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With momentum building on Capitol Hill to address longstanding problems with the Medicare Physician Fee Schedule, APTA, APTA Private Practice, the American Speech-Language-Hearing Association, and the American Occupational Therapy Association are urging lawmakers to adopt an “all of the above” game plan laid out in a set of joint principles for reform. It's a multipronged approach that includes not only the adoption of legislation to tie fee schedule payment to inflation, but even more far-reaching changes that would significantly improve the Medicare payment environment for rehabilitation therapy providers.

The "Policy Principles of Outpatient Therapy Reform Under the Medicare Physician Fee Schedule" is a conceptual roadmap offering five changes specific to outpatient therapy that the organizations say need to be made for the continued sustainability of Medicare in rehabilitation therapy. The recommendations include everything from abolishing the Multiple Procedure Payment Reduction policy, or MPPR, to reforms that would allow physical therapists, occupational therapists, and speech-language pathologists to more fully participate in alternative payment systems, along with changes that would significantly reduce red tape for providers.

"Over the last three years, rehabilitation therapy providers have received some of the largest cuts of any health care providers as a result of the fee schedule's budget neutrality policies," the organizations write in a joint statement to Congress that accompanies the principles document. "These joint policy principles … identify some of the high-impact reforms that are needed to address administrative burden, value-based payment, and patient choice challenges that limit patient access to providers of occupational therapy, physical therapy, and speech-language-pathology services."

In an APTA news release, APTA President Roger Herr, PT, MPA, said "Reforms to the Medicare fee schedule must address the unique challenges faced by therapy providers. These joint policy principles impacting outpatient therapy services provide a starting point, and APTA is eager to work with our congressional champions and provider allies in seeking meaningful fee schedule reforms."

The principles come just as the U.S. Centers for Medicare & Medicaid Services puts final touches on its proposed 2024 physician fee schedule rule, expected to be published sometime in July. APTA will offer ways for members to make their voices heard during the subsequent public comment period.

Specifically, the principles include:

Elimination of MPPR. A longtime target of criticism from APTA and other organizations, the MPPR policy requires a 50% reduction in payment for all therapy services beyond the first service (the one with the highest practice expense value) provided to the same patient on the same day. The coalition describes this 12-year-old system as "inherently flawed" and unnecessary, given the ways CPT codes are valued to guard against duplication in work or practice expense. Elimination of the flawed MPPR policy would provide a much-needed boost to therapy payment.

Extension of Medicare opt-out to PTs, OTs, and SLPs. Under the current fee schedule, PTs, OTs, and SLPs who participate in Medicare are considered all-in when it comes to payment; they are limited to the payment rates established under Medicare and for only those services covered. Bottom line: Even when the beneficiary would prefer to privately contract with a PT, OT, or SLP to receive services, that therapist can't enter into such a contract outside of Medicare. This ability to opt out of Medicare isn't a radical idea, even within the Medicare system: It's permitted for services rendered by several other health care providers, including physicians, physician assistants, dentists, social workers, psychologists, and dietitians.

The organizations argue that this unfair restriction hurts patient access to needed care. "Certain evidence-based therapy interventions cannot be reimbursed under current Medicare payment policies," they write. "Allowing therapy providers to opt out would give Medicare beneficiaries the opportunity to benefit from these critical interventions to which they are currently denied access."

Reduced admin burden through streamlined plan-of-care certifications. While Medicare beneficiaries can receive therapy evaluation and treatment from a PT, OT, or SLP without a physician order, current Medicare rules require the therapy provider to submit a plan of care to the patient's physician and have it signed within 30 days to receive payment — even when the patient has come to the therapist by way of a physician order. The groups recommend that in those instances, simply submitting the plan of care to the referring physician should suffice. Under the current rules, "the time and resources spent by both therapists and physicians in procuring a timely signature within 30 days adds unnecessary cost, potentially delays essential services, and fails to contribute to improved quality of care," the groups state.

No more direct supervision requirements for PTAs and OTAs in outpatient private practices. This fairly straightforward change would bring the supervision of PTAs and OTAs in outpatient private practices in line with supervision requirements in all other settings under Medicare by ending the requirement for "direct" supervision. Instead, "general" supervision would be permitted, relieving PTs and OTs in private practices from a significant administrative burden, and potentially increasing patient access to PTAs and OTAs, especially in rural and underserved areas. 

Fixes to the Quality Payment Program that would allow for greater participation. When the Quality Payment Program, or QPP, was first rolled out as part of the 2015 Medicare Access and CHIP Reauthorization Act, the idea was that it would help speed up the adoption of alternative payment models under Medicare. That hasn't happened — at least not for PTs, OTs, and SLPs, who are still prevented from participating in the QPP in meaningful ways. The therapy groups view this as a major flaw in the QPP that needs to be addressed immediately to allow patient-centered models of care — and better payment options — to truly grow.

"Therapists in particular have struggled to meaningfully participate in [the Merit-based Incentive Payment Program] or engage in APMs, one reason being that CMS has failed to pilot or implement several alternative payment and delivery models applicable to therapy providers," the groups write. "Congress must enact meaningful reforms to the QPP that recognize the value of therapy providers and allow them to provide effective oversight of the QPP to determine its effectiveness at measuring therapy performance and outcomes."

But wait there's more: a fee schedule conversion factor tied to inflation. Although not among the five basic principles that are specific to outpatient therapy included in the plan, the principles document also urges lawmakers to follow through on proposed legislation that would tie the fee schedule's all-important conversion factor to the Medicare Economic Index, a calculation that accounts for inflation faced by providers relative to practice costs and general wage levels. The plan, articulated in the APTA-supported Strengthening Medicare for Patients and Providers Act (H.R. 2474), already has bipartisan support.

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