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The 2024 Medicare Physician Fee Schedule rule proposed by the U.S. Centers for Medicare & Medicaid Services is partly a continuation of trends that must stop, and partly a possible early indication that the agency could be open to making some positive changes to the outdated system. 

In its own comment letter to CMS, the association leveraged its power as the voice of the profession to let CMS know how the proposed rule could affect beneficiaries who receive care from PTs and PTAs. Here are some of the major takeaways.

The Good

Proposed fee schedules usually aren't known to contain a wealth of positive news for the profession and patients, but this year was a little different: While continued cuts are unacceptable and still the standout issue in the proposal, several provisions were steps in the right direction.

An end to direct supervision of PTAs on the horizon. CMS asked for input on moving away from direct supervision of PTAs and occupational therapy assistants in private practice settings — currently the only setting under Medicare in which 100% face-to-face supervision is normally required — in favor of general supervision. APTA welcomed the possibility of change, laying out the strong arguments for why general supervision would allow PTAs to perform at the top of their licensure while maintaining needed oversight. APTA asserts that existing safeguards regulating the relationship between PTs and PTAs ensure safe, effective, and high-quality care in all settings, and that state law specifying licensure and scope of practice requirements dictate what services a PTA can safely provide to patients both in a health care setting and off the premises.

The continuation of telehealth through 2024. CMS wants to follow through on its assurances that it would adopt a Dec. 31, 2024, date for the end of telehealth allowances for PTs and PTAs under Medicare. The end date brings Medicare policy in line with requirements of the Consolidated Appropriations Act of 2023. In addition, the fee schedule corrects an earlier CMS error — the exclusion of institutional settings from the list of settings allowed to provide PT services via telehealth. APTA applauded both proposals and urged CMS to provide even more clarification around coding issues.

The introduction of caregiver training codes. CMS proposed the adoption of codes that would allow PTs, OTs, speech-language pathologists, and other providers to bill for training of caregivers when patients living with a functional deficit cannot be present — something many PTs and PTAs have been doing for free. APTA stated its support for the change, provided recommendations on minimizing administrative burden around use of the new codes, and suggested that CMS allow the codes to be used via telehealth.

A first-ever MIPS cost measure for use by PTs. If adopted as proposed, 2024 would be the first year PTs would have the potential to participate in every Merit-based Incentive Payment System category, a change that moves the program toward a more level playing field between PTs and providers who have been participating in all MIPS categories. The change, which would adopt a cost measure related to low back care, would also open the door for participation in the MIPS Value Pathways program, or MVP, via an MVP for musculoskeletal care that uses the measure. APTA supported the change, but voiced concerns about proposed reliance on FOTO patient outcome measures, which aren't universally used among physical therapy practices. The association also encouraged CMS to develop a robust measure set for nonphysicians.

The Bad

As expected, the proposal continues with cuts to payment for PTs and a host of other providers — an unsustainable path that points to the inadequacy of the current system and need for reform.

In its comments, APTA didn't mince words.

"CMS has done nothing to mitigate the damage to payment, in spite of the COVID-19 pandemic, the opioid crisis, and extreme health care shortages," the association wrote. "It has become clear that the agency is comfortable with proceeding with its annual updates without consideration of the reality we live in: CMS is content to either rely on Congress to mend these systematic issues, or it severely underestimates the significance of what these cuts mean to the provision of health care in the United States."

APTA backs up its position with payment data for the past 10 years that recounts the payment squeeze being applied to PTs, and shares information from two APTA reports — one on wages and another on hiring challenges — that show how the repeated cuts have damaged the physical therapy workforce, in turn reducing patient access to needed care.

"It's no wonder that private practices have been unable to increase wages," APTA wrote. "The constant threat of reductions in reimbursement, with only the hope of Congress mitigating the damage at the last minute, has left practices struggling to predict their financial solvency for the following year, let alone budget cost-of-living wage increases for their staff." The association informed CMS that the situation is one of the reasons APTA is pursuing legislation that would allow PTs to opt out of Medicare and contract with patients individually.

The association also urged CMS to face up to the big-picture issue — namely, that the fee schedule system is broken — and shares a list of five major reforms it's pursuing in cooperation with the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and APTA Private Practice.  

APTA also strongly opposed the proposal to begin including physical therapists in the MIPS Promoting Interoperability category, which the association asserted “would only serve to widen the gulf between providers who have and those who do not have certified [electronic health record] technology.”

The Unclear

Proposed fee schedule rules often contain provisions that lack specifics or seem uninformed. This is actually part of the process that allows the agency to get its footing in the final rule by way of comments from sources closer to the issues at stake. APTA requested clarification or reconsideration of several portions of the proposal, including multiple issues related to remote therapeutic monitoring, point-of-service codes for telehealth resulting in payment of different rates to facilities compared with non-facilities, and the availability of exemptions to participating in the above-mentioned Promoting Interoperability category of MIPS.

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