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  • New Physical Activity Guidelines Stress the Importance of Movement of any Duration

    You want blunt? The US Department of Health and Human Services can do blunt—at least when it comes to physical activity (PA) recommendations for Americans.

    "Adults should move more and sit less throughout the day," HHS says in its latest edition of nationwide guidelines for PA. "Some physical activity is better than none."

    That's the bottom-line recommendation that HHS rolled out this week in its revised Physical Activity Guidelines for Americans. And there's arguably little room for nuance: according to HHS, 80% of all Americans are not meeting current PA recommendations, a failure that is contributing the prevalence of a host of chronic health conditions.

    The new guidelines, with their emphasis on the importance of movement to prevent disease and extend life no matter an individual's age, echo many perspectives long-championed by APTA and its members.

    "These revised guidelines create a clear roadmap for where we need to be as a nation, and the physical therapy profession is here to help people get the movement they need to optimize their health," said APTA President Sharon L. Dunn, PT, PhD. "APTA will continue to advocate on behalf of our patients to ensure that our nation’s public policies align with these recommendations."

    The revision, the first in 10 years, doesn't alter many of the now-familiar PA goals for adults: at least 150 minutes of moderate-intensity PA per week, or 75 or more minutes of vigorous-intensity PA per week. But the new guidelines further reinforce the benefit of PA at any level by removing statements saying that PA must occur for at least 10 minutes to be effective, and by clarifying that virtually any kind of movement is better than nothing. "Adults who sit less and do any amount of moderate-to-vigorous [PA] gain some health benefits," according to the guidelines.

    The guidelines themselves vary by age and other factors. Here are the basics for each group identified by HHS.

    Preschool-aged children (3 to 5 years): HHS recommends that this age group "should be physically active throughout the day" and that caregivers "should encourage active play that includes a variety of activity types."

    Children and adolescents (6 to 17 years): The guidelines recommend 60 minutes or more per day of moderate-to-vigorous PA; with at least 3 days of vigorous-intensity PA per week, at least 3 days of muscle-strengthening PA per week, and at least 3 days of bone-strengthening PA per week.

    Adults: 150 minutes per week of moderate-intensity PA, or 75 or more minutes per week of high-intensity PA is recommended for adults; at least 2 or more days per week should include muscle-strengthening activities.

    Older adults: If possible, 150 minutes per week of moderate-intensity PA, tempered by an individual's "level of [PA] relative to their fitness," and a clear understanding of how various chronic conditions can affect the ability to reach PA goals. No matter what PA level is achieved, activities should include balance training, aerobic, and muscle-strengthening activities.

    Women who are pregnant and postpartum: The guidelines recommend at least 150 minutes of moderate-intensity PA per week, spread throughout the week, during both pregnancy and postpartum. The guidelines also advise that women "who are habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period."

    Adults with chronic health conditions and/or disabilities: These adults should follow the same targets as nonsymptomatic adults, but with a recommendation that should a chronic condition or disability interfere with their ability to meet these guidelines, PA should occur to whatever extent possible; individuals should avoid inactivity. The guidelines also recommend that people with chronic conditions "consult with a health care professional or [PA] specialist about the types and amounts of activity appropriate for their abilities and chronic conditions."

    A summary of the guidelines was featured in JAMA, accompanied by an editorial that emphasizes the importance of educating the public on the idea that PA has health benefits no matter the scale of the effort.

    "Probably the most important message…is that the greatest health benefits accrue by moving from none to even small amounts of [PA], especially if that activity is moderate…to vigorous..." editorial authors write. "The key point for patients is that large health benefits accrue from even small amounts of [PA] and that even short-duration activity lasting less than 10 minutes is beneficial."

    The JAMA editors also think that clinicians need to take care to avoid an overly cautious approach to PA recommendations for patients, writing that they "must avoid being a barrier to [PA] because of concerns about the cardiovascular and orthopedic risks…." They describe those risks as "extremely small with gradually progressive [PA]."

    Given PA's demonstrated effects on both physical and emotional well-being, and the relatively low costs involved in incorporating PA into patient lifestyles, "clinicians cannot afford to allow patients to miss out on this inexpensive path to healthier lives," the editorial authors write.

    Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness.

    Proposed Medicaid, CHIP Rule Reflects State Movement Toward Managed Care Systems

    As states continue to move toward wider use of managed care organizations (MCOs) in their Medicaid systems, the US Centers for Medicare and Medicaid Services (CMS) is looking at ways to guide the evolution while maintaining state flexibility. A few of those ideas have been fleshed out in a recently released proposed rule from CMS on both Medicaid and the Children's Health Insurance Program (CHIP).

    APTA regulatory affairs staff members are analyzing the proposed rule, and the association will provide comments to CMS by the January 19, 2019, deadline. In the meantime, here are a few basics:

    Allowing temporary pass-through payments for states transitioning to MCOs. Currently, providers in fee-for-services Medicaid arrangements are eligible for additional payments, known as "pass-through" payments, but these payments are being phased out for MCO Medicaid arrangements, and new payments are prohibited. But what about states that are transitioning to managed care? In response to some states' requests that pass-throughs continue to be allowed as a part of the transition process, CMS is proposing that new payments be allowed during a limited time period.

    Easing network adequacy standards and providing flexibility in the definition of "specialist." CMS proposes moving away from network adequacy standards based on travel time and geographic location, and toward a system that allows states to factor in other issues, including the availability of contracted providers who are accepting new patients, maximum wait times for appointments, and a facility's hours of operation. Additionally, the agency would like to give states more flexibility in defining which providers are considered "specialists."

    Loosening requirements for state quality-rating systems (QRS). CMS would like to allow states more leeway in their QRS systems: rather than requiring that the approaches provide data substantially similar to data provided by the CMS-developed QRS, the agency is proposing that state QRS systems need only be "comparable to the extent feasible to enable meaningful comparison across states." The proposed rule also would eliminate a requirement that states get CMS approval before starting up an alternative QRS.

    Making it easier for enrollees to navigate the appeals system. Under the proposed rule, Medicaid enrollees would no longer be notified of claims denials based on administrative errors; they would only receive notification of "substantive" denials. Additionally, enrollees who submit an oral appeal to a denial would no longer be required to submit an additional written and signed appeal.

    CMS Finalizes 'Site Neutral' Outpatient Plan; New Approach to DMEPOS Bidding

    As it continues to roll out final payment rules for 2019, the US Centers for Medicare and Medicaid Services (CMS) is sticking to its pattern of mostly following through on its original proposals—this time by ending payment rates that favor hospital-owned outpatient facilities over independent physicians' offices, and adopting a new supplier bidding system for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

    Outpatient Prospective Payment System (OPPS)
    As it proposed, CMS will expand the use of a "site-neutral" payment model in its reimbursement for the clinic visit service (HCPCS G0463), the most common service billed under the OPPS. Currently, Medicare and beneficiaries often pay more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting. CMS is doing away with the current system that pays so-called "off-campus" hospital-owned facilities an estimated $75 to $85 more than it does independent counterparts for this service. According to a CMS fact sheet, the agency estimates that the change, implemented over a 2-year period, will save an estimated $380 million in 2019 alone. The change does not directly affect physical therapists (PTs) working in outpatient hospital settings, given that outpatient therapy services delivered by PTs are paid under the physician fee schedule, not OPPS.

    Also final-as-proposed: a CMS decision to make separate payments for nonopioid pain-management drugs that function as a supply when used in an ambulatory surgical center (ASC) procedure.

    Overall, OPPS rates will increase by 1.35% in 2019, with a 2.9% market basket update offset by a 0.8% productivity adjustment and a 0.75% adjustment related to the Affordable Care Act (ACA). ASC payment will increase by 2% and in the future will be updated based on the hospital market basket update instead of the "consumer price index-urban all item" system, a change that will remain until 2023 at the earliest.

    Although not reflected in the final rule, during the public comment period on the OPPS proposed rule, CMS asked for input on issues including wound care, price transparency, and the opioid crisis as it relates to outpatient services. APTA provided comments in all 3 areas, advocating for better promotion of and payment for nonopioid approaches to pain management, a collaborative approach to price transparency that emphasizes consumer education, and careful attention to wound care reimbursement recommendations provided by the Alliance of Wound Care Stakeholders, of which APTA is a member.

    CMS fact sheet on OPPS final rule
    Complete OPPS final rule

    The biggest news in the DMEPOS arena is the CMS decision to move ahead with its proposal to use "lead item pricing" as a way to improve competitive bidding for DMEPOS. The system eliminates the need for suppliers to submit multiple different bids on items in a product category—instead, they can anchor bids to an item with the highest Medicare-allowed charges in a product category, folding in services and equipment directly related to providing the item (as appropriate). CMS hopes this "composite bid" approach will simplify the bidding process and ease burdens on suppliers.

    APTA generally supported the proposal but shared concerns with CMS over creating lead pricing categories that are overly large, including an unwieldy range of DMEPOS. In response, CMS assured commenters that the system would be built around "discrete categories of like items that are generally provided together to address a beneficiary’s medical needs." CMS also assured APTA and other commenters that the lead pricing system would not allow suppliers to win bids on categories that they do not cover in full.

    In a second move supported by APTA, CMS followed through on a proposal to continue to apply a 50/50 blend of adjusted and nonadjusted reimbursement rates to "noncontiguous areas"—primarily Alaska and Hawaii. In its comments to CMS, the association urged the agency to consider the challenges faced by rural and noncontiguous areas when it comes to distances that must be covered to receive or provide care. CMS said that those challenges had been factored into its final rule.

    CMS fact sheet on DMEPOS final rule
    Complete DMEPOS final rule

    Physician Fee Schedule and QPP: A New Payment World Awaits PTs in 2019

    Many physical therapists (PTs) will face a new payment landscape beginning in January, now that the US Centers for Medicare and Medicaid Services (CMS) has finalized a rule that ends functional limitation reporting (FLR) and moves certain PTs into the Quality Payment Program (QPP). That program, which includes the Merit-based Incentive Payment System (MIPS), is at the center of a sweeping shift toward value-based payment in Medicare.

    The confirmation of PTs' inclusion in QPP came in conjunction with the release of the final 2019 physician fee schedule. For PTs and physical therapist assistants (PTAs), the final versions by-and-large mirror the rule proposed by CMS earlier this year. But a few important changes and clarifications, some in response to comments from APTA and other stakeholders, are worth noting—particularly in regard to the way CMS wants to approach coding and paying for services delivered totally or "in part" by a PTA or occupational therapy assistant (OTA).

    APTA regulatory affairs staff are reviewing the final rule and will publish a detailed summary in the coming weeks. In the meantime, here are some highlights.

    Bottom line: get ready for MIPS and other components of the QPP.
    It's official: beginning in 2019, PTs in private practice who furnish services under Medicare are included in QPP, an entirely new payment system for the profession. Under QPP, qualifying PTs have a choice of participating in the Merit-based Incentive Payment System (MIPS) or—if available to them—an advanced alternative payment model (Advanced APM). A subset of these PTs who meet volume thresholds will be required to participate in one or the other. PTs in private practice who don't qualify for participation in MIPS can do so voluntarily, something APTA encourages given that all signs point to further expansion of the QPP in the future.

    The program—particularly MIPS—is largely centered on reporting requirements. 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 will 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 (EHR) vendors or registries such as APTA’s Physical Therapy Outcomes Registry.  

    The Advanced APM-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 rule also includes an option for QPP participation through a Medicare Advantage demonstration.

    In addition to its acknowledgement of PTs as providers who are integral to the evolution toward value-based care, CMS also included a welcome change: the elimination of functional limitation reporting (FLR), a fraught system that met with criticism from APTA since its implementation.

    But that's just the big-picture picture. PTs and PTAs are well-advised to learn as much as possible about QPP and MIPS sooner rather than later, and to understand how this major shift may impact their practice. Scroll down to the end of this article for suggested links that help to fill in the details of how the program works.

    In terms of the fee schedule itself, the required adjustment factor for 2019 is 0.25% before applying other adjustments. But remember: this is the last year there will be an update to the physician fee schedule through 2025. Beginning in 2026, payment rates will be updated based on the eligible clinician’s participation in MIPS or Advanced APMs.

    CMS efforts to clarify PTA-related coding are a mixed bag.
    CMS was required by law to establish modifiers to indicate services provided by PTAs and OTAs. In the final rule, CMS clarifies that services furnished in whole or in part by a PTA or OTA will be identified –through payment modifiers—"CQ" for services delivered by a PTA and "CO" for services delivered by an OTA. The definitions of the therapy services codes (GP, GO, GN) remain unchanged. The new payment modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.

    The PTA and OTA issue isn't just about coding, however. CMS is also attempting to specify what it means by services delivered "in part" by a PTA or OTA. Despite significant advocacy efforts by APTA and other stakeholders, CMS made only a moderate change between the proposed and final definition of services furnished “in part.” In the final rule, CMS adopts a "de minimis" standard, establishing that anything over 10% of the total patient service delivered by a PTA constitutes "in part" services. Although many questions remain, CMS has stated it will further clarify the de minimis standard in 2020 rulemaking. APTA had advocated that CMS hold off on making a final decision on this issue until the agency gathered more information from stakeholders or, if it did move forward, that it adopt a higher bar for what constituted services delivered "in part" by a PTA or OTA.

    The modifiers and definition of services furnished “in part” are crucial concepts as CMS moves toward the implementation of an 85% payment differential for services delivered "in part" by PTAs beginning in 2022. There will be more opportunities for APTA to advocate on changes to the definition of “in part” in future fee schedules leading up to the 2022 final rule, and the association will continue to advocate for changes to the proposal. Among the association's concerns: the potential impact of the differential on patient access, particularly in rural and medically underserved areas.

    The KX modifier isn’t going away, and the therapy threshold amount will get a (tiny) boost.
    As CMS prepares for its second year in a post-therapy cap environment, it's holding on to the KX modifier process for claiming outpatient therapy services over a specified amount—next year, $2,040, compared with $2,010 in 2018. As is the case in 2018, that amount will be for physical therapy and speech-language pathology services combined.

    CMS will consider ways to facilitate participation in Advanced APMs by nonphysicians who may not use certified electronic health record technology (CEHRT) due to lack of certified systems for their specialties.
    APTA joined a host of other commenters in suggesting that nonphysician provider participation in Advanced APMs would be hindered by a CMS proposal to increase the CEHRT minimum use threshold—an important consideration, given that participation in an Advanced APM is one way qualified providers are supposed to be able to meet QPP requirements. The argument made by APTA and others was that CEHRT standards are built around the particulars of physician-focused electronic health records (EHRs) that aren't as applicable to nonphysician EHRs, thereby creating an artificial barrier to nonphysician participation in APMs.

    Not so, CMS responded in the final rule. "We reiterate that the Advanced APM minimum CEHRT-use threshold applies to APMs and the requirements they impose on participating APM Entities, not to the individual APM Entities participating in APMs," CSM writes. "This means there can be a percentage of eligible clinicians participating in an APM Entity who are not using CEHRT and the APM Entity will still be in compliance with the APM’s terms and conditions." However, CMS has promised to monitor the situation and consider possible solutions to facilitate participation in Advanced APMs by nonphysicians and nonprescribing eligible clinicians in the future.

    PTs are still mostly excluded from allowances for telehealth—but APTA has convinced CMS to think about making changes.
    Despite APTA's advocacy, the final rule allowing for "virtual check-ins" applies only to providers who are qualified for reimbursement for evaluation/management services—in other words, not PTs. Additionally, PTs aren't included among providers who can be reimbursed for "interprofessional internet consultations."

    This situation is fluid, however. CMS responded to APTA’s calls for more PT inclusion in telehealth by stating that it would consider exploring a demonstration or pilot through its Center for Medicare and Medicaid Innovation. And if a proposed Medicare Advantage (MA) rule is any indication, CMS may be seeing the light—that proposal allows MA plans to include telehealth services as a "basic benefit," and APTA is pressing for PTs to be included in the list of qualified providers who may furnish telehealth services to MA enrollees.

    "All in all, the final fee schedule and QPP rule is what was expected, but what was expected is a significant shift in payment methodology," said Kara Gainer, APTA's director of regulatory affairs. "It's now critically important that physical therapists learn as much as possible about QPP and how they can best navigate the new system."

    Learn more about QPP, MIPS, and APMS

    • APTA's MIPS webpage: includes articles, recorded webinars, podcasts, decision-making guidance for voluntary participation, links to a MIPS discussion board, and more.
    • APTA's QPP webpage: take a readiness quiz, watch a short video, download recorded webinars, get detailed fact sheets, connect with other websites, and more.
    • "Moving Toward Quality Payment" (November PT in Motion magazine feature)

    Final Home Health Rule Keeps New Payment Model—With a Few APTA-Supported Changes

    Although comments from APTA and other stakeholders helped to spark a few positive changes, the final home health (HH) rule released by the US Centers for Medicare and Medicaid Services (CMS) is nearly the same as what was proposed in July, complete with a major shift to an entirely new payment methodology.

    That payment system, known as the Patient Driven Groupings Model (PDGM), moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. However, CMS seems to have listened to APTA and others who called for more detailed clinical care groupings and a clarification that therapists will be permitted to use remote patient monitoring. Mandated by the Balanced Budget Act of 2018, the new system commences in January 2020. Meanwhile, according to a CMS fact sheet, home health providers are on track for a 2.2% payment increase in 2019—the first increase in 10 years.

    What didn't change from the proposed rule
    The PDGM remains fundamentally the same as proposed—a system that classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status in 5 major areas—timing, admission source, clinical group, function level, and comorbidity adjustment—and within some of those areas can be assigned to more detailed clinical categories. The combination of categories assigned to a patient is what generates a particular case-mix grouping. The PDGM also eliminates therapy-use thresholds.

    What's different in the final rule
    APTA and other commenters were particularly concerned about the proposed rule’s lack of specificity in some of the subcategories—particularly the "Medication Management, Teaching, and Assessment" (MMTA) category in the "Clinical Group" bucket. As proposed, the various grouping combinations resulted in 216 case-mix groups (the current home health system offers 153).

    However, in response to comments, CMS dumped the MMTA category and replaced it with 7 new clinical subgroups: surgical aftercare, cardiac/circulatory, endocrine, GI/GU, infectious disease/neoplasms/blood-forming diseases, respiratory, and other. The additional groupings expand the possibilities for classification combinations, increasing the number of possible case-mix groupings to 432.

    Additionally, in response to APTA and other commenters voicing serious concerns as to how PDGM may impact access to necessary therapy services, CMS stated it “will continue to analyze utilization trends, including therapy visits as reported on home health claims, to identify any issues that may warrant any quality or program integrity intervention.”

    "The PGDM remains problematic on several levels, but the expansion of case-mix groupings helps to respond to one of APTA's major criticisms that the system does not adequately describe patient characteristics and care needs," said Kara Gainer, APTA director of regulatory affairs. "The increased case-mix possibilities will help to ensure that home health payment aligns with patient care needs and the cost of care and will better allow CMS to track patterns over time."

    What's been clarified in the final rule
    The rule as proposed included language around remote patient monitoring; specifically, how it could and couldn't be billed, and who could do it. The proposed rule was less specific on the "who" part of the equation, however, and APTA pressed for clarity from CMS that physical therapists (PTs) will be included among the providers able to conduct remote monitoring. In the final rule, CMS clarified that this is indeed the case, stating that "As therapy goals must be established by a qualified therapist in conjunction with the physician while determining the plan of care, we believe therapists involved in care planning, as well as other skilled professionals acting within their scope of practice, may utilize remote patient monitoring to augment this process."

    What's still being considered
    CMS has yet to fully work out exactly how medical reviews related to the admission source category would be triggered in the PDGM. APTA had suggested that CMS conduct post-payment review only for home health agencies that have claims that are consistently associated with claim denials, or whose pattern of codes varies dramatically from peers. CMS responded that it appreciated APTA's suggestions and "will consider such metrics in the development of any targeted reviews."

    What's next
    While the PDGM won't be implemented until 2020—most likely through a months-long rollout process—the $420 million payment increase is set to go into effect in January 2019. APTA will publish a summary of the final rule in the coming weeks. More resources, including webinar recordings on the PDGM, are available at APTA's home health webpage. The complete final rule can be found on the Federal Register website.

    CMS Wants Medicare Advantage to Increase Telehealth Coverage

    In a proposed rule, the US Centers for Medicare and Medicaid Services (CMS) gives the green light to expand coverage for telehealth in Medicare Advantage (MA) plans. But when—and if—those changes would affect physical therapists (PTs) remains an open question.

    The proposal from CMS would begin covering MA plans in 2020 within a range of areas, including changes for beneficiaries who are dually enrolled in Medicare and Medicaid, and tightened accountability within MA and Medicare Part D programs. But the provisions getting the most attention center on a CMS proposal to allow MA plans to treat telehealth benefits as basic benefits. It's a move prompted by the Bipartisan Budget Act (BBA) of 2018, which set the stage for wider use of telehealth under Medicare.

    Under the proposed rule, MA plans would be allowed to offer what are known as "additional telehealth benefits" as basic benefits if they are available under Medicare Part B and deemed "clinically appropriate" for what CMS is calling "electronic exchange" services. Deciding what is and isn't "clinically appropriate" and thereby covered would be left to individual MA plans.

    Additionally, the proposed rule would allow MA enrollees to engage in telehealth services in their homes or other locations, rather than requiring them to go to a specific facility. The range of technologies that would qualify is fairly broad under the proposal and includes secure messaging, store-and-forward technologies, telephone, videoconferencing, and other Internet-enabled technologies, as well as "evolving technologies."

    "While MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that MA plans will offer them and that more enrollees will be able to use the benefits," according to a CMS press release.

    APTA has advocated for the increased use of—and reimbursement for—telehealth services by PTs for several years, and is a supporter of the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) Act. The proposal would lift many of the current restrictions on the use of telehealth in Medicare, particularly in MA, accountable care organizations, and certain bundled payment models.

    Kara Gainer, APTA director of regulatory affairs, said that while the increased acceptance of telehealth in the proposed rule is a move in the right direction, CMS has yet to respond to the calls of APTA and other stakeholder groups to deliver more clarity on which providers it would expect to be included in any coverage of telehealth services.

    "Implementation of the Bipartisan Budget Act provisions will no doubt increase patient access to needed care through electronic exchange, but many more details need to be worked out," Gainer said. "Physical therapists have an opportunity right now to make their voices heard by working with the Medicare Advantage plans they contract with and advocate for coverage of certain physical therapy services, and to explain how that coverage could save money and improve outcomes."

    At the CMS level, Gainer also suggests that PTs and other stakeholders comment on the agency's proposals. APTA is reviewing the proposal and will provide comments to CMS by the December 31 deadline.

    Updated MedPAC 'Payment Basics' Series Provides Medicare Payment System Overview

    Given some of the major shifts in the Medicare payment landscape over the past few years, gaining an understanding of even the big-picture workings of the system can be a tall order. The Medicare Payment Advisory Commission (MedPAC) offers an updated resource that can help.

    Now available for free download: MedPAC's latest version of "Payment Basics," a series of informational sheets that describe the need-to-know elements of 20 different Medicare payment systems. Areas covered include outpatient therapy, skilled nursing facilities, home health services, hospital acute inpatient services, and more. The newest version of the resource updates the 2015 edition.

    Most information sheets provide background on how the system is organized and flowcharts for a visual representation of how that particular payment system works.

    Quick facts from MedPAC Payment Basics: According to the MedPAC report on outpatient therapy, in 2016 Medicare spent $7.6 billion on outpatient therapy services, a 6% increase from 2015. Physical therapy services accounted for 72% of all spending in this area. In terms of settings, nursing facilities and physical therapy private practice clinics accounted for 71% of the spending, at 37% and 33%, respectively. Hospitals were next, at 16%.

    New Report Looks at Link Between Surgery-Related Opioid Prescriptions, Later Opioid Abuse

    Calling surgery "a long-ignored gateway to persistent opioid use, dependence, and addiction," the Plan Against Pain (PAP) has issued a new report that focuses on the relationship between opioid prescriptions for surgical procedures and later opioid dependence and abuse. The bottom line: though there are glimmers of hope, the overall outlook remains bleak, with 12% of patients who had a soft tissue or orthopedic operation in the past year reporting that they had become addicted or dependent on opioids after surgery. APTA's #ChoosePT opioid awareness campaign is a Selected Partner of PAP.

    The report, which tracks surgery-related prescribing rates overall and as linked to 7 common surgical procedures—including total knee arthroplasty (TKA), total hip arthroplasty (THA), and rotator cuff repair—also breaks down statistics by demographic and geographic variables. Researchers relied on data from the National Prescription Audit, the PharMetrics Plus Database, and surveys of 500 US adults who had soft tissue or orthopedic surgery in the past 12 months. In addition, 200 surgeons were surveyed to assess, among other issues, their motivations for prescribing opioids. The study results were released on October 10 in conjunction with the "Summit for Solutions" event In Washington, D.C., attended by APTA.

    Among the findings:

    Overall opioid prescription numbers are declining, but state rates vary dramatically.
    Nationally, in 2017, there were enough opioids prescribed to supply every person in the US with 32 pills, only a slight decrease from the 36-pill rate reported in 2016. And while every state in the country reported a drop in opioid use in 2017, those reductions varied widely, and the improvements for some states, while significant, only made a dire situation slightly better. Example: Alabama, the nation's top opioid-prescribing state, recorded a 10% decrease in opioid prescriptions between 2016 and 2017, but that only brought its opioid pills-per-resident ratio down to 65 pills for every resident—more than twice the national average.

    Progress has been slow in reducing opioid prescription rates related to surgery.
    Researchers found that among the 7 surgeries studied—TKA, THA, rotator cuff surgery, hysterectomy, hernia surgery, colectomy, and sleeve gastrectomy—the average number of opioid pills prescribed dropped, but only slightly, from 85 pills per patient to 82. Authors of the report speculate that the slow progress could be due in part to the level of pressure surgeons feel to prescribe more opioids then they feel are necessary—a pressure reported by 66% of surgeons surveyed.

    The number of pills prescribed doesn't tell the whole story. The use of fewer pills at a higher potency also poses a risk—especially for orthopedic patients.
    The study found that more than half of patients undergoing TKA, THA, and rotator cuff surgery were prescribed opioids of 50 or more morphine milligram equivalents (MMEs), more than double the 20 MME dosage recommended by the US Centers for Disease Control and Prevention (CDC). Nearly 1 in 4 orthopedic patients received prescriptions in excess of 90 MMEs per day, an amount that the CDC says poses a serious overdose risk.

    Average rate of later opioid dependence and addiction among surgical patients hovered at 12%, but was higher for TKA patients.
    Patients who received colectomy reported the highest incidence of later dependence, at 17%, but TKA patients weren't far behind, with a 15.2% rate of later misuse. Rotator cuff surgery and THA patients reported lower rates of later dependence, at 9.5% and 9.3% respectively. The 12% overall average is an increase from the 2017 study, which estimated the later dependence rate at 9%.

    Women—and Millennial women in particular—are the most at-risk for becoming "newly persistent" opioid users after surgery.
    Women were found to be 40% more likely than men to become "newly persistent" users—individuals who received opioid prescriptions 90 to 180 days post-discharge. Millennial women were found to be particularly at-risk, with more than 10% reporting persistent use, compared with 6% or Millennial men. The persistent use rate for Millennial women in the 2018 PAP study represents a 17% jump from the previous survey.

    Authors of the report believe that until better guidelines are developed it's unlikely gains can be made in more careful use of opioids related to postsurgical pain. Although there has been some progress in this area, they write, more needs to be done to "relieve the pressure surgeons often feel to prescribe more opioids than patients actually need and help set patient expectations on the amount of opioids they'll be prescribed."

    "[The lack of clear guidelines] has left surgeons mainly on their own in determining the appropriate quantity and strength of opioids needed to address their patients' pain," authors write. "As this report reveals, the absence of clear guidelines has led to tremendous variation in prescribing patterns and a great deal of overprescribing that can lead to persistent opioid use, addiction and dependence among patients, as well as unused pills that can be misused or abused by others."

    APTA has been heavily engaged in the fight against opioid misuse on several fronts. In addition to its flagship #ChoosePT opioid awareness campaign, the association also hosted a Facebook Live panel discussion and satellite media tour to highlight the effectiveness of nonopioid approaches to pain management. In addition, APTA produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship.

    Massive APTA-Supported Opioid Bill Ready for President's Signature

    Expansive legislation aimed at battling the opioid crisis will soon become law, complete with provisions that echo APTA's recommendations for education on—and patient access to—nonopioid approaches to pain management.

    On October 3 the US Senate passed the final version of the legislation by a 98-1 margin after the US House of Representatives passed the measure, 393-8. The bill is headed to the White House, where President Donald Trump is expected to sign it into law.

    The legislation is wide-ranging, covering treatment for opioid addiction and use disorder, initiatives to help promote nonopioid alternatives to pain management, and stepped-up efforts to prevent foreign shipments of illegal opioids such as fentanyl, among other provisions. Changes included in the bill affect "almost every federal agency," according to a report in The Washington Post.

    APTA strongly supported passage of the bill and worked with legislators and staff to advocate for policies that emphasize patient education and clinical research on pain and how it can be effectively managed without the overuse of opioids. The final version of the legislation echoes many of the recommendations included in an APTA white paper on the opioid crisis. Titled "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health," the document advocates for better public awareness efforts and improved benefit design for both public and private health plans.

    "The bill now on its way to the White House represents a significant step in the right direction," said Kristina Weger, APTA congressional affairs senior specialist. "But there's much more work to be done—there are many provisions that direct agencies to begin reviews and studies on potential changes that we may not see for years. We need to continue our advocacy and outreach to help fight this crisis."

    Among the components of the legislation:

    • Clarification of states' abilities under Medicaid to provide care for infants with neonatal abstinence syndrome in neonatal residential pediatric recovery centers
    • Increased screening for opioid use disorder and other substance use disorders during Medicare wellness and preventive care visits
    • Better education for Medicare beneficiaries on opioid use and pain management, including more information on nonopioid approaches and advice to discuss opioid use and pain management with their physicians
    • Direction that the US Department of Health and Human Services (HHS) submit a report to Congress on how to improve reimbursement and coverage for multidisciplinary, evidence-based nonopioid treatment for chronic pain, due within a year after the legislation is signed into law
    • Stepped-up guidance from HHS to Medicare-participating hospitals for reducing opioid use, developed in consultation with health care organizations, consumers, and other stakeholders
    • Establishment of an HHS technical expert panel to provide recommendations for best practices in surgical settings, including limits on the use of opioids in perioperative settings, with a report due within 1 year of the law's enactment
    • More information on the risks of opioid use and better coverage for nonopioid alternatives to pain management in Medicare Advantage plans and Medicare Part D prescription drug plans beginning in 2021
    • Expanded research overseen by the Interagency Pain Research Coordinating Committee to include investigations into best practices for the use of nonpharmacological pain treatments
    • Development of a demonstration program to test alternative pain management protocols in hospital emergency departments

    APTA's involvement in addressing the opioid crisis dates back to late 2015 and includes the award-winning #ChoosePT public awareness campaign. The association is urging members to promote the profession's role in effective pain management during October as part of National Physical Therapy Month, and recently a physical therapy student-led "flash action strategy" focused on nonopioid pain management for an intensive 48-hour advocacy campaign with legislators on Capitol Hill. APTA also hosted a satellite media tour on the issue that resulted in more than 200 television and radio interviews across the country to an audience of more than 13.1 million, and in February hosted a Facebook Live event, "Beyond Opioids: Transforming Pain Management to Improve Health."

    New Pediatric mTBI Guidelines from CDC Take Comprehensive Approach

    In light of what it describes as a "significant public health concern," the US Centers for Disease Control and Prevention (CDC) has issued what it says are the first-ever comprehensive clinical guidelines for the diagnosis and management of mild traumatic brain injury (mTBI) in children. The 19 sets of recommendations address the condition from diagnosis through management and treatment, and cover settings including primary care, outpatient settings, inpatient care, schools, and emergency departments.

    The resource, published in JAMA Pediatrics and available for free, is organized into 3 main areas—diagnostic recommendations, prognostic recommendations, and recommendations related to management and treatment—with each area containing several recommendations based on extensive literature reviews. The 46 discrete recommendations are organized into 19 topic areas, and include do's and don'ts that cover the gamut from the use of serum testing to diagnose mTBI to the best approaches for talking with families about the injury.

    APTA members John DeWitt, PT, DPT, ATC; and Anne Mucha, PT, DPT, MS, were members of the CDC Pediatric Mild Traumatic Brain Injury Workgroup responsible for development of the recommendations, which are published in JAMA Pediatrics. Additionally, APTA submitted extensive comments on the guidelines during the public comment period during fall of 2017. A number of issues highlighted by APTA were included or addressed in the final version.

    Among the highlights from each broad area:

    Diagnostic recommendations: imaging is (mostly) not necessary, but rating scales and testing are crucial.
    Authors of the guidelines acknowledge that while assessing for intracranial injury (ICI) is important, the use of head computed tomography (CT) should not be routine and that providers should rely more heavily on clinical decision rules including those related to the Glasgow Coma Scale (GCS). The guidelines also caution against the routine use of magnetic resonance imaging (MRI), single photon emission CT, and skull radiographs, but they stress the importance of age-appropriate rating scales and cognitive testing. Authors warn, however, that clinicians shouldn't rely solely on the Standardized Assessment of Concussion to diagnose mTBI in children ages 6 to 18. Also not recommended: the use of "biomarkers" to establish the presence of mTBI "outside of a research setting."

    Prognostic recommendations: providers need to be sensitive to factors that can lead to variation in recovery.
    The guidelines support the idea that providers should help patients and families understand that for 70%-80% of children with mTBI, significant difficulties don't persist past 1 to 3 months after the injury and that "recovery from mTBI is unique and will follow its own trajectory." However, authors also advise providers to evaluate any factors that were present in a child before the mTBI that are linked to delayed recovery, such as learning difficulties, the presence of a neurologic disorder, or a history of previous mTBI. Providers should also assess for any risk factors not related to premorbid health or functional conditions, including socioeconomic factors and the severity of the presenting injury.

    Management and treatment recommendations: the keys are education, continued assessment of progress, and understanding when to refer for specialized care.
    The authors stress the importance of patient and family education around what to look for during recovery from mTBI, including warning signs of more serious injury and management of physical and cognitive activity. The guidelines also provide detailed recommendations on returning to activity and school, and stress the importance of careful monitoring in the classroom and provision of educational supports if necessary. Also included in this section are guidelines around headache management and treatment, and the importance of providers' understanding of when to refer a patient for additional treatment, particularly in the areas of vestibule-oculomotor dysfunction, disordered sleep, and cognitive impairment.

    The CDC is accompanying release of the guidelines with an educational push to promote consistent implementation. In addition to the guidelines themselves, providers can also download resources that include screening tools, online trainings, and fact sheets in support of the recommendations.

    According to authors, the guidelines arrive at a time when pediatric mTBI is on the rise, with more than 2 million outpatient visits and just under 3 million emergency department visits for mTBI in children taking place between 2005 and 2009. The CDC believes its resource is the first comprehensive set of mTBI guidelines focused exclusively on children in the US.

    Physical therapists (PTs) play an important role in the treatment of individuals who have suffered concussions. Get the latest information on these injuries and what’s being done to reduce them at the APTA traumatic brain injury webpage (look under the "Concussion or mTBI" header). 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.