agency task force on pain management best practices is out, and its call for greater collaborative care and improved access to physical therapy comes through loud and clear. It's a report that in many ways echoes APTA's white paper on opioids and pain management published nearly 1 year ago.

    The "Report on Pain Management Best Practices" changed little from its draft version released in January [Editor's note: this PT in Motion News article covered the draft in depth]. Like its predecessor, the report identifies gaps and inconsistencies in pain management that can contribute to opioid misuse.

    While the task force acknowledges that opioids may be appropriate when carefully prescribed in some instances, it also argues that other approaches—including "restorative therapies" furnished by physical therapists and other health care professionals—should be on equal footing with pharmacological alternatives, particularly when it comes to reimbursement and patient access.

    "Restorative therapies play a significant role in acute and chronic pain management, and positive clinical outcomes are more likely if restorative therapy is part of a multidisciplinary treatment plan following a comprehensive assessment," the report states, while pointing out that "use of restorative therapies is often challenged by incomplete or inconsistent reimbursement policies."

    APTA submitted comments on the draft report, and offered members a chance to contribute to the report's development through a customizable template letter. Association staff members also met in person with Vanila M. Singh, MD, task force chair, and provided public commentary to the task force on 2 occasions.

    The HHS report is consistent with a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches.

    "This report from HHS adds to an overwhelming body of knowledge that spells out the need for patient-centered, collaborative care that makes nonpharmacological approaches to pain management more accessible to public," said Katy Neas, APTA executive vice president of public affairs. "But the question is, what will the public, federal agencies, and other stakeholders do with the information in this report and so many others like it? Will payers actually change their reimbursement guidelines to align with best practices, or should more regulatory changes be brought to bear? The path forward is clear, and some positive changes are happening, but as this report makes clear, it's time to pick up the pace."

    APTA continues to build on its successful #ChoosePT campaign to educate the public on safe, effective alternatives to opioids for pain management. The most recent addition: a downloadable pain profile chart that makes it easy for patients to assess the severity and impact of the pain they're experiencing.

    Legislation to Include PTs in Student Loan Relief Program Now in House and Senate

    A little more than 1 month after its companion bill was introduced in the US Senate, legislation that could open up student loan repayment opportunities for physical therapists (PTs) has been introduced in the House of Representatives. The proposed change, strongly supported by APTA, would allow PTs to participate in the National Health Services Corps (NHSC), a federal initiative that provides greater patient access to health care in rural and underserved areas—and incentivizes health care provider participation through a student loan forgiveness program.

    Like the Senate version (S 970), the House version, titled the "Physical Therapist Workforce and Patient Access Act" (HR 2802), would allow PTs to participate in the NHSC loan repayment program. The initiative serves an estimated 11.4 million Americans who live in designated Health Professional Shortage Areas (HPSA) and repays up to $50,000 in outstanding student loans to certain health care professionals who agree to work in an HPSA for at least 2 years. The House bill is cosponsored by Reps Diane DeGette (D-CO) and John Shimkus (R-IL).

    "If enacted, this legislation would be very good news for PTs, and even better news for patients who need increased access to care," said Katy Neas, APTA's executive vice president of public affairs. "Legislators on both sides of the aisle are recognizing that access to physical therapist services can be a useful tool in the fight against the opioid crisis, which has been especially devastating in rural and underserved areas. Physical therapists are expert in musculoskeletal systems and can provide invaluable services to patients with acute and chronic pain, and this bill will make it easier for patients in rural and underserved areas to access those services."

    In addition to its positive impact on health care access, the legislation could also provide some relief for the rising level of student debt being experienced by graduates of physical therapist education programs. It's a challenge that APTA is working to address, according to APTA Vice President of Government Affairs Justin Elliott

    "APTA's strategic plan envisions a physical therapy profession that's as diverse as the patient population it serves, and that means we must take a hard look at barriers to pursuing a career in physical therapy," said Elliott. "Clearly one of those barriers is the cost of physical therapist education. While this bill doesn't solve the problem, it could provide at least some relief for PTs facing significant student debt."

    APTA encourages members to join the push for the bills by contacting their legislators to urge them to become cosponsors by way of a prewritten letter, available at the APTA Legislative Action Center, that helps to deliver a unified message (member login required).

    APTA staff will closely track the progress of this legislation—be on the lookout for more opportunities to advocate for this important change.

    Study: 54% of Middle-Income Seniors Won't be Able to Afford Assisted Living Costs, Medical Expenses in 10 Years

    Authors of a new study say that as the wave of aging baby boomers advances, the middle-income elderly population could find itself in a particularly problematic situation—at least when it comes to finding housing that can accommodate declining mobility and increased care needs. By researchers' estimates, in as few as 10 years, over half of middle-income adults 75 and older, too affluent to qualify for Medicaid assistance, won't be able to afford many of the private seniors' housing options available today.

    The study, appearing in Health Affairs, looked at the current population of adults 75 and older in terms of population, demographics, and income status, and compared those data with projections for 2029. Authors then extended trends for health and mobility limitations to create a glimpse into what the housing landscape could be like in a decade. The results aren't encouraging for middle-class seniors, defined as those 75 and older with annuitized financial resources of between $25,000 and $74,298 in 2014 dollars.

    Among the findings:

    The senior population will increase dramatically, with middle-income seniors outpacing the high- and low-income group.
    The population of individuals 75 and older is expected to balloon from an estimated 20 million in 2014 to 33.5 million in 2029—a 68% increase. Of those 33.5 million, 43% will be seniors at the middle-income level, approximately 14.4 million people. The number of middle-income seniors ages 75-84 will nearly double, from 5.57 million in 2014 to 10.81 million in 2029. By that point, middle-income seniors will constitute the largest segment of the 75-and-older population.

    1 in 5 middle-income seniors will have 3 or more chronic conditions and 1 or more limitations in activities of daily living (ADL) by 2029—and 60% will have mobility limitations that could prevent them from living independently.
    If current prevalence levels continue, 20% of middle-income seniors will classify as "high needs," and 3 in 5 will have significant mobility limitations—factors that increase the chances that they will require more assistance in living arrangements. Additionally, an estimated 6% of middle-income seniors 75-84, and 15% of those 85 and older, are expected to have cognitive impairments.

    An estimated 54% of middle-income seniors won't have enough annual financial resources to pay for average assisted living costs and medical expenses—and that's a best-case scenario.
    Researchers say that in 2014 dollars, the annual average cost for assisted living rent and "estimated medical out-of-pocket spending" is about $62,000. Only 46% of the middle-income population will have that much available to them. The percentage drops even further among middle-income seniors who lack equity in housing, where only 19% are anticipated to have enough money to pay for average costs.

    "This confluence of factors creates a significant unmet future need, which demands new housing and care solutions to support the emerging generation of America's seniors," authors write, suggesting that responses need to come from both the public and private sectors. And those responses need to take a 2-pronged approach, by lowering the cost of assisted living and making it easier for seniors to continue living in their own homes for as long as possible.

    Researchers say that in the private sector, technology improvements could make a difference by increasing staff efficiency and thereby reducing costs, as could systems that "more formally involve family caregivers, outside volunteers, and healthier residents" in providing care, and those that offer "a la carte" care models. Authors also suggest that the private sector could respond to the coming gap by dialing back expectations for return on investments by, among other things, "charging less rent and reducing profit margins." Some of that sacrifice, they add, could be buffered through tax incentives

    In the public sector, authors suggest raising eligibility limits for housing assistance, providing subsidies and voucher programs, and encouraging "housing communities with sufficient capacity to establish their own Medicare Advantage plan." They also contemplate wider use of a 2019 change to Medicare Advantage that allows administrators to offer supplemental benefits to cover nonmedical services, including in-home modifications.

    Authors add that Medicaid could also play a role by "broadening eligibility and expanding coverage to home and community-based services for beneficiaries with higher incomes and less acute health needs." Doing so, they write, may "forestall health and functional deterioration and keep seniors in noninstitutional settings longer, when preferred."

    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.

    APTA, Other Organizations, Will Share Anti-Opioid Efforts

    There may be just about as many approaches to battling the opioid crisis as there are organizations committed to the fight—but now APTA and more than 100 other groups will be sharing experiences and learning from each other by way of a collaborative effort led by the National Academy of Medicine (NAM).

    The exchange of information is being managed through NAM's Action Collaborative on Countering the US Opioid Epidemic. The group includes community organizations, hospitals, nonprofit organizations, health professional societies, private insurers, and academia, all of which have committed to sharing their work and goals to counter the opioid epidemic through efforts that address prescribing guidelines, prevention, treatment, research, policies,and data, among other areas. Along with APTA, the more than 100 participants include the American Association of Colleges of Nursing, the American Pharmacists Association, Kaiser Permanente, and the Mayo Clinic.

    APTA has plenty to share. In addition to its award-winning #ChoosePT opioid awareness campaign, the association produced a white paper, hosted a Facebook Live event, sponsored a media tour, established an opioid and pain management resource on PTNow, and helped to develop a crossdisciplinary "playbook" on opioid stewardship—and that was just in 2018. APTA's efforts date back to 2016, when it unveiled #ChoosePT as the official campaign to educate the public on physical therapy as an effective nonopioid and nondrug option in the treatment of chronic pain.

    In APTA's statement of commitment to the collaborative, the association writes that "physical therapy providers intimately know that physical activity reduces risk of chronic conditions, many of which include pain," adding that "pain is personal, and treating it takes teamwork, including the membership and empowerment of the person being treated."

    "It is imperative in the fight against the opioid epidemic that everyone plays a role in not only the successful treatment of pain but the culture of pain," said Hadiya Green Guerrero, PT, DPT, APTA senior practice specialist. "Care providers must commit to utilizing each other’s expertise, including in the areas of educational and interprofessional training. APTA is eager to bring its perspective on preventing and treating pain to the table, and to learn from so many other organizations that share our commitment to ending the devastation of opioid misuse and addiction."

    NAM President Victor Dzau agrees that collaboration is the key to making a real difference.

    "Reversing the opioid epidemic requires a multi-sectoral response—no organization, agency, or sector can solve this problem on its own," Dzau said in an NAM press release. "We are thrilled to see such a robust commitment from organizations across the country in joining us to be part of the solution."

    This isn't APTA's only connection with NAM—the association is also a member of the Academy's Action Collaborative on Clinician Well-Being and Resilience.

    Proposed SNF Rule Relaxes Group Therapy Requirements, Increases Payment by 2.5%

    In a proposed change strongly supported by APTA, skilled nursing facilities (SNFs) could see more flexibility when it comes to the number of residents considered acceptable for "group therapy" under Medicare. The loosened definition is part of the proposed fiscal year (FY) 2020 payment rule for SNFs recently issued by the US Centers for Medicare and Medicaid Services (CMS), a plan that also includes an overall 2.5% payment increase.

    Currently, treatment of 4 patients performing same or similar activities qualifies as "group therapy" for purposes of Medicare payment in SNFs. The proposed FY 2020 rule—which would go into effect on October 1, 2019—would allow qualified rehabilitation therapists including physical therapists (PTs) to form groups with as few as 2 and as many as 6 patients. The change would make SNF group therapy rules more consistent with other care settings and "create opportunities for site-neutral payments," according to a CMS fact sheet on the proposed rule.

    "The expanded definition of group therapy is very much in line with APTA's ongoing effort to advocate for the value of the PT's clinical judgment by allowing for more clinical flexibility in determining the most appropriate number of participants in a particular group," said Kara Gainer, APTA's director of regulatory affairs. "The change makes sense in terms of both payment and providing appropriate patient care."

    The proposed rule would also boost payments to SNFs by about $887 million in FY 2020, with average increases varying depending on, among other things, the location of a particular SNF: facilities in urban areas would likely receive a 1.8% increase on average, while SNFs in rural areas could average a 6.4% increase.

    PDPM System Moves Ahead—and Aims to Keep Up With ICD-10 Tweaks
    As anticipated, the proposed rule proceeds with implementation of the Patient-Driven Payment Model (PDPM). The model is based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employs a per diem system that adjusts payment rates over the course of the stay. APTA has developed a number of resources on PDPM.

    The CMS proposal also would allow the agency to use a "subregulatory" process to keep up with nonsubstantive updates to the ICD-10 codes used in PDPM, while substantive changes will be made through the traditional notice-and-comment rulemaking process. CMS writes that the change would "help ensure SNFs have the most up-to-date ICD-10 code information as soon as possible, in the clearest and most useful format."

    Patient Assessment and Quality Reporting Data Requirements Expand
    Also not much of surprise—CMS is proposing to continue its efforts to standardize patient assessment data collection across postacute care settings as required by the 2014 IMPACT Act.

    Similar to its proposed FY 2020 rule for inpatient rehabilitation facilities (IRFs), CMS plans to require SNFs to report resident data on admissions and discharges in the following areas: cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidity; impairment; and a new category—social determinants of health. SNFs have been reporting on some components of these areas since 2018, mostly related to function, pressure wounds, and skin integrity.

    In another proposed change that echoes the rule being considered for IRFs, the SNF Quality Reporting Program (QRP) would increase from 11 to 13 measures, adding assessments related to transfers of current reconciled medication lists at resident discharge or transfer; as well as the transfer of a similar list to the patient/resident, family, or caregiver upon discharge from a postacute facility.

    The proposed rule also requires SNFs to collect and submit minimum data sets (MDS) on all SNF residents regardless of payer, a change that CMS says "may create additional burden" but would "ensure that Medicare residents are receiving the same quality of SNF care as other residents." As for MDS reporting related to post-hospital SNF care, the proposed rule clarifies that the "5-day assessment" requirement must be completed no later than the eighth day of the SNF stay, and that the requirement will go under a new name—"initial patient assessment"—beginning in FY 2020.

    Amid all the additional requirements, CMS is proposing 1 reduction: baseline nursing facility residents would be excluded from the QRP related to discharge to community.

    What APTA's Doing—and What You Can Do
    The association will submit comments on the proposed rule by the June 18, 2019, deadline. Interested PTs, PTAs, students, and other stakeholders also are invited to provide comments, and will be able access information on how and where to submit comments at APTA's regulatory Take Action webpage in the coming days.

    Members with an interest in postacute care are also encouraged to join APTA's online postacute care community on The Hub. The community is a staff-administered collaborative space for members to ask questions, share information, and identify areas of opportunity in relation to the new postacute care payment methodologies and other CMS postacute payment reforms. If you are interested in joining this online community, please email Kara Gainer at karagainer@apta.org with “Join PAC Community” in the subject line and your member ID number in the body of the email.

    IRFs Could See 2.5% Increase From CMS in FY 2020; Additional Reporting Requirements in FY 2022

    If a proposed rule from the US Centers for Medicare and Medicaid (CMS) is adopted as planned, inpatient rehabilitation facilities (IRFs) will see a 2.5% payment increase in the 2020 fiscal year (FY), which begins October 1, 2019—an approximate boost of $195 million. But they'll also need to prepare for some expanded reporting measures in the years to come—including a requirement to report data on social determinants of health (SDOH).

    Reporting requirements wouldn't change much in fiscal year (FY) 2020 (beginning October 1, 2019). However, beginning with the FY 2022 IRF Quality Reporting Program (QRP), IRFs would be required to provide certain standardized patient assessment data (SPADE) to CMS. The additional SPADE requirements are aimed at bringing IRFs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care (PAC) settings.

    Beginning in the 2022 fiscal year, IRFs would be required to report patient data on admissions and discharges dating back to October 1, 2020, in the following areas: cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidity; impairment; and a new category—social determinants of health (SDOH). IRFs have been reporting on some components of these areas since 2018, mostly related to function, pressure wounds, and skin integrity.

    The new SDOH would gather data on race, ethnicity, preferred language, interpreter services, health literacy, transportation, and social isolation—factors that CMS writes "[have] been shown to impact care use, cost, and outcomes for Medicare beneficiaries."

    CMS also wants to introduce 2 new process measures; one having to do with whether a provider receives a current reconciled medication list at discharge or transfer, and another relating to whether the patient, family, or caregiver receives a similar list upon discharge from a PAC setting.

    Among other elements of the proposed rule:

    The compliant IRF list may go. CMS is proposing to stop publishing a list of compliant IRFs on the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) website.

    Reporting for some baseline nursing facility residents would decrease. Specifications of the discharge-to-community PAC measure would be altered to exclude baseline nursing facility residents.

    IRFs could make the call on who's considered a "rehabilitation physician." The proposed rule would loosen the definition of "rehabilitation physician," allowing individual IRFs to make the determination. At the same time, CMS is seeking comments on refining the definition in light of the proposed change.

    As is typical, CMS is also seeking input on several areas not related to specific impending rule changes for FY 2020, including stakeholder comments on pain interference on sleep, therapy activities, and day-to-day activities—provisions that CMS is considering adding in light of the opioid crisis. The agency also seeks general feedback on possible additional SPADE data elements including dementia, bladder and bowel continence, care preferences, advance care directives and goals of care, caregiver status, veteran status, health disparities and risk factors, and sexual orientation. Potential measures CMS would like feedback on include assessments related to opioid use, and frequency and exchange of electronic health data as well as interoperability.

    APTA will submit comments on the proposed rule by the June 17 deadline. To weigh in on the proposed rule, check out APTA's regulatory "Take Action" webpage in the coming days for information on how and where to submit comments.

    CMS Adds to DMEPOS Prior Authorization List

    Physical therapists (PTs) who are providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) will see an expansion of the range devices that require prior authorization under Medicare, when the US Centers for Medicare and Medicaid Services (CMS) adds 12 more items to its list beginning July 22 of this year.

    Seven of the 12 new codes are related to power mobility devices, with the additional 5 related to pressure-reducing support surfaces. The additions follow last year's introduction of 31 DMEPOS items that CMS moved to a nationwide preauthorization system. Prior to that, the preauthorization policies for those devices were limited to a demonstration project in 18 states.

    CMS also added 4 new items to the master list of DMEPOS that are considered frequently subject to unnecessary use, including a particular back brace (L0650). CMS uses the master list to decide which items it will add to the prior authorization list.

    CMS offers a webpage focused on the DMEPOS prior authorization program and has published a notice and list of the 12 codes to be added. A full list of DMEPOS requiring prior authorization is also available from CMS. APTA offers more resources at its DMEPOS webpage as well as through a clinical mobility device documentation guide.

    CDC Reiterates Limits of Opioid Prescribing Guideline

    The US Centers for Disease Control and Prevention (CDC) wants to make it clear: its guideline on the use of opioids for the treatment of chronic pain is not intended to apply to pain related to cancer treatment, palliative care, or end-of-life care. The clarification is consistent with messaging used by APTA in its #ChoosePT opioid awareness campaign and its MoveForwardPT.com consumer-focused website.

    In a February 28, 2019, letter from CDC Chief Medical Officer Deborah Dowell, MD, MPH, the agency restates its intentions around the prescribing guideline, issued in 2016, that recommends nonopioid approaches including physical therapy as a preferred first-line treatment for some—but not all—types of chronic pain.

    "The Guideline was developed to provide recommendations for primary care physicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care," Dowell writes. "Because of the unique therapeutic goals, and balance of risks and benefits with opioid therapy in such care, clinical practice guidelines specific to cancer treatment, palliative care, and end-of-life care should be used to guide treatment and reimbursement decisions regarding use of opioids as part of pain control in these circumstances."

    The letter was written in response to concerns voiced by the National Comprehensive Care Network, the American Society of Clinical Oncology, and the American Society of Hematology that some payers were balking on paying for opioid prescriptions in circumstances outside the scope of the CDC guidelines.

    Even without the clarification, the original guideline is explicit in its intent, which appears in the first sentence of the document and again when the CDC describes the scope of the guideline and intended audience. Similarly, APTA makes it clear that doctor-prescribed opioids are appropriate in some cases and has included that message in both its #ChoosePT webpage and its public service announcement related to the opioid crisis.

    "The Guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management," Dowell writes. "Rather, the Guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options."

    President's Budget Proposes Cuts to Public Health Programs, Health Research, Medicare, and Medicaid

    Although characterized by supporters as an approach that "embodies fiscal responsibility," the 2020 federal budget proposal from the Trump administration is facing criticism that the $4.1 trillion plan cuts too deeply into health care and education. Many of the proposed changes run counter to current APTA public policy priorities by reducing access to care and sacrificing important investments in research and education.

    The proposed budget, released by the White House last week, was touted by acting Office of Management and Budget Director Russ Vought as a plan that "takes aim at Washington's fraud, waste, and abuse," and will lead to a balanced budget in 15 years.

    Others see things differently. The approach is accompanied by significant cuts to a range of issues important to APTA, including funding decreases for the National Institutes of Health, the Centers for Disease Control and Prevention, the Administration for Community Living, the National Health Services Corps, and the Maternal and Child Health Block Grant program. The budget also includes policy recommendations that alter Medicaid and Medicare.

    The budget proposal is just that—a proposal. Congress must act on the plan in order for it to become law. APTA Executive Vice President of Public Affairs Katy Neas says that while the budget itself isn't likely to survive, there's a danger that some of the more damaging concepts could live on.

    "It's unlikely that Congress will embrace the changes to Medicare, Medicaid, and funding for important work at the National Institutes of Health," Neas said. "However, the challenge for APTA, the physical therapy profession, and patients will be to keep up the pressure against some of the budget's more damaging ideas that may resurface from time to time in policy debates."

    Among those more damaging ideas, according to APTA: the administration's proposal to move Medicaid away from its current funding system to a per-capita block grant program. The administration estimates the change could result in a $160 billion savings, but critics say the shift would reduce access to care, as would another provision in the plan that would mandate work or community volunteer requirements for "able-bodied, working-age individuals."

    The plan also calls for cuts to Medicare, primarily through a combination of payment decreases, more stringent oversight of individual provider reimbursement patterns, and more extensive prior authorization requirements for physicians.

    Among the provisions of particular interest to physical therapists (PTs) and their patients and clients:

    • Durable medical equipment, prosthetics, and orthotics (DMEPOs). Under the Trump budget, the US Centers for Medicare and Medicaid Services (CMS) competitive bidding program would be extended to apply to ventilators and orthotics, which could interfere with patient access to these devices as well as the ability for patient-specific adjustments to be made by providers. Additionally, the proposal would expand CMS prior authorization authority to additional DMEPOs—another provision that APTA believes could delay or prevent patient access.

    • Postacute care payment. The proposed budget steadily lowers annual Medicare payment updates for skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities beginning in the 2020 fiscal year, leading up to the adoption of a unified postacute payment system for all settings in the 2025 fiscal year.

    • Prior authorization authority. The budget extends CMS authority to require prior authorization for all Medicare fee-for-service items and services, specifically those that CMS claims are at high risk for fraud and abuse.

    • Oversight of "excessive" physician orders for certain services—including therapy. The administration budget seeks to establish a prior authorization program for high-utilization practitioners of radiation therapy, therapy services, advanced imaging, and anatomic pathology services beginning in 2021. CMS would conduct annual reevaluations to identify the physicians who would be subject to prior authorization in the next calendar year.

    • National Institutes of Health (NIH) funding. The proposal would lower NIH funding by $4.5 billion to $6 billion compared with 2018, including a $900 million reduction in funding for the National Cancer Institute.

    • Education. In addition to reducing funding for college work-study programs and ending loan forgiveness for public-sector workers, the administration's plan would cancel a $1.4 billion surplus in the federal Pell grant program.

    "APTA's advocacy focus is on increasing patient access to effective care, eliminating inefficiencies and reducing administrative burden on providers, and supporting research and innovation," Neas said. "The administration's 2020 budget in many ways stands in contrast to those priorities, and we will continue to help legislators and policymakers understand the important differences."