The Medicare Payment Advisory Commission (MedPAC) may be right in its claim that Medicare Part B payment should be increased for ambulatory evaluation and management (E&M) services, but it's dead wrong when it says that those increases should be paid for by cuts to physical therapy-related payment: that's the message APTA, its Private Practice Section (PPS), and the Alliance for Physical Therapy Quality and Innovation (Alliance) delivered to MedPAC recently.
The comments were provided in response to MedPAC's 2018 report to Congress on Medicare. In the chapter titled "Rebalancing Medicare's physician fee schedule toward ambulatory evaluation and management services,” MedPAC argues that ambulatory E&M services—defined by MedPAC as office visits, hospital outpatient department visits, visits to patients in other settings such as nursing facilities, and home visits—are "underpriced." That's a problem in need of fixing, MedPAC says, because E&M services "are critical for both primary and specialty care."
MedPAC's suggestion for how to pay for repriced E&M services, however, isn't exactly a study in nuance. The commission recommends that the increase can be accomplished in a way that won't hurt Medicare's bottom line simply by reducing payment for a wide range of "procedures, images, and tests" that it believes are over-valued—including physical therapy-related services. Depending on the procedure, imaging, or test in question, the recommended cuts are as high as 3.8%.
In separate letters—1 from APTA alone, and 1 from the 3 organizations jointly—APTA, PPS, and the Alliance write that the goal of adjusting pricing for E&M services is laudable, but when it comes to physical therapy, the logic behind MedPAC's pay-for approach is built on fundamental misunderstandings of the payment code valuation process, the impact of the Multiple Procedure Payment Reduction (MPPR) payment policy, and the true role of the physical therapist (PT) in health care, among other concepts.
"Our organizations have concerns about the Commission's recommendation to reduce the value of physical therapist services," the combined group letter states. "Such reduction to reimbursement would exacerbate the overall inadequacies in physical therapy reimbursement…and harm the sustainability of the value of the physical therapy profession, and in turn diminish clinical care and outcomes and increase the cost of care to thousands of Americans each and every day."
At the heart of the MedPAC argument is an assertion that certain non-E&M services have experienced "efficiency gains" over time, making them less complex and time-consuming for providers, and thus ripe for reimbursement reductions. The letters from APTA and the combined group suggest that MedPAC is ignoring important Medicare policies that already address that exact issue—particularly the process for reassessing possibly "misvalued" coding and the MPPR, which requires a reduction in payment when multiple procedures are provided to a patient on the same day of service.
Essentially, the letters argue that the misvalued code initiative—a process that resulted in revalued codes for many physical therapy-related services in 2017—is already serving as a check against so-called efficiency gains, and that adopting a separate reduction scheme that ignores that process courts disaster.
"Our organizations have serious concerns that payment policy recommendations which supersede the misvalued codes initiative would not only harm beneficiary accessibility to services offered by physical therapists, but would also compound the payment challenges facing small, medium, and large-sized physical therapy practices," the joint letter states. "To that end, we fail to see where…the Commission assessed how beneficiary access to physical therapy would be impacted should their recommendation be adopted by CMS."
APTA, PPS, and the Alliance argue that in a similar way, the MPPR already addresses the idea of payment reductions related to efficiencies—a factor also seemingly ignored by MedPAC when it developed its proposal.
"Should CMS move forward with the Commission's suggestions to further reduce reimbursement for services furnished by physical therapists, the 50% MPPR on the [practice expense] for physical therapy services would duplicate the payment adjustments that MedPAC is recommending to account for the 'efficiencies' in therapy services," the joint letter states. "Moreover, because commercial payers frequently follow CMS's lead regarding code valuations, physical therapists would be subjected to even lower reimbursement from such payers, further challenging their ability to continue to deliver care to patients."
The APTA letter extends a similar criticism to MedPAC's lack of attention to the potential impact of a proposal to introduce payment differentials for services provided by physical therapist assistants (PTAs), asserting that that change alone could result in reductions in care, only to be made worse through adopting the MedPAC recommendations.
Beyond those failures in analysis, the MedPAC proposal also includes a more general lack of awareness of the value of physical therapy—both as a key player in value-based care, and an important tool in pain management in ways that help reduce the severity of the opioid crisis in the United States.
"Moving forward, it is imperative that [the US Centers for Medicare and Medicaid Services] acknowledge the important role physical therapists play in prevention and treatment of acute and chronic pain," the joint letter states. "MedPAC's proposal to reduce reimbursement for physical therapy services at a time when benefit design and reimbursement models should support early access to nonpharmacological interventions—including physical therapy—for the primary care of pain conditions is short-sighted and unfounded."
The APTA letter also characterizes the MedPAC proposal as "contradictory to the commission's current efforts to incentivize value over volume."
"Reducing reimbursement for highly sought-after (and consequently, highly utilized) services will force providers to find ways to increase the volume of services; thus, in future years, the commission will be prompted to recommend greater reimbursement recommendations, and so forth, resulting in a vicious, circuitous cycle that may encourage fraud, waste, and abuse," APTA writes. "We recommend the commission examine payment policies that will incentivize providers, including PTs, to transition to a value-based payment system, as opposed to putting forth proposals that promote the delivery of unnecessary interventions."
The APTA letter also argues that there's a solid case to be made for including physical therapy among the E&M services in need of repricing, asserting that PTs meet MedPAC's definition of E&M services as those provided by clinicians to diagnose and manage patients' chronic conditions, treat acute illnesses, develop care plans, coordinate care across providers and settings, discuss patient preferences, and engage in shared decision-making with patients. According to APTA, that's what PTs do, too.
"PTs, like most health professionals, are educated to provide services in the health services delivery environment," APTA writes. "PTs are also uniquely educated and trained to adapt health care recommendations to the community environment where individuals live, work, and play. This knowledge and ability enables PTs to adapt medical recommendations to specific environments, to meaningfully interpret health recommendations, to help individuals modify their health behaviors, and to ensure that clinical and community services are integrated, available, and mutually reinforcing."